Ch 1 - Nurse's Role in Health Assessment: Collecting and Analyzing Data
Which statement by the new nurse demonstrates an understanding of the nurse's responsibility to conduct an effective health assessment of the client?
"I am always trying to improve my assessment skills."
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 client asks why a health assessment needs to be done. What should the nurse respond to this client?
"It determines your health status, risk factors and educational needs to develop a plan of care."
Which of the following client situations would the nurse interpret as requiring an emergency assessment?
a client who took a drug overdose
When assisting a client with health promotion, what must the nurse also nurture?
a healthy environment
A client 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 client?
airway
When making rounds, the RN should prioritize follow-up care for which client?
an oncology client with a cough but no fever
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing?
assessing
Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?
collecting information regarding the client's health status
A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?
comprehensive
The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?
comprehensive
When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?
diagnosis
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?
diagnostic reasoning
What are the types of nursing assessments?
emergency, comprehensive, and focused
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.
When doing an overall assessment of a client, the nurse is able to utilize findings and do what?
identify in what areas the client needs the most care
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
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
nursing process
The nurse is exhibiting critical thinking in which client care situation?
performing a focused assessment 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
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
The nurse plans to follow the Health Belief Model when identifying a client's care needs. On what will the nurse focus when using this model? Select all that apply
sufficient motivation, making a change would be beneficial, and belief of being susceptible to a health problem
The nurse tells a newly admitted client that she is going to do a health assessment to help in planning care and educational needs during the client's hospital stay. Before the physical examination, the nurse should first
take a complete health history
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
the client's acuity
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?
the client's range of motion in her right arm
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing?
continuous
Which of the following is the best example of assessment in everyday life?
measuring the remaining tread on a car tire to determine whether it is time to replace it
The client has a murmur. This is what type of data?
objective
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status
A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?
recognize the need to reevaluate the client's plan of care
Why is the nurse always reassessing the client for changes?
to achieve the best results
The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?
a clinical judgment about client responses to health difficulties.
Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to
arrive at conclusions about the client's health
How does the nurse best facilitate the nursing health assessment?
asking the appropriate questions
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next
check for the presence of defining characteristics
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
environmental
The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?
functional
Which of the following is an example of a recent trend in nursing roles
gathering forensic evidence for a legal proceeding
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 and physical examination
Which of the following statements best conveys the rationale for health promotion in a school setting?
healthy child development is a critical health determinant because of its implications for lifelong health
The nurse is following a structured head-to-toe approach to identify changes in a client's body systems. Which component of the health assessment is the nurse completing with the client?
physical examination
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
What is the primary function of the health care team?
to decide the best overall care
What is one of the broad goals within nursing?
to treat human responses
Which assessment finding should the nurse document as objective data?
body functions
What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?
collecting data regarding the nature of the pain
A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?
critical thinking
What are the areas of independent nursing practice?
deciding what client teaching is necessary, deciding when a client needs to be turned, and deciding when physical procedures should be performed on a client
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
As a nurse becomes more proficient and comfortable in his or her role, what increases?
knowledge base and expertise
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
To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first
review the client's health care record
Which actions should a nurse perform before beginning the initial shift assessment of a client?
review the client's record before meeting the client, revise nursing care plans to reflect improvements in the clients condition, and check the client's status with the nurse of the previous shift
What is paramount in health promotion?
working with the individual patient and developing the nursing care plan
When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be
"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."
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?
Uses evidence-based techniques
The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?
a focused assessment is more in-depth on specific issues, unlike a comprehensive assessment
What are nurses able to detect through the health assessment?
areas in need of health adjustments
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should
avoid premature judgements about the client
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?
body systems
For which of the following clients should a nurse perform a focused assessment?
client with 4-day history of sore throat and fever with enlarged lymph nodes
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
Revising the plan as needed occurs in what part of the nursing process?
evaluation
The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?
follows a kosher diet
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 and partial
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 client's airway
The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?
perform a physical examination
The purpose of a health assessment includes what?
collecting information about the health status of the patient, evaluating patient outcomes, and synthesizing collected data
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
The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.
validate data, document data, collect objective data, and collect subjective data
Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?
extend the time originally allotted for the completion of the initial health assessment
An assessment that concentrates on patterns of role performance that all humans share is called what?
functional
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 and objective data related to overall function.
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
individual student interview and questionnaire
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
After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?
nursing diagnosis
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
A nurse has completed assessment of a client with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process?
formulation of nursing diagnosis, identification of the need for referrals, and identification of collaborative problems
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
A nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client?
health belief model
After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client?
healthy people 2020
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 client'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
What is the nurse's focus while conducting a health assessment with a client?
completing the health history and conducting a physical examination
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 who visit you regularly?"
A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?
"nurses focus on the diagnosis of actual human responses to disease or life events."
A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?
ongoing
This type of assessment includes a health history and physical assessment.
comprehensive
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
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 adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform?
emergency
A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply
growing aging population with complex communities, increasing impact of children and the homeless on communities, increasing complexity of acute care, and declining numbers of medical students due to rising costs and focus on primary care
The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply.
"are you experiencing any pain at this time?" "are you feeling dizzy now?" "do you know what your blood pressure is usually?"