HA P-U Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data Prep-U Questions.
Why is the nurse always reassessing the patient for changes? To never make a mistake when providing care To always have the best nursing care plan To achieve the best results To update the nursing diagnosis
Correct response: To achieve the best results Explanation: The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 6.
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should analyze data that have already been collected. review any past collaborative problems. avoid premature judgments about the client. consult with the client's family members.
Correct response: avoid premature judgments about the client. Explanation: After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 7.
What is the primary function of the health care team? To work together to obtain maximum coverage To decide the best overall care To guide the patient's care throughout times of crisis To develop an individual focus for each membe
Correct response: To decide the best overall care Explanation: The health care team meets to collaborate on patients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the patient. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
When assisting a patient with health promotion, what must the nurse also nurture? A healthy environment Knowledge of the Healthy People 2020 indicators Family communication School/work attendance
Correct response: A healthy environment Explanation: In order to assist a patient with health promotion, a healthy environment must also be nurtured. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
How does a nurse best facilitate the nursing health assessment? Maintaining privacy Asking the appropriate questions Formulating a nursing diagnosis Creating a nursing care plan
Correct response: Asking the appropriate questions Explanation: 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. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 10.
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? Functional Focused Head-to-toe Body system
Correct response: Head-to-toe Explanation: A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data. Reference: CHAPTER 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 5-6.
A nurse has completed an 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
Correct response: Identification of collaborative problems Identification of the need for referrals Formulation of nursing diagnosis(es) Explanation: 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 the 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. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 8-9.
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? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain-free."
Correct response: "I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
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.
Correct response: "I'm sorry, but assessment is ongoing and continuous." Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 3.
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? Breathing Airway Circulation Disability
Correct response: Airway Explanation: The emergency assessment involves a life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury. Staff members at the ED use triage to determine the level of urgency by considering assessments based on the mnemonic A, B, C, D, E: A—Airway; B—Breathing; C—Circulation; D—Disability; and E—Exposure. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 6-7.
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? Diagnostic reasoning Physical assessment Critical thinking Nursing care plan
Correct response: Critical thinking Explanation: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 9-10.
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? Rationale American Nurses Association recommendations Physical assessment skills Diagnostic reasoning
Correct response: Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 10.
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
Correct response: Empathy Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 9.
What are the types of nursing assessments? (Select all that apply.) Physical Focused Mental Emergency Comprehensive
Correct response: Focused Emergency Comprehensive Explanation: Three types of nursing assessments are common: emergency, focused, and comprehensive. Physical and mental assessments are areas addressed in the various types of nursing assessments. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
An assessment that concentrates on patterns of role performance that all humans share is called what? Head-to-toe Body systems Focused Functional
Correct response: Functional Explanation: A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 6.
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
Correct response: Health Belief Model Explanation: 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. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
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 the client's family history organization standards of care the client's past medical history
Correct response: Healthy People 2020 Explanation: Healthy People 2020 is a framework that identifies risk factors, health issues, and diseases of concern in the United States. The goals and objectives serve to improve the health of individuals and communities with the overall goal to increase quality of life by creating guidelines for a healthy lifestyle as well as educating people and cultivating an awareness that will assist in the elimination of health disparities. Healthy People 2020 promotes health and disease prevention as it improves the quality and length of a person's life. The client's family history or past medical history will not help identify health promotion interventions. The organization's standards of care are generalized and do not identify health promotion interventions. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
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
Correct response: Measuring the remaining tread on a car tire to determine whether it is time to replace it Explanation: 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. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 1.
How does a nurse decide what health-promotion activities are necessary for a particular client? Nurses address areas associated with healthy behaviors only Nurses collaborate with clients to identify areas in which clients are willing to make changes Nurses assess areas in which clients are willing to make changes only Nurses construct their own theories to identify perceptions, barriers, and positive outcomes
Correct response: Nurses collaborate with clients to identify areas in which clients are willing to make changes Explanation: Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
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? Planning Evaluation Implementation Nursing diagnosis
Correct response: Nursing diagnosis Explanation: Analysis of data or nursing diagnosis, is the second phase of the nursing process. Planning occurs after the data is analyzed. Evaluation is the final phase of the process. Implementation occurs after planning. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 8-9.
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
Correct response: Ongoing or partial Explanation: An ongoing, follow-up 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. Reference: CHAPTER 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 6.
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 Focuses primarily on the client's physiologic development status Involves the client's musculoskeletal system and activities of daily living Focuses only on the client's psychological, sociocultural, and spiritual well-being
Correct response: Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: 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. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.
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? Follows the ABC approach Uses evidence-based techniques Asks unlicensed staff to measure vital signs Focuses on the system that caused the hospitalization
Correct response: Uses evidence-based techniques Explanation: 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 Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 2.
A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.) Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat? How will the client use her left arm? How will the client drive?
Correct response: Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat? Explanation: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. The nurse would not be focused on the client's left arm or driving. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 9.
What is paramount in health promotion? (Select all that apply.) Working with the individual patient Demonstrating authority Emphasizing the risks of poor health practices Developing the nursing care plan Limiting the involvements of the patient's friends and family
Correct response: Working with the individual patient Developing the nursing care plan Explanation: Developing the nursing care plan and working with the individual patient are paramount in health promotion. Demonstrating authority, limiting the role of friends and family, and emphasizing negative consequences are inappropriate actions. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
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) ongoing or partial assessment. focused or problem-oriented assessment. emergency assessment. initial comprehensive assessment.
Correct response: focused or problem-oriented assessment. Explanation: 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. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 6-7.
The result of a nursing assessment is the: prescription of treatment. documentation of the need for a referral. client's physiologic status. formulation of nursing diagnose
Correct response: formulation of nursing diagnoses. Explanation: Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data. Reference: Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, pp. 8-9.
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 living a healthy lifestyle disease prevention improving one's quality of life providing affordable health care services increasing the longevity of one's life
Correct response: living a healthy lifestyle disease prevention improving one's quality of life increasing the longevity of one's life Explanation: 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. Reference: 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? cluster the data document the findings determine a problem list perform a physical examination
Correct response: perform a physical examination Explanation: The health assessment includes a health history and physical examination. After completing the health history, the nurse should complete the physical examination. Clustering data and determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history and after completing the physical examination. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's physiologic status. holistic wellness status. developmental history. level of functioning.
Correct response: physiologic status. Explanation: The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being. Reference: CHAPTER 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.
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? lives alone significantly impaired hearing widowed 2 years ago greatly concerned about cost of services
Correct response: significantly impaired hearing Explanation: As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.