CH 1 Assessment`

What is a required component of a health assessment?

Critical thinking

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?

Expansion of health care networks

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

Which of the following is an example of a recent trend in nursing roles?

Gathering forensic evidence for a legal proceeding

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

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

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection

When describing a focused assessment to a group of students, which of the following would the instructor include?

It assesses a particular client problem.

When discussing the nursing process with a group of students, which of the following statements best describes it?

It is ongoing and continuous.

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

Knowledge deficit

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

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

Participating in a client care conference

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

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

Primary

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

Primary prevention

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

What is the primary function of the health care team?

To decide the best overall care

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

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

continuous

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

physiologic status.

The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

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 is working in an ambulatory care clinic. Which client would the nurse determine to be in most need of an emergency assessment?

A 35-year-old man with chest pain and diaphoresis for 1 hour

A group of students is reviewing information about the potential opportunities for nurses with advanced assessment skills. The students demonstrate that they understand the information when they identify which of the following as helping to promote this role?

Expansion of health care networks

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

• "I feel so tired sometimes." • Client complains of a headache • "My father died of a heart attack."

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

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

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

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.

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"