HEALTH ASSESSMENT FINAL EXAM
QUESTIONS AND CORRECT ANSWERS
AA2nurseA2onA2aA2postsurgicalA2unitA2isA2admittingA2aA2clientA2followingA2theA2client'sA2chol
ecystectomyA2(gallA2bladderA2removal).A2WhatA2isA2theA2overallA2purposeA2ofA2assessmen
tA2forA2thisA2client?A2-A2Ans--MakingA2clinicalA2judgments
AA2clientA2hasA2presentedA2toA2theA2emergencyA2departmentA2(ED)A2withA2complaintsA2ofA
2abdominalA2pain.A2WhichA2memberA2ofA2theA2careA2teamA2wouldA2mostA2likelyA2beA2resp
onsibleA2forA2collectingA2theA2subjectiveA2dataA2onA2theA2clientA2duringA2theA2initialA2compr
ehensiveA2assessment?A2-A2Ans--EDA2nurse
TheA2nurseA2hasA2completedA2anA2initialA2assessmentA2ofA2aA2newlyA2admittedA2clientA2an
dA2isA2applyingA2theA2nursingA2processA2toA2planA2theA2client'sA2care.A2WhatA2principleA2sh
ouldA2theA2nurseA2applyA2whenA2usingA2theA2nursingA2process?A2-A2Ans--
ItA2isA2ongoingA2andA2continuous.
TheA2nurseA2whoA2providesA2careA2atA2anA2ambulatoryA2clinicA2isA2preparingA2toA2meetA2a
A2clientA2andA2performA2aA2comprehensiveA2healthA2assessment.A2WhichA2ofA2theA2followi
ngA2actionsA2shouldA2theA2nurseA2performA2first?A2-A2Ans--
ReviewA2theA2client'sA2medicalA2record.
WhichA2ofA2theA2followingA2clientA2situationsA2wouldA2theA2nurseA2interpretA2asA2requiringA
2anA2emergencyA2assessment?A2-A2Ans--AA2clientA2whoA2overdosedA2onA2acetaminophen
InA2responseA2toA2aA2client'sA2query,A2theA2nurseA2isA2explainingA2theA2differencesA2betwe
enA2theA2physician'sA2medicalA2examA2andA2theA2comprehensiveA2healthA2assessmentA2p
erformedA2byA2theA2nurse.A2TheA2nurseA2shouldA2describeA2theA2factA2thatA2theA2nursingA2
assessmentA2focusesA2onA2whichA2aspectA2ofA2theA2client'sA2situation?A2-A2Ans--
EffectA2ofA2healthA2onA2functionalA2status
AfterA2teachingA2aA2groupA2ofA2studentsA2aboutA2theA2phasesA2ofA2theA2nursingA2process,A
2theA2instructorA2determinesA2thatA2theA2teachingA2wasA2successfulA2whenA2theA2students
A2identifyA2whichA2phaseA2asA2beingA2foundationalA2toA2allA2otherA2phases?A2-A2Ans--
Assessment
TheA2nurseA2hasA2completedA2theA2comprehensiveA2healthA2assessmentA2ofA2aA2clientA2w
hoA2hasA2beenA2admittedA2forA2theA2treatmentA2ofA2community-
acquiredA2pneumonia.A2FollowingA2theA2completionA2ofA2thisA2assessment,A2theA2nurseA2
periodicallyA2performsA2aA2partialA2assessmentA2primarilyA2forA2whichA2reason?A2-A2Ans--
ReassessA2previouslyA2detectedA2problems
TheA2nurseA2isA2workingA2inA2anA2ambulatoryA2careA2clinicA2thatA2isA2locatedA2inA2aA2busy,
A2inner-
,cityA2neighborhood.A2WhichA2clientA2wouldA2theA2nurseA2determineA2toA2beA2inA2mostA2ne
edA2ofA2anA2emergencyA2assessment?A2-A2Ans--AA245-year-
oldA2manA2withA2chestA2painA2andA2diaphoresisA2forA21A2hour
AA2nurseA2hasA2completedA2gatheringA2someA2basicA2dataA2aboutA2aA2clientA2whoA2hasA2
multipleA2healthA2problemsA2thatA2stemA2fromA2heavyA2alcoholA2use.A2TheA2nurseA2hasA2t
henA2reflectedA2onA2herA2personalA2feelingsA2aboutA2theA2clientA2andA2hisA2circumstances
.A2TheA2nurseA2doesA2thisA2primarilyA2toA2accomplishA2whichA2ofA2theA2following?A2-
A2Ans--AvoidA2biasesA2andA2judgments
TheA2nurseA2isA2collectingA2dataA2fromA2aA2clientA2whoA2hasA2recentlyA2beenA2diagnosedA
2withA2typeA21A2diabetesA2andA2whoA2willA2beginA2anA2educationalA2program.A2TheA2nurse
A2isA2collectingA2subjectiveA2andA2objectiveA2data.A2WhichA2ofA2theA2followingA2wouldA2the
A2nurseA2categorizeA2asA2objectiveA2data?A2-A2Ans--Appearance
AnA2olderA2adultA2clientA2hasA2beenA2admittedA2toA2theA2hospitalA2withA2failureA2toA2thriveA
2resultingA2fromA2complicationsA2ofA2diabetes.A2WhichA2ofA2theA2followingA2wouldA2theA2nu
rseA2implementA2inA2responseA2toA2aA2collaborativeA2problem?A2-A2Ans--
MeasureA2theA2client'sA2bloodA2glucoseA2fourA2timesA2daily.
TheA2nurseA2atA2aA2busyA2primaryA2careA2clinicA2isA2analyzingA2theA2dataA2obtainedA2from
A2theA2followingA2clients.A2ForA2whichA2clientsA2wouldA2theA2nurseA2mostA2likelyA2expectA2t
oA2facilitateA2aA2referral?A2-A2Ans--AA250-year-
oldA2clientA2newlyA2diagnosedA2withA2diabetes
AnA2instructorA2isA2reviewingA2theA2evolutionA2ofA2theA2nurse'sA2roleA2inA2healthA2assessm
ent.A2TheA2instructorA2determinesA2thatA2theA2teachingA2wasA2successfulA2whenA2theA2stu
dentsA2identifyA2whichA2ofA2theA2followingA2asA2theA2majorA2methodA2usedA2byA2nursesA2e
arlyA2inA2theA2historyA2ofA2theA2profession?A2-A2Ans--NaturalA2senses
WhenA2describingA2theA2expansionA2ofA2theA2depthA2andA2scopeA2ofA2nursingA2assessme
ntA2overA2theA2pastA2severalA2decades,A2whichA2ofA2theA2followingA2wouldA2theA2nurseA2id
entifyA2asA2beingA2theA2primaryA2force?A2-A2Ans--Technology
AA2groupA2ofA2nursesA2areA2reviewingA2informationA2aboutA2theA2potentialA2opportunitiesA2
forA2nursesA2whoA2haveA2advancedA2assessmentA2skills.A2WhenA2discussingA2phenomen
aA2thatA2haveA2contributedA2toA2theseA2increasedA2opportunities,A2whatA2shouldA2theA2nur
sesA2identify?A2-A2Ans--ExpansionA2ofA2healthA2careA2networks
AA2nurseA2hasA2documentedA2theA2findingsA2ofA2aA2comprehensiveA2assessmentA2ofA2aA2
newA2client.A2WhatA2isA2theA2primaryA2rationaleA2thatA2theA2nurseA2shouldA2identifyA2forA2a
ccurateA2andA2thoroughA2documentation?A2-A2Ans--
AssuringA2validA2conclusionsA2fromA2analyzedA2data
AA2nurseA2hasA2receivedA2aA2reportA2onA2aA2clientA2whoA2willA2soonA2beA2admittedA2toA2the
A2medicalA2unitA2fromA2theA2emergencyA2department.A2WhenA2preparingA2forA2theA2asses
,smentA2phaseA2ofA2theA2nursingA2process,A2whichA2ofA2theA2followingA2shouldA2theA2nurse
A2doA2first?A2-A2Ans--CollectA2subjectiveA2data.
AA2communityA2healthA2nurseA2isA2assessingA2anA2olderA2adultA2clientA2inA2theA2client'sA2h
ome.A2WhenA2theA2nurseA2isA2gatheringA2subjectiveA2data,A2whichA2ofA2theA2followingA2wo
uldA2theA2nurseA2identify?A2-A2Ans--TheA2client'sA2feelingsA2ofA2happiness
AA2nurseA2onA2theA2hospital'sA2subacuteA2medicalA2unitA2isA2planningA2toA2performA2aA2cli
ent'sA2focusedA2assessment.A2WhichA2ofA2theA2followingA2statementsA2shouldA2informA2th
eA2nurse'sA2practice?A2-A2Ans--
TheA2focusedA2assessmentA2addressesA2aA2particularA2clientA2problem.
AA2nurseA2isA2completingA2anA2assessmentA2thatA2willA2involveA2gatheringA2subjectiveA2an
dA2objectiveA2data.A2WhichA2ofA2theA2followingA2assessmentA2techniquesA2willA2bestA2allo
wA2theA2nurseA2toA2collectA2objectiveA2data?A2-A2Ans--Inspection
TheA2nurseA2isA2performingA2aA2healthA2assessmentA2onA2aA2community-
dwellingA2clientA2whoA2isA2recoveringA2fromA2hipA2replacementA2surgery.A2WhichA2ofA2theA
2followingA2actionsA2shouldA2theA2nurseA2prioritizeA2duringA2assessment?A2-A2Ans--
InterpretA2theA2informationA2aboutA2theA2clientA2inA2context.
AA2clientA2comesA2toA2theA2healthA2careA2provider'sA2officeA2forA2aA2visit.A2TheA2clientA2has
A2beenA2seenA2inA2thisA2officeA2onA2occasionA2forA2theA2pastA25A2yearsA2andA2arrivesA2toda
yA2complainingA2ofA2aA2feverA2andA2soreA2throat.A2WhichA2typeA2ofA2assessmentA2wouldA2t
heA2nurseA2mostA2likelyA2perform?A2-A2Ans--FocusedA2assessment
AA2nurseA2hasA2assessedA2aA2clientA2whoA2wasA2admittedA2toA2theA2medicalA2unitA2toA2tre
atA2acuteA2complicationsA2ofA2typeA21A2diabetes.A2DuringA2theA2assessment,A2theA2clientA2
admittedA2thatA2hisA2bloodA2sugarA2monitoringA2whenA2heA2isA2atA2homeA2isA2ìaA2bitA2spor
adic.îA2HowA2shouldA2theA2nurseA2bestA2respondA2toA2thisA2assessmentA2finding?A2-
A2Ans--IdentifyA2aA2nursingA2diagnosisA2ofA2IneffectiveA2HealthA2Maintenance.
TheA2nurseA2isA2utilizingA2theA2HealthA2BeliefA2ModelA2inA2theA2careA2ofA2aA2clientA2whoseA
2typeA21A2diabetesA2isA2inadequatelyA2controlled.A2WhenA2implementingA2thisA2model,A2th
eA2nurseA2shouldA2beginA2byA2assessingA2whichA2ofA2theA2following?A2-A2Ans--
TheA2client'sA2motivationA2forA2change
AA2nurseA2willA2completeA2anA2initialA2comprehensiveA2assessmentA2ofA2aA260-year-
oldA2clientA2whoA2isA2newA2toA2theA2clinic.A2WhatA2goalA2shouldA2theA2nurseA2identifyA2forA2
thisA2typeA2ofA2assessment?A2-A2Ans--
EstablishA2aA2baselineA2forA2theA2comparisonA2ofA2futureA2healthA2changes.
AA2nurseA2whoA2providesA2careA2inA2aA2hospitalA2settingA2isA2creatingA2aA2planA2ofA2nursin
gA2careA2forA2aA2clientA2whoA2hasA2aA2diagnosisA2ofA2chronicA2renalA2failure.A2TheA2nurse's
A2planA2specifiesA2frequentA2ongoingA2assessments.A2TheA2frequencyA2ofA2theseA2nursing
, assessmentsA2shouldA2beA2primarilyA2determinedA2byA2whatA2variable?A2-A2Ans--
A2
TheA2client'sA2acuity
AA2clientA2whoA2isA2newA2toA2theA2facilityA2hasA2aA2recentA2historyA2ofA2chronicA2painA2thatA
2isA2attributedA2toA2fibromyalgia.A2TheA2nurseA2hasA2reviewedA2theA2availableA2healthA2rec
ordsA2andA2suspectsA2thatA2painA2managementA2willA2beA2aA2majorA2focusA2ofA2nursingA2c
are.A2HowA2canA2theA2nurseA2bestA2validateA2thisA2assumption?A2-A2Ans--
AskA2theA2clientA2aboutA2theA2mostA2recentA2experiencesA2ofA2pain.
AA2nurseA2isA2preparingA2toA2assessA2anA2adultA2client'sA2bodyA2temperature.A2AtA2whichA2
timeA2ofA2theA2dayA2wouldA2theA2nurseA2expectA2toA2obtainA2theA2lowestA2bodyA2temperatu
re?A2-A2Ans--EarlyA2morning
TheA2nurseA2isA2preparingA2toA2assessA2aA2client'sA2vitalA2signs.A2WhichA2vitalA2signA2shou
ldA2theA2nurseA2assessA2first?A2-A2Ans--Temperature
AA2nurseA2isA2reviewingA2aA2colleague'sA2documentationA2ofA2aA2clientA2assessment.A2Th
eA2nurseA2readsA2thatA2theA2client'sA2radialA2pulseA2wasA22+.A2HowA2shouldA2theA2nurseA2i
nterpretA2thisA2assessmentA2finding?A2-A2Ans--
TheA2client'sA2radialA2pulseA2occludedA2withA2moderateA2pressure.
TheA2nurseA2isA2conductingA2anA2assessmentA2ofA2anA2olderA2adultA2clientA2whoA2hasA2aA2
diagnosisA2ofA2chronicA2heartA2failure.A2HowA2canA2theA2nurseA2bestA2assessA2theA2effects
A2ofA2theA2client'sA2strokeA2volume?A2-A2Ans--
CalculateA2theA2differenceA2betweenA2theA2diastolicA2andA2systolicA2pressures.
AA2nurseA2obtainsA2theA2bloodA2pressureA2ofA2aA2clientA2whoA2isA2uncharacteristicallyA2fati
guedA2andA2whoA2isA2lyingA2inA2bedA2ratherA2thanA2sittingA2inA2aA2chair.A2TheA2nurseA2shou
ldA2interpretA2theA2client'sA2bloodA2pressureA2readingA2inA2lightA2ofA2whatA2principle?A2-
A2Ans--
TheA2client'sA2bloodA2pressureA2willA2beA2slightlyA2lowerA2thanA2standingA2readings.
TheA2nurseA2isA2completingA2anA2initialA2assessmentA2ofA2aA2clientA2whoA2isA2newA2toA2the
A2ambulatoryA2clinic.A2BeforeA2assessingA2theA2client'sA2bloodA2pressure,A2aA2nurseA2asks
A2himA2whatA2hisA2usualA2bloodA2pressureA2is.A2TheA2nurseA2basesA2thisA2actionA2primarily
A2onA2whatA2rationale?A2-A2Ans--
ItA2indicatesA2theA2client'sA2involvementA2inA2hisA2healthA2care.
TheA2nurseA2hasA2begunA2aA2client'sA2assessmentA2andA2isA2applyingA2theA2bloodA2press
ureA2cuffA2onA2aA2client'sA2arm.A2WhichA2actionA2wouldA2beA2mostA2appropriate?A2-A2Ans--
TheA2cuffA2isA2placedA2aboutA21A2inchA2aboveA2theA2antecubitalA2area.
WhichA2ofA2theA2followingA2wouldA2beA2mostA2importantA2forA2theA2nurseA2toA2doA2whenA2a
ssessingA2aA2client'sA2bloodA2pressure?A2-A2Ans--
InflateA2theA2cuffA230A2mmA2HgA2aboveA2whereA2theA2radialA2pulseA2disappears.
QUESTIONS AND CORRECT ANSWERS
AA2nurseA2onA2aA2postsurgicalA2unitA2isA2admittingA2aA2clientA2followingA2theA2client'sA2chol
ecystectomyA2(gallA2bladderA2removal).A2WhatA2isA2theA2overallA2purposeA2ofA2assessmen
tA2forA2thisA2client?A2-A2Ans--MakingA2clinicalA2judgments
AA2clientA2hasA2presentedA2toA2theA2emergencyA2departmentA2(ED)A2withA2complaintsA2ofA
2abdominalA2pain.A2WhichA2memberA2ofA2theA2careA2teamA2wouldA2mostA2likelyA2beA2resp
onsibleA2forA2collectingA2theA2subjectiveA2dataA2onA2theA2clientA2duringA2theA2initialA2compr
ehensiveA2assessment?A2-A2Ans--EDA2nurse
TheA2nurseA2hasA2completedA2anA2initialA2assessmentA2ofA2aA2newlyA2admittedA2clientA2an
dA2isA2applyingA2theA2nursingA2processA2toA2planA2theA2client'sA2care.A2WhatA2principleA2sh
ouldA2theA2nurseA2applyA2whenA2usingA2theA2nursingA2process?A2-A2Ans--
ItA2isA2ongoingA2andA2continuous.
TheA2nurseA2whoA2providesA2careA2atA2anA2ambulatoryA2clinicA2isA2preparingA2toA2meetA2a
A2clientA2andA2performA2aA2comprehensiveA2healthA2assessment.A2WhichA2ofA2theA2followi
ngA2actionsA2shouldA2theA2nurseA2performA2first?A2-A2Ans--
ReviewA2theA2client'sA2medicalA2record.
WhichA2ofA2theA2followingA2clientA2situationsA2wouldA2theA2nurseA2interpretA2asA2requiringA
2anA2emergencyA2assessment?A2-A2Ans--AA2clientA2whoA2overdosedA2onA2acetaminophen
InA2responseA2toA2aA2client'sA2query,A2theA2nurseA2isA2explainingA2theA2differencesA2betwe
enA2theA2physician'sA2medicalA2examA2andA2theA2comprehensiveA2healthA2assessmentA2p
erformedA2byA2theA2nurse.A2TheA2nurseA2shouldA2describeA2theA2factA2thatA2theA2nursingA2
assessmentA2focusesA2onA2whichA2aspectA2ofA2theA2client'sA2situation?A2-A2Ans--
EffectA2ofA2healthA2onA2functionalA2status
AfterA2teachingA2aA2groupA2ofA2studentsA2aboutA2theA2phasesA2ofA2theA2nursingA2process,A
2theA2instructorA2determinesA2thatA2theA2teachingA2wasA2successfulA2whenA2theA2students
A2identifyA2whichA2phaseA2asA2beingA2foundationalA2toA2allA2otherA2phases?A2-A2Ans--
Assessment
TheA2nurseA2hasA2completedA2theA2comprehensiveA2healthA2assessmentA2ofA2aA2clientA2w
hoA2hasA2beenA2admittedA2forA2theA2treatmentA2ofA2community-
acquiredA2pneumonia.A2FollowingA2theA2completionA2ofA2thisA2assessment,A2theA2nurseA2
periodicallyA2performsA2aA2partialA2assessmentA2primarilyA2forA2whichA2reason?A2-A2Ans--
ReassessA2previouslyA2detectedA2problems
TheA2nurseA2isA2workingA2inA2anA2ambulatoryA2careA2clinicA2thatA2isA2locatedA2inA2aA2busy,
A2inner-
,cityA2neighborhood.A2WhichA2clientA2wouldA2theA2nurseA2determineA2toA2beA2inA2mostA2ne
edA2ofA2anA2emergencyA2assessment?A2-A2Ans--AA245-year-
oldA2manA2withA2chestA2painA2andA2diaphoresisA2forA21A2hour
AA2nurseA2hasA2completedA2gatheringA2someA2basicA2dataA2aboutA2aA2clientA2whoA2hasA2
multipleA2healthA2problemsA2thatA2stemA2fromA2heavyA2alcoholA2use.A2TheA2nurseA2hasA2t
henA2reflectedA2onA2herA2personalA2feelingsA2aboutA2theA2clientA2andA2hisA2circumstances
.A2TheA2nurseA2doesA2thisA2primarilyA2toA2accomplishA2whichA2ofA2theA2following?A2-
A2Ans--AvoidA2biasesA2andA2judgments
TheA2nurseA2isA2collectingA2dataA2fromA2aA2clientA2whoA2hasA2recentlyA2beenA2diagnosedA
2withA2typeA21A2diabetesA2andA2whoA2willA2beginA2anA2educationalA2program.A2TheA2nurse
A2isA2collectingA2subjectiveA2andA2objectiveA2data.A2WhichA2ofA2theA2followingA2wouldA2the
A2nurseA2categorizeA2asA2objectiveA2data?A2-A2Ans--Appearance
AnA2olderA2adultA2clientA2hasA2beenA2admittedA2toA2theA2hospitalA2withA2failureA2toA2thriveA
2resultingA2fromA2complicationsA2ofA2diabetes.A2WhichA2ofA2theA2followingA2wouldA2theA2nu
rseA2implementA2inA2responseA2toA2aA2collaborativeA2problem?A2-A2Ans--
MeasureA2theA2client'sA2bloodA2glucoseA2fourA2timesA2daily.
TheA2nurseA2atA2aA2busyA2primaryA2careA2clinicA2isA2analyzingA2theA2dataA2obtainedA2from
A2theA2followingA2clients.A2ForA2whichA2clientsA2wouldA2theA2nurseA2mostA2likelyA2expectA2t
oA2facilitateA2aA2referral?A2-A2Ans--AA250-year-
oldA2clientA2newlyA2diagnosedA2withA2diabetes
AnA2instructorA2isA2reviewingA2theA2evolutionA2ofA2theA2nurse'sA2roleA2inA2healthA2assessm
ent.A2TheA2instructorA2determinesA2thatA2theA2teachingA2wasA2successfulA2whenA2theA2stu
dentsA2identifyA2whichA2ofA2theA2followingA2asA2theA2majorA2methodA2usedA2byA2nursesA2e
arlyA2inA2theA2historyA2ofA2theA2profession?A2-A2Ans--NaturalA2senses
WhenA2describingA2theA2expansionA2ofA2theA2depthA2andA2scopeA2ofA2nursingA2assessme
ntA2overA2theA2pastA2severalA2decades,A2whichA2ofA2theA2followingA2wouldA2theA2nurseA2id
entifyA2asA2beingA2theA2primaryA2force?A2-A2Ans--Technology
AA2groupA2ofA2nursesA2areA2reviewingA2informationA2aboutA2theA2potentialA2opportunitiesA2
forA2nursesA2whoA2haveA2advancedA2assessmentA2skills.A2WhenA2discussingA2phenomen
aA2thatA2haveA2contributedA2toA2theseA2increasedA2opportunities,A2whatA2shouldA2theA2nur
sesA2identify?A2-A2Ans--ExpansionA2ofA2healthA2careA2networks
AA2nurseA2hasA2documentedA2theA2findingsA2ofA2aA2comprehensiveA2assessmentA2ofA2aA2
newA2client.A2WhatA2isA2theA2primaryA2rationaleA2thatA2theA2nurseA2shouldA2identifyA2forA2a
ccurateA2andA2thoroughA2documentation?A2-A2Ans--
AssuringA2validA2conclusionsA2fromA2analyzedA2data
AA2nurseA2hasA2receivedA2aA2reportA2onA2aA2clientA2whoA2willA2soonA2beA2admittedA2toA2the
A2medicalA2unitA2fromA2theA2emergencyA2department.A2WhenA2preparingA2forA2theA2asses
,smentA2phaseA2ofA2theA2nursingA2process,A2whichA2ofA2theA2followingA2shouldA2theA2nurse
A2doA2first?A2-A2Ans--CollectA2subjectiveA2data.
AA2communityA2healthA2nurseA2isA2assessingA2anA2olderA2adultA2clientA2inA2theA2client'sA2h
ome.A2WhenA2theA2nurseA2isA2gatheringA2subjectiveA2data,A2whichA2ofA2theA2followingA2wo
uldA2theA2nurseA2identify?A2-A2Ans--TheA2client'sA2feelingsA2ofA2happiness
AA2nurseA2onA2theA2hospital'sA2subacuteA2medicalA2unitA2isA2planningA2toA2performA2aA2cli
ent'sA2focusedA2assessment.A2WhichA2ofA2theA2followingA2statementsA2shouldA2informA2th
eA2nurse'sA2practice?A2-A2Ans--
TheA2focusedA2assessmentA2addressesA2aA2particularA2clientA2problem.
AA2nurseA2isA2completingA2anA2assessmentA2thatA2willA2involveA2gatheringA2subjectiveA2an
dA2objectiveA2data.A2WhichA2ofA2theA2followingA2assessmentA2techniquesA2willA2bestA2allo
wA2theA2nurseA2toA2collectA2objectiveA2data?A2-A2Ans--Inspection
TheA2nurseA2isA2performingA2aA2healthA2assessmentA2onA2aA2community-
dwellingA2clientA2whoA2isA2recoveringA2fromA2hipA2replacementA2surgery.A2WhichA2ofA2theA
2followingA2actionsA2shouldA2theA2nurseA2prioritizeA2duringA2assessment?A2-A2Ans--
InterpretA2theA2informationA2aboutA2theA2clientA2inA2context.
AA2clientA2comesA2toA2theA2healthA2careA2provider'sA2officeA2forA2aA2visit.A2TheA2clientA2has
A2beenA2seenA2inA2thisA2officeA2onA2occasionA2forA2theA2pastA25A2yearsA2andA2arrivesA2toda
yA2complainingA2ofA2aA2feverA2andA2soreA2throat.A2WhichA2typeA2ofA2assessmentA2wouldA2t
heA2nurseA2mostA2likelyA2perform?A2-A2Ans--FocusedA2assessment
AA2nurseA2hasA2assessedA2aA2clientA2whoA2wasA2admittedA2toA2theA2medicalA2unitA2toA2tre
atA2acuteA2complicationsA2ofA2typeA21A2diabetes.A2DuringA2theA2assessment,A2theA2clientA2
admittedA2thatA2hisA2bloodA2sugarA2monitoringA2whenA2heA2isA2atA2homeA2isA2ìaA2bitA2spor
adic.îA2HowA2shouldA2theA2nurseA2bestA2respondA2toA2thisA2assessmentA2finding?A2-
A2Ans--IdentifyA2aA2nursingA2diagnosisA2ofA2IneffectiveA2HealthA2Maintenance.
TheA2nurseA2isA2utilizingA2theA2HealthA2BeliefA2ModelA2inA2theA2careA2ofA2aA2clientA2whoseA
2typeA21A2diabetesA2isA2inadequatelyA2controlled.A2WhenA2implementingA2thisA2model,A2th
eA2nurseA2shouldA2beginA2byA2assessingA2whichA2ofA2theA2following?A2-A2Ans--
TheA2client'sA2motivationA2forA2change
AA2nurseA2willA2completeA2anA2initialA2comprehensiveA2assessmentA2ofA2aA260-year-
oldA2clientA2whoA2isA2newA2toA2theA2clinic.A2WhatA2goalA2shouldA2theA2nurseA2identifyA2forA2
thisA2typeA2ofA2assessment?A2-A2Ans--
EstablishA2aA2baselineA2forA2theA2comparisonA2ofA2futureA2healthA2changes.
AA2nurseA2whoA2providesA2careA2inA2aA2hospitalA2settingA2isA2creatingA2aA2planA2ofA2nursin
gA2careA2forA2aA2clientA2whoA2hasA2aA2diagnosisA2ofA2chronicA2renalA2failure.A2TheA2nurse's
A2planA2specifiesA2frequentA2ongoingA2assessments.A2TheA2frequencyA2ofA2theseA2nursing
, assessmentsA2shouldA2beA2primarilyA2determinedA2byA2whatA2variable?A2-A2Ans--
A2
TheA2client'sA2acuity
AA2clientA2whoA2isA2newA2toA2theA2facilityA2hasA2aA2recentA2historyA2ofA2chronicA2painA2thatA
2isA2attributedA2toA2fibromyalgia.A2TheA2nurseA2hasA2reviewedA2theA2availableA2healthA2rec
ordsA2andA2suspectsA2thatA2painA2managementA2willA2beA2aA2majorA2focusA2ofA2nursingA2c
are.A2HowA2canA2theA2nurseA2bestA2validateA2thisA2assumption?A2-A2Ans--
AskA2theA2clientA2aboutA2theA2mostA2recentA2experiencesA2ofA2pain.
AA2nurseA2isA2preparingA2toA2assessA2anA2adultA2client'sA2bodyA2temperature.A2AtA2whichA2
timeA2ofA2theA2dayA2wouldA2theA2nurseA2expectA2toA2obtainA2theA2lowestA2bodyA2temperatu
re?A2-A2Ans--EarlyA2morning
TheA2nurseA2isA2preparingA2toA2assessA2aA2client'sA2vitalA2signs.A2WhichA2vitalA2signA2shou
ldA2theA2nurseA2assessA2first?A2-A2Ans--Temperature
AA2nurseA2isA2reviewingA2aA2colleague'sA2documentationA2ofA2aA2clientA2assessment.A2Th
eA2nurseA2readsA2thatA2theA2client'sA2radialA2pulseA2wasA22+.A2HowA2shouldA2theA2nurseA2i
nterpretA2thisA2assessmentA2finding?A2-A2Ans--
TheA2client'sA2radialA2pulseA2occludedA2withA2moderateA2pressure.
TheA2nurseA2isA2conductingA2anA2assessmentA2ofA2anA2olderA2adultA2clientA2whoA2hasA2aA2
diagnosisA2ofA2chronicA2heartA2failure.A2HowA2canA2theA2nurseA2bestA2assessA2theA2effects
A2ofA2theA2client'sA2strokeA2volume?A2-A2Ans--
CalculateA2theA2differenceA2betweenA2theA2diastolicA2andA2systolicA2pressures.
AA2nurseA2obtainsA2theA2bloodA2pressureA2ofA2aA2clientA2whoA2isA2uncharacteristicallyA2fati
guedA2andA2whoA2isA2lyingA2inA2bedA2ratherA2thanA2sittingA2inA2aA2chair.A2TheA2nurseA2shou
ldA2interpretA2theA2client'sA2bloodA2pressureA2readingA2inA2lightA2ofA2whatA2principle?A2-
A2Ans--
TheA2client'sA2bloodA2pressureA2willA2beA2slightlyA2lowerA2thanA2standingA2readings.
TheA2nurseA2isA2completingA2anA2initialA2assessmentA2ofA2aA2clientA2whoA2isA2newA2toA2the
A2ambulatoryA2clinic.A2BeforeA2assessingA2theA2client'sA2bloodA2pressure,A2aA2nurseA2asks
A2himA2whatA2hisA2usualA2bloodA2pressureA2is.A2TheA2nurseA2basesA2thisA2actionA2primarily
A2onA2whatA2rationale?A2-A2Ans--
ItA2indicatesA2theA2client'sA2involvementA2inA2hisA2healthA2care.
TheA2nurseA2hasA2begunA2aA2client'sA2assessmentA2andA2isA2applyingA2theA2bloodA2press
ureA2cuffA2onA2aA2client'sA2arm.A2WhichA2actionA2wouldA2beA2mostA2appropriate?A2-A2Ans--
TheA2cuffA2isA2placedA2aboutA21A2inchA2aboveA2theA2antecubitalA2area.
WhichA2ofA2theA2followingA2wouldA2beA2mostA2importantA2forA2theA2nurseA2toA2doA2whenA2a
ssessingA2aA2client'sA2bloodA2pressure?A2-A2Ans--
InflateA2theA2cuffA230A2mmA2HgA2aboveA2whereA2theA2radialA2pulseA2disappears.
