Advanced Assessment: Unit 1 Study
Guide Exam with Actual Answers.
Following completion of the comprehensive health assessment, the nurse periodically performs
a partial assessment primarily for which reason? - Answer Reassess previously detected
problems
Explanation:
A periodic partial assessment consists of a mini-overview of the client's body systems and
holistic health patterns as a follow-up on his or her health status. Any problems that were
initially detected in the client's body system or holistic health patterns are reassessed in less
depth to determine any major changes from the baseline data. In addition, a brief reassessment
of the client's normal body system or holistic health patterns is performed whenever the nurse
or another health care professional has an encounter with the client.
What is the primary purpose of health assessment? - Answer To gather information about
the health status of the client
Explanation:
Health assessment is "gathering information about the health status of the client, analyzing and
synthesizing those data, making judgments about nursing interventions based on the findings,
and evaluating client care outcomes" (AACN, 2011). Health assessment is not making judgments
about a client's lifestyle; it does not involve care based on the nurse's views and beliefs, nor
does it help the physician diagnose illness without further testing.
How does a nurse decide what health-promotion activities are necessary for a particular client?
- Answer 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,
nurses collaborate with them to identify areas in which clients are willing to make changes.
When caring for a client, a nurse does not address healthy behaviors only; nurses do not
address only areas where clients are willing to make changes, nor do they construct their own
theories to identify perceptions, barriers, and positive outcomes.
During a health assessment, the nurse learns that an adolescent is sexually active. What
information can the nurse provide the client in order to support the Healthy People 2020
indicator of responsible sexual behavior? - Answer The importance of using a condom when
engaging in sexual activity
Explanation:
An objective to support the Healthy People 2020 indicator of responsible sexual behavior is to
increase the proportion of sexually active persons who use condoms. The nurse should instruct
the patient about condom use with sexual activity. The objectives of Healthy People 2020 do
not include promoting sexual abstinence. While diagnostic testing and reducing the percentage
,of adolescents diagnosed with HIV may be worthwhile goals, they are not identified as such by
Healthy People 2020
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? - Answer To determine any changes from the baseline data
Explanation:
Ongoing or partial assessments help to determine any major changes from the baseline data.
The nurse 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. The nurse makes a rapid assessment for prompt treatment in life-threatening
situations when an immediate diagnosis is needed to provide prompt treatment (emergency
assessment). Evaluation is done after an intervention to determine whether the outcomes have
been achieved.
The nurse has completed the 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? - Answer Reassess previously detected problems
Explanation:
A periodic partial assessment consists of a mini-overview of the client's body systems and
holistic health patterns as a follow-up on health status. Any problems that were initially
detected in the client's body system or holistic health patterns are reassessed in less depth to
determine any major changes from the baseline data. In addition, a brief reassessment of the
client's normal body system or holistic health patterns is performed whenever the nurse or
another health care professional has an encounter with the client.
A client who is new to the facility has a recent history of chronic pain that is attributed to
fibromyalgia. The nurse has reviewed the available health records and suspects that pain
management will be a major focus of nursing care. How can the nurse best validate this
assumption? - Answer Correct response:
Ask the client about the most recent experiences of pain.
Explanation:
Data are best validated by the client. Other sources are valid and useful, but the client is the
ultimate source, especially in the case of subjective data.
The nurse is exhibiting critical thinking in which client care situation? - Answer Performing a
focused assessment on a client who is complaining of shortness of breath.
Explanation:
The nurse investigating a client problem by performing a focused assessment is exhibiting
critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are
not examples of critical thinking that entail outcome-directed thinking based on the nursing
process.
, Why is the nurse always reassessing the patient for changes? - Answer To achieve the best
results
Explanation:
The nurse or detective is always reassessing the patient or case for changes in order to achieve
the best results. Each relies on both the science and art of his or her respective profession.
The result of a nursing assessment is the - Answer Formulation of nursing diagnoses.
Explanation:
Analysis of data (often called nursing diagnosis) is the second phase of the nursing process.
Analysis of the collected data goes hand in hand with the rationale for performing a nursing
assessment. The purpose of assessment is to arrive at conclusions about the client's health. To
arrive at conclusions, the nurse must analyze the assessment data.
A nurse provides care for a client with an elevated temperature. The client is given the
prescribed medication and the nurse checks the client's temperature at repeated intervals.
What step of the nursing process is the nurse using to determine if the client has achieved the
outcome criteria of the treatment? - Answer Evaluation
Explanation:
The evaluation stage of the nursing process involves assessing whether the outcome criteria
have been met and the nursing care plan needs to be revised. The assessment stage involves
collecting subjective and objective data. The diagnosis phase involves analyzing subjective and
objective data to make a professional nursing judgment. The implementation phase involves
carrying out the plan to meet the determined outcome criteria.
For which client should a nurse perform a focused assessment? - Answer Four-day history of
sore throat and fever with enlarged lymph nodes
Explanation:
A client with a sore throat and fever with enlarged lymph nodes requires only a focused
assessment by the nurse. A focused assessment consists of a thorough assessment of a
particular client problem. An elevated blood pressure with no previous history of heart
problems requires an initial or comprehensive assessment. Right upper abdominal pain that
radiates into the groin area is an emergency situation and the nurse should collect only the data
necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a
chronic, ongoing health problem that needs reassessment and possibly a change in treatment.
What will be the nurse's initial role when conducting a health assessment with a client reporting
abdominal pain? - Answer Collecting data regarding the nature of the pain
Explanation:
The nurse's initial role in health assessment is to collect data. Teaching would occur later in the
process. Planning care and identifying interventions are parts of the nursing process and not the
health assessment.
Guide Exam with Actual Answers.
Following completion of the comprehensive health assessment, the nurse periodically performs
a partial assessment primarily for which reason? - Answer Reassess previously detected
problems
Explanation:
A periodic partial assessment consists of a mini-overview of the client's body systems and
holistic health patterns as a follow-up on his or her health status. Any problems that were
initially detected in the client's body system or holistic health patterns are reassessed in less
depth to determine any major changes from the baseline data. In addition, a brief reassessment
of the client's normal body system or holistic health patterns is performed whenever the nurse
or another health care professional has an encounter with the client.
What is the primary purpose of health assessment? - Answer To gather information about
the health status of the client
Explanation:
Health assessment is "gathering information about the health status of the client, analyzing and
synthesizing those data, making judgments about nursing interventions based on the findings,
and evaluating client care outcomes" (AACN, 2011). Health assessment is not making judgments
about a client's lifestyle; it does not involve care based on the nurse's views and beliefs, nor
does it help the physician diagnose illness without further testing.
How does a nurse decide what health-promotion activities are necessary for a particular client?
- Answer 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,
nurses collaborate with them to identify areas in which clients are willing to make changes.
When caring for a client, a nurse does not address healthy behaviors only; nurses do not
address only areas where clients are willing to make changes, nor do they construct their own
theories to identify perceptions, barriers, and positive outcomes.
During a health assessment, the nurse learns that an adolescent is sexually active. What
information can the nurse provide the client in order to support the Healthy People 2020
indicator of responsible sexual behavior? - Answer The importance of using a condom when
engaging in sexual activity
Explanation:
An objective to support the Healthy People 2020 indicator of responsible sexual behavior is to
increase the proportion of sexually active persons who use condoms. The nurse should instruct
the patient about condom use with sexual activity. The objectives of Healthy People 2020 do
not include promoting sexual abstinence. While diagnostic testing and reducing the percentage
,of adolescents diagnosed with HIV may be worthwhile goals, they are not identified as such by
Healthy People 2020
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? - Answer To determine any changes from the baseline data
Explanation:
Ongoing or partial assessments help to determine any major changes from the baseline data.
The nurse 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. The nurse makes a rapid assessment for prompt treatment in life-threatening
situations when an immediate diagnosis is needed to provide prompt treatment (emergency
assessment). Evaluation is done after an intervention to determine whether the outcomes have
been achieved.
The nurse has completed the 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? - Answer Reassess previously detected problems
Explanation:
A periodic partial assessment consists of a mini-overview of the client's body systems and
holistic health patterns as a follow-up on health status. Any problems that were initially
detected in the client's body system or holistic health patterns are reassessed in less depth to
determine any major changes from the baseline data. In addition, a brief reassessment of the
client's normal body system or holistic health patterns is performed whenever the nurse or
another health care professional has an encounter with the client.
A client who is new to the facility has a recent history of chronic pain that is attributed to
fibromyalgia. The nurse has reviewed the available health records and suspects that pain
management will be a major focus of nursing care. How can the nurse best validate this
assumption? - Answer Correct response:
Ask the client about the most recent experiences of pain.
Explanation:
Data are best validated by the client. Other sources are valid and useful, but the client is the
ultimate source, especially in the case of subjective data.
The nurse is exhibiting critical thinking in which client care situation? - Answer Performing a
focused assessment on a client who is complaining of shortness of breath.
Explanation:
The nurse investigating a client problem by performing a focused assessment is exhibiting
critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are
not examples of critical thinking that entail outcome-directed thinking based on the nursing
process.
, Why is the nurse always reassessing the patient for changes? - Answer To achieve the best
results
Explanation:
The nurse or detective is always reassessing the patient or case for changes in order to achieve
the best results. Each relies on both the science and art of his or her respective profession.
The result of a nursing assessment is the - Answer Formulation of nursing diagnoses.
Explanation:
Analysis of data (often called nursing diagnosis) is the second phase of the nursing process.
Analysis of the collected data goes hand in hand with the rationale for performing a nursing
assessment. The purpose of assessment is to arrive at conclusions about the client's health. To
arrive at conclusions, the nurse must analyze the assessment data.
A nurse provides care for a client with an elevated temperature. The client is given the
prescribed medication and the nurse checks the client's temperature at repeated intervals.
What step of the nursing process is the nurse using to determine if the client has achieved the
outcome criteria of the treatment? - Answer Evaluation
Explanation:
The evaluation stage of the nursing process involves assessing whether the outcome criteria
have been met and the nursing care plan needs to be revised. The assessment stage involves
collecting subjective and objective data. The diagnosis phase involves analyzing subjective and
objective data to make a professional nursing judgment. The implementation phase involves
carrying out the plan to meet the determined outcome criteria.
For which client should a nurse perform a focused assessment? - Answer Four-day history of
sore throat and fever with enlarged lymph nodes
Explanation:
A client with a sore throat and fever with enlarged lymph nodes requires only a focused
assessment by the nurse. A focused assessment consists of a thorough assessment of a
particular client problem. An elevated blood pressure with no previous history of heart
problems requires an initial or comprehensive assessment. Right upper abdominal pain that
radiates into the groin area is an emergency situation and the nurse should collect only the data
necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a
chronic, ongoing health problem that needs reassessment and possibly a change in treatment.
What will be the nurse's initial role when conducting a health assessment with a client reporting
abdominal pain? - Answer Collecting data regarding the nature of the pain
Explanation:
The nurse's initial role in health assessment is to collect data. Teaching would occur later in the
process. Planning care and identifying interventions are parts of the nursing process and not the
health assessment.
