Health Assessment WK2 Health Assessment Basics

The nurse enters a client's room and finds them looking at the packet of papers that are given to all clients at the time of admission. As the client sets the folder aside, they ask, "Why do they give me this stuff every time I come to the hospital? Do they not realize I've seen it all before?" What is the best response by the nurse?

"I know you are familiar with the information, but not everyone is. By providing the packets to each client, we are sure everyone has access to information about the hospital and their rights as a client."

The nurse enters the room of a newly admitted client to complete the health assessment. While introducing themselves, the nurse begins to clean and arrange the equipment needed during the assessment and discovers that the wheels on the client's bed are not locked.

1. Lock the wheels. 2. Ask the client if they are comfortable. 2. Explain the purpose of the health assessment. 4.Complete the health assessment. 5. Ask the client if they need anything. 6. Document the health assessment. 7. Follow up with the colleague who brought the client into the room to remind them to check the bed locks every time they are in a client's room.

third level priority

Often encountered in a clinic or healthcare provider's office setting​. After ensuring there are no first- or second-level priority needs, proceed with the traditional order of the health assessment.​

second level priority

Requiring attention so as to avoid further deterioration When a client is stable and may not stay that way without rapid intervention, it is appropriate to multitask by assessing and providing care at the same time. Often encountered in an outpatient procedure, acute inpatient, or long-term care facility

While documenting health assessment data on the point of care (POC) electronic health record (EHR), the nurse becomes aware that a colleague who is not caring for the client is standing behind them reading what is on the screen. What steps will the nurse take to protect the client's privacy?​

Block colleagues view of the EHR Apologize to the client for the interruption Ask the coleague if they need assistance If the colleague needs assistance, step out of room to discuss Determine the priority of the colleagues request Return to the health assessment if the colleagues request is not a first level priority

While completing a health assessment, the client begins slurring their speech. The nurse notes that the client, who was confused a moment ago, now has right-sided facial drooping. What is the most appropriate action for the nurse to take next?

Call out for help. he cues present—slurred speech and facial drooping that began suddenly—indicate this individual has a level-one priority need and the most immediate need is for the nurse to get assistance to the room quickly. This is best done by dialing the designated number to initiate a rapid response team or calling out for help and stating the location (e.g., "I need help in room 2204 now."). These actions can be completed while moving toward the client to begin an assessment focused on the most likely cause of the emergency (in this case the neurological exam is indicated based on symptoms of a stroke).

first level priority

Emergent, life threatening, and immediate Often encountered in an urgent care or emergency department setting.​

Prior to leaving the hospital room at the end of an assessment, what actions are completed by the examiner?

comfort by returning the bed to the lowest elevation, ensuring the wheels are locked by looking at the lock and pushing gently on the bed, placing the call light where the individual can reach it asking about their pain/comfort and other needs.