3111 HA: Chapter 1 Intro to Health Assessment

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: a. collect all home medications brought to the hospital b. formulate a plan of care c. take a complete health history d. make a list of appropriate nursing diagnoses

c. take a complete health history The health assessment consists of a physical examination and a health history. Information gathered during the health history may help direct the nurse in doing a more complete physical examination on a specific system.

The nurse discusses earplugs for a patient with low tone-deafness when working in a noisy environment. The nurse is utilizing: a. secondary prevention b. primary prevention c. tertiary prevention

c. tertiary prevention Tertiary prevention decreases the effects of a disease and prevents additional loss. Earplugs will help decrease further hearing loss.

When the nurse is performing a physical examination on admission of a patient to the medical unit, the pt says to the doctor already did an exam. The best response by the nurse would be: a. "each assessment is important and the nurse and doctor will get together to determine what orders need to be written." b. "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." c. "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home." d. "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately."

b. "the doctor focuses on the treatment of the disease process and the nursing assessment focuses on the body's response to the disease." The medical examination focus is on diagnosis and treatment of the disease and the nursing examination focuses on the human response

When assisting a patient with health promotion, what must the nurse also nurture: a. knowledge of the Healthy People 2020 indicators b. a healthy environment c. school/work attendance d. family communication

b. a healthy environment In order to assist a patient with health promotion, a healthy environment must also be nurtured.

The depth and scope of nursing assessment has expanded significantly over the past decades primarily because of: a. an increase in the number of baccalaureate programs in nursing b. an increase in the number of nurse practitioners c. rapid advances in biomedical knowledge and technology d. the growing elderly population with chronic illness

c. rapid advances in biomedical knowledge and technology Advances in technology have expanded the role of assessment.

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the clinic's record, the nurse should: a. avoid premature judgments about the client b. analyze data that have already been collected c. consult with the client's family members d. review any past collaborative problems

a. avoid premature judgments about the client After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data.

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process: a. emotional b. social c. mental d. spiritual

a. emotional A subdued affect would be part of the emotional assessment.

When planning a community program related to Healthy People 2020, the critical first step involves: a. formulating questions to ask community leaders b. defining the community c. planning an introductory program for the community d. assessing the community

b. defining the community To determine what is needed in a program, the community must first be defined to narrow the focus and plan specific interventions.

Mrs. Williams is an 89-year-old independent woman who lives alone and has several 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: a. "are you friendly with your neighbors?' b. "have you tried to schedule a cleaning service?" c. "do you have family who visit you regularly?" d. "what amount of cleaning have you been doing in the past?"

c. "do you have family who visit you regularly?" Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment.

When utilizing the website www.healthypeople.gov, the nurse notes completion of the first two areas in the acronym MAP-IT while working on a project for a Hispanic community within a large city. What action by the nurse would fulfill the next step in this process: a. facilitating input by scheduling a community meeting b. planning a community kick-off event at the school gym c. developing a goal for the community involved d. evaluating what changes are needed before the next event

c. c. developing a goal for the community involved The acronym MAP-IT represents Mobilize Assess Plan Implement Track and is utilized as a guide to implementing Healthy People 2020. Developing a goal is part of the third step of planning.

Staff is talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the US." The educator bases her response on the knowledge of: a. Health People 2020 b. the nursing process c. the Dept of Health & Human Services d. the three levels of preventative care

a. Healthy People 2020 Healthy People 2020 is a government project intended to increase the quality of life for ppl in the US

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): a. focused or problem-oriented assessment b. ongoing or partial assessment c. emergency assessment d. initial comprehensive assessment

a. focused or problem-oriented assessment A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

What is the primary function of the healthcare team a. to decide the best overall care b. to work together to obtain maximum coverage c. to develop an individual focus for each member d. to guide the pt's care throughout times of crisis

a. to decide the best overall care The healthcare team meets to collaborate with patients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The healthcare team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the patient.

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed: a. entry b. comprehensive c. exploratory d. focused

b. comprehensive An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) 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.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's: a. holistic wellness status b. physiologic status c. developmental history d. level of functioning

b. physiologic status 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.

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is: a. secondary prevention b. tertiary prevention c. primary prevention

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

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first: a. discuss the client's symptoms with other team members b. plan for potential laboratory procedures c. review the client's health record d. determine potential healthcare resources

c. review the client's health care record Before actually meeting the client and beginning the nursing health assessment, it is helpful to review the client's medical record, if available. Knowing the client's basic biographical data (age, sex, religion, educational level, and occupation) is useful. The medical record provides background and about chronic diseases and gives clues to how a present illness may impact the client's activities of daily living (ADL). An awareness of the client's previous and current health status provides valuable information to guide interactions with the client.

How does a nurse best facilitate the nursing health assessment: a. Creating a nursing care plan b. Formulating a nursing diagnosis c. Maintaining privacy d. Asking the appropriate questions

d. Asking the appropriate questions 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.

When answering questions about health during a presentation at a woman's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to: a. changes in environment b. stress reduction c. the absence of disease d. a healthy lifestyle

d. a healthy lifestyle Education is key to assisting people in making the connection between a healthy lifestyle and the prevention of disease. The absence of disease does not define health. Stress reduction and changes in the environment influence a person's ability to live up to his or her potential as it relates to health.

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is: a. completed on admission b. linear c. performed only by nurses d. continuous

d. continuous Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all phases of the nursing process.