HEALTH ASSESSMENT EXAM REVIEW

HEALTH ASSESSMENT EXAM REVIEW A patient is admitted to the medical-surgical unit with a diagnosis of hypertension. The nurse is using the nursing process to develop the plan of care. Which steps should the nurse incorporate? A. Assessment, treatment, planning, evaluation, discharge, follow-up B. Admission, assessment, diagnosis, treatment, discharge planning C. Admission, diagnosis, treatment, evaluation, discharge planning D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation - CORRECT ANSWER-D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nurse must analyze and interpret these data before initiating a plan of care. The nurse is incorporating the principles of the quality and safety competencies from the Institute of Medicine (IOM) recommendations into the health assessment of a patient in the long-term care setting. What principles should the nurse consider? Select all that apply: A. Use evidence to support interventions. B. Evaluate the plan of care. C. Use a step-by-step approach to problem solving. D. Use technologies and informatics in delivering care. E. Place the patient at the center of care. F. Include other disciplines in the plan of care. - CORRECT ANSWER-A, D, E, F Use Evidence to support interventions Use technologies and informatics in delivering care Place the patient at the center of care Include other disciplines in care The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs: provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics. The student nurse is preparing to assess a patient in the hospital clinical setting. Which components best describe the concept of health assessment? Select all that apply: A. Collection of objective data B. Collection of subjective data C. Collection of data and identification of nursing diagnosis D. Planning and evaluation of data E. Analysis of data F. Physical exam G. Documentation of data - CORRECT ANSWER-A, B, F, G Collection of objective data Collection of subjective data Physical exam Documentation of Data Components of health assessment include conducting a health history (the collection of subjective data), performing a physical examination (the collection of objective data), and documenting the findings. The nurse is documenting the findings from the health assessment. Which example of data documentation reflects the opinion of the nurse? A. The patient is uncooperative and unfriendly. B. The patient avoids eye contact. C. The patient states, "I do not want to get out of bed." D. The patient states, "I am very angry." - CORRECT ANSWER-A. The patient is uncooperative and unfriendly Nurses must record data accurately, concisely, and without bias or opinion. In this example, the nurse is offering an opinion, which may contain bias. The nurse is assessing a patient for the first time in the outpatient diabetic clinic. A ____________ type of health assessment would be most appropriate for this visit? A. Focused assessment B. Episodic follow-up assessment C. Shift assessment D. Comprehensive health assessment - CORRECT ANSWER-D. Comprehensive health assessment The type of health assessment performed by the nurse is also driven by patient need. A comprehensive health assessment involves a detailed history and physical examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility.