Chapter 1 HA
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 Physiologic development status Musculoskeletal system and activities of daily living Psychological, sociocultural, and spiritual well-being
A A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.
In which situation should a nurse perform an emergency assessment of a client? Shortness of breath Broken arm Body rash Ear pain
A An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. In such situations, an immediate assessment is needed to provide prompt treatment. An example of an emergency assessment is the evaluation of the client's airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected. Shortness of breath requires an emergency assessment to promptly assess the client's ability to maintain an adequate airway. A broken arm, body rash, and ear pain require a focused assessment to gather information specific to the problem.
Which of the following is an example of a recent trend in nursing roles? Gathering forensic evidence for a legal proceeding Using auscultation to examine heart sounds Using palpation to assess the abdomen of a pregnant woman Performing visual inspection of a client's eyes to detect illness
A Forensic nursing is an example of one of the rapidly evolving roles of nursing that requires extensive focused assessments and the development of related nursing diagnoses. Auscultation, palpation, and inspection are all techniques that have been used by nurses for over 100 years.
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 To collect subjective data related to the client's overall health To perform a rapid assessment for prompt treatment To evaluate whether outcomes of treatment are met
A Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.
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. Declining numbers of medical students due to rising costs and focus on primary care Increasing complexity of acute care Growing aging population with complex comorbidities Increasing impact of children and the homeless on communities Declining health care needs of single parents
A, B, C, D There is tremendous growth of the nursing role in the managed care environment. The most marketable nurses will continue to be those with strong assessment and client teaching abilities, as well as those who are technologically savvy. The following factors will continue to promote opportunities for nurses with advanced assessment skills: 1) rising educational costs and focus on primary care that affect the numbers and availability of medical students; 2) increasing complexity of acute care; 3) growing aging population with complex comorbidities; 4) expanding health care needs of single parents; 5) increasing impact of children and the homeless on communities; 6) intensifying mental health issues; 7) expanding health service networks; and 8) increasing reimbursement for health promotion and preventive care services.
Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply. Check the client's status with the nurse of the previous shift Gather assessment tools after meeting the client. Review the client's record before meeting the client. Revise nursing care plans to reflect improvements in the client's condition. Reflect on own feelings regarding the initial encounter with the client. Determine knowledge of self-care based on age, education, and experience.
A, C, D The nurse should review the client's record before meeting the client, as it provides a background on chronic diseases and gives clues to how the present illness may impact the client's activities of daily living. Reviewing documented information about the client's medical diagnoses gives an opportunity to verify what the client tells the nurse with what is documented. Once basic data about the client has been gathered, the nurse should take a minute to reflect on his or her own feelings regarding the initial encounter with the client. The nurse should obtain and organize the assessment tools before meeting the client for the assessment. Nursing care plans are to be revised as the outcome criteria are met and the client makes progress towards the expected goals. This will be done after the nurse performs an assessment and implements treatments. The nurse should not determine knowledge of self-care based on age, education, and experience; the nurse should validate all information with the client and not assume that the client is eligible for self-care.
A nurse has completed assessment of a patient 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? Select all that apply. Identification of collaborative problems Assessment of the outcome of the care plan Identification of the need for referrals Formulation of nursing diagnosis(es) Development of a nursing care plan
A, C, D The second phase of the nursing process is to identify collaborative problems and the need for referrals as well as formulate nursing diagnoses, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process, which involves development of a nursing care plan and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process.
For which of the following clients should a nurse perform a focused assessment? Client with elevated blood pressure with no previous history of heart problems Client with 4-day history of sore throat and fever with enlarged lymph nodes Client with right upper abdominal pain that radiates into the groin area Diabetic with elevated blood sugars for the past 2 weeks
B A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment).
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? Initial comprehensive Ongoing or partial Focused or problem-oriented Emergency
B An ongoing or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. 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 and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem. An emergency assessment is a very rapid assessment performed in life-threatening situations.
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? Interjection of the nurse's thoughts or feelings into the data Making incorrect nursing judgments or diagnoses Relying on objective and subjective information Validating information that is already correct
B Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.
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? Emergency Partial Focused Comprehensive
B Ongoing or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data? What type of work the client does The client's range of motion in her right arm What types of foods the client typically eats Whether the client is caring for any dependents at home
B Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are what the nurse directly observes when examining the client, such as the range of motion in the client's right arm.
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? Pender Health Promotion Model Health Belief Model Healthy People 2020 U.S. Preventive Services Task Force
B The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans. The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings.
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? Perform a musculoskeletal examination. Collect subjective and objective data related to overall function. Take anthropometric measurements. Obtain a 24-hour diet recall.
B The nurse is responsible for collecting subjective and objective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietitian may take anthropometric measurements in addition to a subjective nutritional assessment, such as a 24-hour diet recall.
Which of the following is the best example of holistic data collection by a nurse? Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Performing an x-ray, ECG, exercise stress test, and complete blood count Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test
B The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The mind, body, and spirit are considered to be interdependent factors that affect a person's level of health. The nurse, in particular, focuses on how the client's health status affects his activities of daily living and how the client's activities of daily living affect his health. For example, a client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational camping. If this client walks to work in a smoggy environment, it may adversely affect his asthma. The other answers pertain only to the physiologic functioning of the client and not the other aspects.
A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings? Ambulatory care Public health Hospice Critical care
C Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. Hospice nurses assess the needs of the terminally ill clients and their families. Ambulatory care nurses assess and screen clients to determine the need for physician referrals. Public health nurses assess the needs of communities, and school nurses monitor the growth and health of children. Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment.
A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client? The client's latest CD4 cell count The client's current body weight The client's pain level Presence of bacterial pneumonia on blood test results
C Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are those that the nurse observes directly, and include the following: physical characteristics (e.g., skin color, posture); body functions (e.g., heart rate, respiratory rate); appearance (e.g., dress and hygiene); behavior (e.g., mood, affect); measurements (e.g., blood pressure, temperature, height, weight); and results of laboratory testing (e.g., platelet count, x-ray findings).
A client presents to the health care facility with reports of new onset of chest pain of 3 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 to perform for this client? Emergency Partial Comprehensive Focused
C This client presents with a new problem, for which the nurse should perform a comprehensive assessment. Chest pain is an emergent problem, but the client has stable vital signs and no chest pain; an emergency assessment thus is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly diagnose the cause of a new problem.
A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation? Initiation of a referral that the client doesn't want Omission of pertinent data needed to make a diagnosis Performance of unnecessary diagnostic tests Formation of judgments that may interfere with the interview
D After reviewing the client's record, the nurse should remember to keep an open mind and to avoid premature judgments that may alter the ability to collect accurate data. Making a referral that the client may not want, omitting pertinent data, or performing unnecessary tests does not involve personal feelings.
A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following? "Fortunately, assessment only needs to be done at the beginning of your stay." "I'll just need to evaluate you once more, at the end of your stay." "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." "I'm sorry, but assessment is ongoing and continuous."
D 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 the phases of the nursing process.
Which of the following is the best example of assessment in everyday life? Taking the dog for a walk in the park to get exercise Listening to a favorite song to relax in the evening Texting a friend to let her know that you made it home safely Measuring the remaining tread on a car tire to determine whether it is time to replace it
D As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.
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? Inspection Palpation Sympathy Empathy
D Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.
A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision? Pender Health Promotion Model Health Belief Model Healthy People 2020 U.S. Preventive Services Task Force
D The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings. The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans.
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 whether the client has achieved the outcome criteria of the treatment? Assessment Diagnosis Implementation Evaluation
D The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and whether the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.