Nurses Role in Health Assessment Test Exam with Answers, Exams of Nursing

Download Nurses Role in Health Assessment Test Exam with Answers and more Exams Nursing in PDF only on Docsity! NURSES ROLE IN HEALTH ASSESSMENT TEST EXAM WITH ANSWERS .  A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment ? Correct response: Complete health history Explanation: The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an • outpatient basis, • following admission to a hospital • long-term care facility • or as defined in a facility's standards of care in the acute care setting. emergency assessment – includes Circulatory assessment , assessment of the airway, and disability assessment Question 1 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? 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 , Physical assessment is important in the building the foundation of the nursing care plan ; it directs the care that will be provided for the individual client, care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. Question 7 The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? Correct response: Objective Explanation: The physical assessment follows the history and focused interview, and includes objective data, which are measurable. Question 8 An assessment that concentrates on patterns of role performance that all humans share is called what? Correct response: Functional Explanation: 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. Question 9 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? Correct response: environmental Explanation: environment influences conditions to promote health . Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making. Question 10 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? Correct response: Nursing diagnosis Analysis of data or nursing diagnosis, is the second phase of the nursing process. Planning occurs after the data is analyzed. Implementation occurs after planning Evaluation is the final phase of the process. Question 3 What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? Correct response: Collecting data regarding the nature of the pain Explanation: The nurse's initial role in health assessment is to collect data. Teaching - occurs later in the process. Planning care and identifying interventions are parts of the nursing process and NOT the health assessment. Reference: Page 7 STEPS OF HEALTH ASSESSMENT: NURSING PROCESS • collection of subjective data *Assessment • collection of objective data *Diagnosis • validation of data *Planning • documentation of data *Implementation *Evaluation Question 4 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? Correct response: Empathy Explanation: particular client problem, and does not cover areas not related to the problem. emergency assessment is a very rapid assessment performed in life-threatening situations. Reference: p. 6. Question 7 Page 3 of 19 The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? Correct response: Objective Explanation: The physical assessment follows the history and focused interview, and includes objective data, which are measurable. Question 8 A student nurse is learning to document an initial assessment . What would the instructor tell the student that accurate documentation of this specific assessment best provides? Correct response: A baseline for comparison with future findings Explanation: Accurate documentation provides a baseline so that changes are noted between assessments. Reference: p. 6. Question 9 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? Correct response: Airway Page 4 of 19 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: Page 6-7 Question 10 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? Correct response: environmental Explanation: The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making. Question 1 How does a nurse decide what health-promotion activities are necessary for a particular client? 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, Page 7 of 19 Synthesizing collected data Explanation: Health assessment is • "gathering information about the health status of the patient, • analyzing and synthesizing those data, • making judgments about nursing interventions • based on the findings and evaluating patient care outcomes" (AACN, 2008). While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are NOT TO IDENTIFY the patient's major disease process or ability to pay. Question 4 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? 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 Physical assessment is important in the building the foundation of the nursing care plan. Page 8 of 19 Nursing care plan directs the care that will be provided for the individual client Question 5 Page 9 of 19 Which assessment finding should the nurse document as objective data? Correct response: Body functions Explanation: Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.n Reference: Page 8 Question 6 Which of the following is the best example of assessment in everyday life ? 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). Reference: Page 1 Question 7 Page 12 of 19 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: Page 6-7 Question 10 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? 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. Page 13 of 19 Question 1 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? Correct response: To determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. Collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. Rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation – done after an intervention to determine whether the outcomes have been achieved. Reference: Page 6 Question 2 The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? Correct response: Primary Explanation: Page 14 of 19 Primary prevention involves strategies aimed at preventing problems. • Immunizations, • health teaching, • safety precautions, • nutrition counseling Page 17 of 19 Correct response: To establish a database against which subsequent assessments can be measured Explanation: A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against. Reference: Page 10 Page 18 of 19 Question 2 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? 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. Physical therapist assessment focuses mainly on the client's musculoskeletal system and activities of daily living. Reference: Page 4 Question 3 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? correct response: Page 19 of 19 Individual student interview and questionnaire Explanation: Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members. Question 4 Revising the plan as needed occurs in what part of the nursing process? Correct response: Evaluation Explanation: Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs . Assessment is the collection of data. Planning is determining outcome criteria and developing a plan . Reference:Page 4 Question 5 What is paramount in health promotion? (Select all that apply.) Correct response: • Working with the individual patient • Developing the nursing care plan Explanation: Page 22 of 19 Correct response: Head-to-toe Explanation: A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data. Reference:Page 5-6 Question 9 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? 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. Question 10 When the client begins to cry, the nurse recognizes the need to focus the assessment on the Page 23 of 19 client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying? correct response: the rapport that exists between the nurse and the client Reference p. 7. Page 24 of 19 Question 1 An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse? Correct response: Open the client's airway Explanation: All life-threatening problems identified during the initial assessment require the initiation of critical interventions. The nurse opens the client's airway; assists the client's breathing; provides assistance with circulation (CPR if needed); if the client is injured, protects the cervical spine; ensures that the disoriented or suicidal client is safe; and provides pain management and sedation. The client has assessments and critical interventions performed simultaneously as life- threatening problems are treated. Reference:Page 6-7 Question 2 Which of the following statements best conveys the rationale for health promotion in a school setting? Correct response: Healthy child development is a critical health determinant because of its implications for lifelong health. Explanation: The future implications of healthy child development coupled with the fact that children Page 27 of 19 In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. 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. 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. Emergency assessment is a very rapid assessment performed in life-threatening situations. Reference:Page 6 Question 5 When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? Correct response: Diagnosis Explanation: Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data . Planning is determining outcome criteria and developing a plan . Evaluation assesses whether the outcome criteria have been met. Reference:Page 9 Question 6 Page 28 of 19 The client has a headache. What type of data is this? Correct response: Subjective Explanation: Subjective data is what the client states, feels or senses. The nurse cannot observe a headache. Objective data includes data that is measurable. Reference:Page 7-8 Question 7 When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed Correct response: comprehensive. Explanation: Initial comprehensive assessment involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. Reference:Page 5 Page 29 of 19 Question 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 ? 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:Page 2 Question 9 The nurse plans to follow the Health Belief Model when identifying a client’s care needs. On what will the nurse focus when using this model? Select all that apply. Correct response: Sufficient motivation Making a change would be beneficial Belief of being susceptible to a health problem Explanation: Health Belief Model is based on three concepts : Page 32 of 19 Gordon's functional health assessment focuses on the effects of health and illness on a client's overall quality of life. Analytical framework is not a primary framework for conducting a health assessment on a client Reference:Page 4 Question 2 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? Correct response: Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements. Reference:Page 10 Question 3 A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? Correct response: Nursing process Explanation: Nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Reference:Page 2 Page 33 of 19 Question 4 What are the types of nursing assessments? (Select all that apply.) Correct response: Focused Emergency Comprehensiv e 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:p. 5 Question 5 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? Correct response: Head to toe Explanation: head-to-toe method is efficient and provides more modesty for clients. focused assessment is not appropriate for the newly admitted client. Reference:Page 5 Question 6 Page 34 of 19 For which client should a nurse perform a focused assessment? Correct response: Four-day history of sore throat and fever with enlarged lymph nodes Page 37 of 19 Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to Correct response: arrive at conclusions about the client’s health. Explanation: 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:Page 8 Page 38 of 19 Question 10 A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments? Correct response: “Nurses focus on the diagnosis of actual human responses to disease or life events .” Explanation: medical focus is on diagnoses and treatment of the disease. Nurses focus on diagnoses and treatment of the actual or potential human responses to disease or life events. The assessments are NOT the same and are not used to validate collected information . Reference:p. 2. Question 1 A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data . The instructor is teaching about which type of assessment? Correct response: Body systems Explanation: A body systems assessment is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data. Page 39 of 19 The comprehensive assessment is more encompassing in nature, including more aspects that the body systems approach. The head-to-toe assessment does not look at promoting critical thinking and clustering, rather going through a process to organize data in a logical fashion. The emergency assessment involves a life-threatening or unstable situation Question 2 When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be Correct response: "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease ." Explanation: The medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response . Reference:Page 2 Question 3 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? Correct response: Page 42 of 19 The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client’s record, the nurse should 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:Page 7 Question 7 A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? Correct response: Ongoing Explanation: Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline . emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. Page 43 of 19 focused assessment gathers information specific to the problem and does not cover any other areas. comprehensive assessment is not necessary at this time because the client already has a documented problem. Reference:Page 6-7 Page 44 of 19 Question 8 Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility? Correct response: collecting information regarding the client's health status Explanation: Regardless of the care setting, the nurse’s initial role in health assessment is to collect data. Reference:Page 4 Question 9 When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying? Correct response: the rapport that exists between the nurse and the client Explanation: The amount of success that nurse has in discovering the reason behind the client's crying is heavily dependent upon the relationship (rapport) that exists between the nurse and the client. It is this mutual respect and trust that allows the nurse to enter into conversations that would otherwise be off limits. Reference:Page 7 Question 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