Ch 1 Nurse's Role In Health Assessment: Collecting & Analyzing Data

The nurse recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply? 1. living a healthy lifestyle 2. disease prevention 3. improving one's quality of life 4. providing affordable health care services 5. increasing the longevity of one's life

1. living a healthy lifestyle 2. disease prevention 3. improving one's quality of life 5. increasing the longevity of one's life **[Rational: Healthy People 2020 promotes a healthy lifestyle, disease prevention, improved quality of life, and length of a person's life. While important to the general wellness achieved by any individual, health care costs are not addressed by the Healthy People 2020 guidelines. p5]

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

Evaluation [ Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data - Page 4]

Which of the following statements best conveys the rationale for health promotion in a school setting? a.- Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. b.- Healthy child development is a critical health determinant because of its implications for lifelong health.

Healthy child development is a critical health determinant because of its implications for lifelong health. **[The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion. p3]

What is paramount in health promotion? a. Working with the individual patient b. emonstrating authority c. Emphasizing the risks of poor health practices d. Developing the nursing care plan e. Limiting involvements of the pt's friends & family

a. -Working with the individual patient d. -Developing the nursing care plan **[P5 Rational: Developing the nursing care plan & working w/the individual patient are paramount in health promotion. Demonstrating authority, limiting the role of friends & family, & emphasizing negative consequences are inappropriate actions.]

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

b-Asking the appropriate questions **[Page 5: Rational: 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.]

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? a. cluster the data b. perform a physical examination c. document the findings d. determine a problem list

b. perform a physical examination [Rational: The health assessment includes a health history & physical examination. After completing the health history, nurse should complete physical examination. Clustering data & determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history & after completing the physical examination. p 5]

What are nurses able to detect through the health assessment? a. Areas that need continuous care b. Areas that need in-hospital care c. Areas that need referral to a specialist d. Areas in need of health adjustments

d. Areas in need of health adjustments **[Rational: Through the health assessment nurses are able to detect areas in need of health adjustments.]

An assessment that concentrates on patterns of role performance that all humans share is called what? a.Head-to-toe b. Body systems c. Focused d. Functional

d. Functional [Rational: A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity & exercise, nutrition & metabolism, elimination, sleep & rest, cognition & perception, self-perception & self-concept, roles & relationships, coping & stress tolerance, sexuality & reproduction, & values & beliefs. p6]

For which client should a nurse perform a focused assessment? a. Diabetic w/ elevated BS for the past 2 wks b. Elevated BP w/no previous hx of heart problems c.Right upper abdominal pain that radiates into the groin area d.4-day hx of sore throat & fever w/enlarged lymph nodes

d.4-day history of sore throat & fever w/enlarged lymph nodes **[Rational: A client w/a sore throat & fever w/enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. Elevated BS w/no previous hx of heart problems requires an initial or comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation & the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment. A client w/ diabetes has a chronic, ongoing health problem that needs reassessment & possibly a change in tx. p5-6]

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? a .Follows the ABC approach b. Uses evidence-based techniques c. Asks unlicensed staff to measure vital signs d. Focuses on the system that caused the hospitalization

b. Uses evidence-based techniques **[To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems p2]

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? a. Head to toe b. Body systems c. Functional d. focus

a. Head to toe [Rational: The head-to-toe method is efficient & provides more modesty for clients. The body systems and functional assessment do not address the modesty issue in the question. p5]