Health Assessment PrepU Ch 1-2
A nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of am acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply. - the clients medical diagnosis - recent abnormal laboratory findings - the clients recent divorce - the clients tonsillectomy 45 years ago - recent changes in the clients blood pressure readings
- The clients medical diagnosis recent abnormal laboratory findings -recent changes in the clients blood pressure readings
When assisting a client with health promotion what must the nurse also nurture?
A healthy environment
John nurse interacts with four different clients one afternoon at the health clinic the nurses able to talk Leo says three of them and makes a referral for the fourth which of the following client should the nurse refer to another professional
An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture
A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is
Analyze the data
A client admitted with a small bowel obstruction requires I need a gastric tube to continuously wall suction the nurse monitors gastric output of 250 mL at 830 mL at 900 the nurse understands that drainage should keep her and not decrease probably within an hour what is the best action of the nurse?
Assess nasogastric tube for proper functioning
The nurse is attempting to cluster the data collected during the initial assessment of an older adult client the nurse notes that the client has a swollen love me and complained of a bit of soreness in the joint but the nurse is not have enough data to support a nursing diagnosis of impaired physical mobility what should the nurse do next?
Assess the client further for evidence of reduce mobility and decreased range of motion
After teaching a group of students about the phases of the nursing process the instructor determines that the Teaching was successful when the students identify which phase as being foundational to all other phases
Assessment
Nursing Process
Assessment, diagnosis, planning, implementation, evaluation
Implementation
Carrying out the plan
Assessment
Collecting subjective and objective data
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 be taken first.
Conduct a focused assessment
The nurse recognizes that the second step or phrase of the nursing process why is the data analysis a difficult step?
Diagnostic reasoning skills are required to interpret data accurately
A nurse is conducting an interview with a new client which of the following would the nurse identify as a abnormal
Difficulty sleeping Recently unemployed significant unexpected weight loss
The nurse has complete an assessment on a new client. After gathering the data formulating a nursing diagnosis and developing a plan of care, it is important for the nurse before finalizing the plan to
Discuss the plan with a client
A client has presented to the emergency departement (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective date on the client during the initial comprehensive assessment
ED nurse
A nurse reviews the vital signs of a client High temperature high heart rate increase blood pressure saturation of oxygen decreasing. The nurse applies soxygen to the client, what action should the nurse take next?
Evaluate outcome
The client has been admitted with new onset hypertension with a past medical history of asthma, type two diabetes, and hypercholesteremia. After developing a nurse care plan the nurse reports binding to the healthcare provider. After receiving medication orders from the healthcare provider the nurse a minute shares several medication's for hypertension. What is the next best action of the nurse?
Evaluate patient outcome
The nurse provides care for a client with an elevated temperature the client is given the prescribe medication and the nurse check the client temperature in repeated intervals what step of the nursing process is the nurse using to determine if the client has achieve the outcome criteria of the treatment? The four
Evaluation
And assessment of a client who already has complete record database in the system and returns to the healthcare agency with a specific health concern is referred to as a(n)
Focused or problem oriented assessment
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? Health history, wellness teaching, physical examination, outcome identification, medication administration.?
Health history, wellness teaching, physical examination, outcome identification
A hospital nurse Has identified I need to improve are critical thinking skills in the effort to improve client care the nurse should identify which of the following characteristics of critical thinking
It involves reflections on thoughts before reaching conclusions
A nursing instructor is describing why did analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?
It requires diagnostic reasoning skills
A nurse at a busy primary care clinic is analyzing the data team from the following client for which client with the nurse most likely expect to facilitate a referral?
50 year old client newly diagnosed with diabetes
A nurse is preparing to document conclusions after analyzing data and includes information about related factors in manifestations. What is the nurse formulating?
Actual nursing diagnosis
Diagnosis
Analyzing objective and subjective data to make a professional nursing judgement
What are nurses able to detect through the health assessment
Areas in need of health adjustments
The nurse reviews a 70 year old client labs. The nurse is concerned about renal function. What action should the nurse take?
Assess urine output, assess clients weight , Determined client 24 hour intake
Evaluation
Assessing whether outcome criteria have been met and revising the plan as necessary
A nurse assesses a heart rate of 110 bpm cool clammy skin and blood pressure 88/58 which heading should the nurse use to cluster this data?
Low fluid volume
Planning
Determining outcome criteria and developing a plan
The eight dimensions of heath
Emotional, social, spiritual, physical, occupational, educational /intellectual, economical / financial, environmental
A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic what color should the nurse identify for this type of assessment?
Establish a baseline for the comparison of future health changes
An older adult client had hip replacement surgery two days ago the nurse enters a client room and encourages the client to use the incentive spirometer 10 times every hour what is this action an example of?
Nursing intervention
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
A client is receiving a unit of packed red blood cells (PRBC). The client develops a low-grade temperature one (1) hour after transfusion was initiated. what type of assessment should the nurse perform
Focused
If a client comes to the healthcare providers office for a visit. The client has been seen in the office on occasion for the past five years and arrive today complaining of a fever and sore throat. Which type of assessment with the nurse most likely perform?
Focused assessment
An assessment of a client who already has a complete recorded database in the system and returns to the healthcare agency with a specific health concern is referred to as a(n)
Focused or problem oriented assessment
The nurse receives a report on a group of clients. Which client statement requires further clarification to ensure client Safety?
I do not usually take insulin, this looks like a new pill, I felt at home last month
An unlicensed assistive personnel UAB report pillow oxygen percent on a client. The nurse enters the room to find a client talking on the phone with a family member laughing what is the first action of the nurse? If I
Recheck the clients oxygen saturation
The nurse student demonstrates a need for further teaching in when she states which of the following
Patients do not need to understand their problems
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the Client's
Physiological status
The nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and there's no 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
Swelling, redness around the site, clear drainage on the dressing (objective)
During a health assessment the nurse learned that in the 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
A nurse is collecting data on a client chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
What other symptoms occurred during the spell?
The nurse is caring for a client in the healthcare providers office in reviewing a clients chart the nurse recognizes the need for providing the client on additional education related to COVID-19 noting which of the following about the client
Works in the service industry
The nurse is reviewing a clients health history and the results of the most recent physical examination, which of the following data would the nurse identify as being subjective? Select all n
"A client says something" s complains, feather died of heart attack
How do nurses facilitate the achievement of high-level wellness with a client
Promoting health in the client
The nurse has completed a 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
We are going during an initial health history of plants days I haven't slept in weeks the nurse Alex you are saying that you have not had any sleep in weeks? What communication technique is the nurse using to obtain accurate subjective data from work?
Rephrasing
The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assesment which of the following actions should the nurse perform first?
Review the clients medical record
The nursing instructor realizes that the nursing student understand all the criteria necessary for developing expertise and making clinical professional judgment by identifying the following as being a barrier to diagnostic reasoning
Seeing things only I was right or wrong
The nurse collects data from a client with a nonproductive cough and labored respiration happens at a rate of 24 per minute What other dealership the nurse collector for formulating an appropriate nursing diagnosis
Status of breath sounds
When documenting clinical data after an assessment of the client know what might you right in your physical assessment
Thyroid isthmus barely palpable lobes not felt
A nursing instructor is Discussing the purposes of health assessment. What is the purpose of health assessment?
To establish a database against which subsequent assessments can be measured
Role of the Nurse
Use your findings to decide on which areas patient needs the most care, promote health and prevent disease, determine what affects the patients health, make decisions about what will affect patient safety and quality of care, daily patient goals, watch for Subtle changes in the patient, Rely on skills and health history and physical assessment, continually reassess the patient for changes
A nurse has selected several nursing diagnosis is in the process of data analysis for a client with poorly control type one diabetes. One of these collaborative problems is altered health maintenance due to an infrequent blood glucose monitoring has manifested by elevated Hg A-1 C. How would the nurse best validate this diagnosis with the client?
Would you agree that there's room for improvement in your routines for blood sugar monitoring?
A nurse is conducting a health assessment. How will the information collected from the client be used?
as a basis for the nursing process
The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following
cues that are clustered yet unrelated
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data what assessment is a preceptor talking about?
head to toe
Three types of reasoning for clinical problem solving
pattern recognition, development of schemas, application of relevant basic and clinical science
After initial assessment the nurse has identified support of an abnormal Hughes has class sure the cues which of the following phrases indicates a client concern
A client with a diagnosis of heart disease and stress at work
Health assessment is used to evaluate health states of a person by gathering 2 components:
Comprehensive health history (questions first) Complete physical examination (examine)
A nurse has completed a data analysis? Identifying normal and abnormal findings, on a newly admitted client to the medical surgical unit. Which of the following steps of the clinical judgment process with the nurse complete before identifying a client concern? Select all that apply
Identify supportive and abnormal cues, cluster cues, draw inferences
The client has been diagnosed with diabetes mellitus and the nurse knows that the client requires education on the dietary restrictions what would be an appropriate intervention by the nurse
Make a referral to the dietitian
Your client has been directly admitted from the doctors office. The only paperwork he has brought in with him is his admission orders. You are gathering your admission data one ordered lab work is collected. When documenting your history physical examination assessment and plan what would you write under the heading laboratory data.?
None currently
Collecting subjective data (OLD CART)
Onset (when began) Location Duration (how long, around when) Characteristic symptoms (describe feel) Associated manifestations (other symptoms occurs) Relieving factors (anything tried?helped?) Treatment (anything tried?helped?) Severity
The client admitted to the hospital with status Asthmaticus suddenly develops the following signs and symptoms;: increase heart rate 105 BPM increase respiratory rate 24/men O2 saturation 90% on 100% non-rebreather mask and set an absence of wheezing. Which action should the nurse take?
Perform an emergency assessment
During an initial health history a client states I haven't slept in weeks the nurse asked you were saying that you have not had any sleep in weeks? What communication technique is a nurse using to obtain accurate subjective data from the client
Rephrasing
A nurse working on medical surgical unit in a hospital reviews of clients chart. The client is alert and oriented. No bowel movement has been documented for five days. What is the first action of at the nurse?
Verify the information with a client
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent wet air from utilizing the is the nursing process?
Making Ingrid nursing judgments or diagnosis
When entering questions about health during a presentation at a woman's club luncheon the nurse emphasizes the prevention of disease is multi faceted but it's connected directly to
A healthy lifestyle
A nurse practitioner is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent aputation of her lower leg, which skill will the nurse most need to perform this assessment?,
Empathy
A nurse has gathered abnormal in support of cues after comprehensive assessment and physical examination on an older adult, during the analysis of cute clusters, the nurse identifies activity intolerance and functional urinary incontinence the client is Confused and unable to communicate effectively with the nurse. What would be the next best option for the nurse to take?
Make inferences from the cue clusters
The nurse is completing an assessment on a new client at the community health clinic and would like to screen the clients cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful and directing the nurse to a screening tool to assess the client cognitive ability?
The Alzheimer's Association (AA)
The nurse has completed a comprehensive assessment and physical examination on a 28-year-old client who recently admitted to the medical surgical unit after suffering non-life-threatening injuries in a motor vehicle accident. The nurse identify as possible client concerns after analyzing and making inferences from the abnormal in support of cues. What is the best action for the nurse to take
Validate client concerns with the client