Nurs 224 Ch.1: The Nurse's Role in Health Assessment
The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply.
the client's medical diagnosis recent abnormal laboratory findings recent changes in the client's blood pressure readings
The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.
"I feel so tired sometimes" Client complains of a headache "My father died of a heart attack"
The nurse is collecting data from a client. Which of the following best reflects objective data?
Appearance
A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?
Avoid biases and judgments
The nurse reviews the laboratory values of a client and observes a decrease in the client's hematocrit and hemoglobin since admission. The nurse reviews the client's vital sign trend since admission and sees the BP has been decreasing as well. What is the best action of the nurse?
Develop a nursing diagnosis.
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?
Evaluate patient outcome.
When assisting a client with health promotion, what must the nurse also nurture?
Healthy environment
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?
Making incorrect nursing judgments or diagnoses
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
Perform an emergency assessment.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
To determine any changes from the baseline data
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
focused or problem-oriented assessment.
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
Evaluate outcome.
An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?
Measure the client's blood glucose four times daily.
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
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
Individual student interview and questionnaire
A nurse on the subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?
The focused assessment addresses a particular client problem.
During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2030 indicator of responsible sexual behavior?
The importance of using a condom when engaging in sexual activity