Chapter 1

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 caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking

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

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

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

A patient 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 patient?

airway

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

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?

objective

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

physiologic status

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 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 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

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

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