NUR 3065 - Prep U Chapter 1

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment Explanation: In order to assist a client with health promotion, a healthy environment must also be nurtured.

What are nurses able to detect through the health assessment?

Areas in need of health adjustments Explanation: Through the health assessment nurses are able to detect areas in need of health adjustments.

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions Explanation: Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

Establish a baseline for the comparison of future health changes. Explanation: An initial comprehensive assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. It does not form the basis for medical treatment. The client's "ABCs" are included, but this is not the primary focus of an initial assessment.

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes. Explanation: Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention Explanation: Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the client's health status and current problems. Reference:

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing Explanation: An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.

How do nurses facilitate the achievement of high-level wellness with a client?

Promoting health in the client Explanation: High-level wellness is a process by which people maintain balance and direction in the most favorable environment. The role of nurses is to facilitate this achievement through health promotion and teaching. Nurses do not facilitate the achievement of high-level wellness by encouraging clients to keep appointments, providing information on alternative treatments, or providing "good" client care.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured Explanation: A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention Explanation: Exercise and healthy eating improve wellness and help protect from disease and disability, which is primary prevention.

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health. Explanation: The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status. Explanation: The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

The second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply.

- Documents the diagnoses - Derives the diagnosis based on assessment data - Validates the diagnoses with the client, family, and other health care providers Explanation: To accomplish the second standard, the nurse derives the diagnoses based on assessment data, validates the diagnoses with the client, family, and other health care providers, and documents the diagnoses. Prioritizing the data collection activities based on the client's needs and involving the client, family, and other care providers when collecting data are actions to take when completing the first standard within the Nursing Scope and Standards of Practice.

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of

Healthy People 2020 Explanation: Healthy People 2020 is a government project intended to increase the quality of life for people in the United States.

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes Explanation: During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

Review the client's medical record. Explanation: Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority.

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental Explanation: The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

Focused assessment Explanation: The nurse would most likely perform a focused assessment, which is done when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A comprehensive assessment would have been done for this client when he or she first visited the office. An ongoing assessment would be done to evaluate problems identified earlier, to determine any changes. This might be the type of assessment done when the client returns after receiving treatment for the current complaints. An emergency assessment would be done if the client came in with a life-threatening complaint or problem.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary Explanation: Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples. • Secondary prevention includes the early diagnosis of health problems and prompts treatment to prevent complications. Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples. • Tertiary prevention focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching for clients with diabetes, inhaler teaching for clients with lung disease, and exercise programs for those who have had myocardial infarction are examples. A holistic approach to health care may be applied to all levels of interventions but is not a "level" of intervention itself.