Intro to HA questions
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? "Do you have family who visit you regularly?" "What amount of cleaning have you been doing in the past?" "Have you tried to schedule a cleaning service?" "Are you friendly with your neighbors?"
"Do you have family who visit you regularly?" Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment. Chapter 1: Introduction to Health Assessment - Page 7-8
Kyphosis
A spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back. The condition is sometimes known as "roundback" or—in the case of a severe curve—as "hunchback." Kyphosis can occur at any age, but is common during adolescence.
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
Comprehensive 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. Chapter 1: Introduction to Health Assessment - Page 4
A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding? Identify a nursing diagnosis of Ineffective Health Maintenance. Identify a collaborative problem that should involve the occupational therapist. Make a referral to the unit's social work department. Reassess the client's blood glucose level.
Identify a nursing diagnosis of Ineffective Health Maintenance. Explanation: This statement is suggestive of a nursing concern, which the nurse would characterize as a nursing diagnosis and follow up with education. Social work and occupational therapy are not relevant to this statement, and rechecking the client's glucose level does not address the problem at hand.
The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? Review the client's medical record. Obtain basic biographic data. Consult clinical resources explaining the client's diagnosis. Validate information with the client.
Review the client's medical record Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority. Chapter 1: Introduction to Health Assessment - Page 4
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? How much time the nurse has The client's acuity The client's cooperation Onset of current symptoms
The client's acuity Explanation: Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms. Reference: Chapter 1: Introduction to Health Assessment - Page 5
Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what? Venous thromboembolism Arterial occlusion Neuropathy Venous obstruction
Venous thromboembolism Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism. Arterial occlusion is characterized by pain with exercise. Neuropathy is characterized by no pain. Symptoms of a venous occlusion would include edema. pg 454
While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process? emotional social mental spiritual
emotional Explanation: A subdued affect would be part of the emotional assessment. Reference: Chapter 1: Introduction to Health Assessment - Page 4
In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason? Establish a baseline from which to start interviewing the family Identifying the primary problems or patterns of concern Communicate information to the physician Communicate information to other staff members
Correct response: Identifying the primary problems or patterns of concern Explanation: The nurse prioritizes, collects, and analyzes subjective and objective data and summarizes and states the two to three most important patterns or problems might be. **The nurse's priority is not use the data gathered in the client interview as a baseline for interviewing the family or for communicating to the physician or other staff members. Chapter 4: The Health History - Page 72
The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what? Body systems Functional Focused Head to toe
Head to toe The head-to-toe method is efficient and provides more modesty for clients. The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client. Chapter 1: Introduction to Health Assessment - Page 5
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? Select all that apply. Health history Wellness teaching Physical examination Outcome identification Medication administration
Health history Physical examination A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation. Chapter 1: Introduction to Health Assessment - Page 4
Healthy People 2020
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. Chapter 1: Introduction to Health Assessment - Page 6
A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding? Identify a nursing diagnosis of Ineffective Health Maintenance. Identify a collaborative problem that should involve the occupational therapist. Make a referral to the unit's social work department. Reassess the client's blood glucose level.
Identify a nursing diagnosis of Ineffective Health Maintenance. This statement is suggestive of a nursing concern, which the nurse would characterize as a nursing diagnosis and follow up with education. Social work and occupational therapy are not relevant to this statement, and rechecking the client's glucose level does not address the problem at hand. Reference: Hogan-Quigley, B., Palm, M.L., & Bickley, L., Bates' Nursing Guide to Physical Examination and History Taking, 2nd ed., Philadelphia, Wolters Kluwer, 2017.
As a nurse becomes more proficient and comfortable in his or her role, what increases? Confidence and knowledge base Time management and confidence Knowledge base and expertise Expertise and time management
Knowledge base and expertise Explanation: As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence. Reference: Chapter 1: Introduction to Health Assessment - Page 8
An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? Natural senses Biomedical knowledge Simple technology Critical pathways
Natural senses Early on, nurses relied on their natural senses to perform assessment. Early nursing assessment was based on observation of the client's face and body for changes indicating improvement or deterioration of the client's condition. Chapter 1: Introduction to Health Assessment - Page 8-10
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? Diagnostic reasoning Critical thinking Community care map Nursing process
Nursing process The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are not frameworks for providing individualized care to a community. Chapter 1: Introduction to Health Assessment - Page 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
Uses evidence-based techniques 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 Chapter 1: Introduction to Health Assessment - Page 4
The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply. Validate data Document data Collect objective data Analyze outcome data Collect subjective data
Validate data Document data Collect objective data Collect subjective data Explanation: The assessment phase of the nursing process has four major steps: collect subjective data; collect objective data; validate data; and document data. Analyzing outcome data is performed during the evaluation phase of the nursing process. Reference: Chapter 1: Introduction to Health Assessment - Page 12
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
perform a physical examination 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. Chapter 1: Introduction to Health Assessment - Page 4