PrepU Health Assess Ch. 1 Assignment 1

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?

"I'm sorry, but assessment is ongoing and continuous."

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?

significantly impaired hearing

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client

The client has a headache. What type of data is this?

Subjective

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

A healthy environment

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

Which assessment finding should the nurse document as objective data?

Body functions

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

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

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?

Head to toe

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?". Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

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

The client has a murmur. This is what type of data?

Objective

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

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

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

Performing a focused assessemt on a client who is complaining of shortness of breath.

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

Primary

What is the primary function of the health care team?

To decide the best overall care

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings?

Hospice

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

physiologic status.

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

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply.

-Health history -Physical examination

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?

Diagnosis

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?

Head-to-toe

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 judgments or diagnoses

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

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.