Health Assessment Chapter 1 PrepU (Week 1)
A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?
Ask the client if they have allergies.
A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first?
Assess the client
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?
Inspection
The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?
It is ongoing and continuous.
As a nurse becomes more proficient and comfortable in his or her role, what increases?
Knowledge base and expertise
While assessing vital signs, the nurse 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 spouse. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?
Mental
The client has a murmur. This is what type of data?
Objective
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 or partial
Nurses provide both direct and indirect care. What is an example of indirect care?
Participating in a client care conference
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.
A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify?
The client's feelings of happiness
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
A nurse is conducting a health assessment. How will the information collected from the client be used?
as a basis for the nursing process
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
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.
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 is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.
- "I feel so tired sometimes" (correct) - Weight—145 lb (incorrect) - Lungs clear to auscultation (incorrect) - Client complains of a headache (correct) - "My father died of a heart attack" (correct) - Pupils equal, round, and reactive to light (incorrect)
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
Nurse
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
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
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
In which situation should a nurse perform an emergency assessment of a client?
Shortness of breath
During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2030 indicator of responsible sexual behavior?
The importance of using a condom when engaging in sexual activity
What is the primary function of the health care team?
To decide the best overall care
What is the primary purpose of health assessment?
To gather information about the health status of the client
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
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status.
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?
Identify in what areas the client needs the most care.
The nurse is reviewing the medical record of a newly admitted client to the rehabilitation center. Which subjective question should the nurse confirm with the client?
"Are you aware of any allergies that you may have?"
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
Ask the client about the most recent experiences of pain.
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
Assess the nasogastric tube for proper functioning.
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 data related to overall function
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?
Conduct a focused assessment.
A client has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this client?
Knowledge deficit
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
A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Focused assessment
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of
Healthy People 2030
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
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
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 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
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
The second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply.
- Documents the diagnoses (correct) - Derives the diagnosis based on assessment data (correct) - Prioritizes data collection activities based on the client's needs (incorrect) - Involves the client, family and other care providers when collecting data (incorrect) - Validates the diagnoses with the client, family, and other health care providers (correct)
The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?
Reassess previously detected problems
The nurse is collecting data from a client. Which of the following best reflects objective data?
Appearance
The nurse notices a large number of positions available for employment in managed care. Which are reasons for the growth in nursing opportunities in this care environment? Select all that apply.
- Complex acute care (correct) - Aging of baby boomer generation (correct) - Expanding health service networks (correct) - Uncontrollable costs for health care (incorrect) - Expanding health needs of single parents (correct)
A nursing instructor is emphasizing the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors that will increase opportunities for nurses with advanced assessment skills shoulds the instructor stress? Select all that apply.
- Declining numbers of medical students due to rising costs and focus on primary care. (correct) - Increasing complexity of acute care (correct) - Growing population of older adults with complex comorbidities (correct) - Increasing impact of children and the homeless on communities (correct) - Declining health care needs of single parents. (not correct)
A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply.
- headache (incorrect) - swelling (correct) - photophobia (incorrect) - redness around the site (correct) - clear drainage on dressing (correct)
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?
Avoid biases and judgments
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
A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?
Establish a baseline for the comparison of future health changes.
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
Evaluate outcome
A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?
focused
