prepU Chapter One Health Assessment

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"Im sorry, but assessment is ongoing and continuous"

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

The RN is completing an admission database and must include priority nursing diagnoses for the plan of care. Which statement describes the purpose of nursing diagnosis?

A clinical judgment about client responses to health difficulties

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

Air way

When making rounds, the RN should prioritize follow-up care for which client?

An oncology client with a cough but no fever

The nurse is collecting data from a client. Which of the following best reflects objective data

Appearance

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective data

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?

Collect subjective data related to over all function

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

Continuous

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy, which is an intuitive awareness of what the client is going through, helps the nurse to be effective in providing for the clients needs while remaining compassionate

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

Focused assessment

Reflection of the nurse upon personal feelings prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may interfere with the interview

What are the primary frameworks used in conducting a health assessment

Head to toe, body systems and functional

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

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Heat-to-toe, this assessment is the most organized system for gathering comprehensive physical data

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

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

Nurses provide both direct and indirect care. What is an example of indirect care

Participating in a client care conference

The nurse is exhibiting critical thinking in which client care situation?

Perform a focused assessment on a client who is complaining of shortness of breath

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

Primary Prevention

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this?

Primary prevention which involved strategies to prevent problems

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

Primary, primary prevention involved strategies aimed at preventing problems

Before meeting the client and performing a comprehensive health assessment, which of the following would be most important for the nurse to do?

Review the clients medical records because it provides a basic biographical data and background

Four broad goals describe the role of a professional nurse. What is one of these goals?

To advocate for individuals, families, communities and populations

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-yr old client newly diagnosed with diabetes

What is the primary function of the health care team?

To decide the best overall care

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?

Open the clients airway

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The clients feelings of happiness

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?

The clients range of motion in her right arm

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data

Appearance, this is something that can be directly observed by the nurse and is considered objective data

A nurse is conducting a health assessment. How will the information collected from the patient be used?

As a basis for the nursing process

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

Assessment which is the first and most critical phases of the nursing process

Which assessment finding should the nurse document as objective data?

Body functions, subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

Do you have family that visit you regularly? this question is providing a link to getting them assistance for cleaning the apartment

The nurse is preparing to conduct a health assessment with a patient. What will be the nurse's initial role when caring for this patient?

Collecting data. The nurses initial role in health assessment is to collect data

What is a required component of a health assessment

Critical thinking

What is a required component of a health assessment?

Critical thinking, is a required component of health assessment and nursing life

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation, this stage of the nursing process involves assessing whether the outcome criteria have been met and if the nursing care plan needs to be revised

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation- involved assessing whether the outcome criteria have been met and if the nursing plan needs to be revised

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of ineffective health maintenance-- statement is suggestive of nursing concern

As a nurse becomes more proficient and comfortable in his or her role, what increases?

Knowledge base and expertise

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient?

Knowledge deficit, this diagnosis is appropriate for any new diagnosis and or medication

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgements or diagnoses.

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 interventions, which are used to monitor health status, prevent, resolve or control a problem; assist and promote optimum health and independence

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, this assessment of the client consists of a data collection that occurs after the comprehensive data base is established

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

Physiologic status

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

Review the clients health records

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first

Take a complete health history which can help direct the nurse in doing a more complete physical examination on a specific system