NR302 Week 1 Health Assessment Exam Review | Key Concepts
& Immediate Actions | Practice Questions & Verified Answers
Clinical Judgment in Health
Assessment
Which assessment findings require immediate action by the nurse?
Drag the choices from the bottom and drop them under the
appropriate category of requiring or not requiring immediate action.
Require Immediate Action:
The person is breathing so quickly they are unable to speak.
The individual is unresponsive.
Not Require Immediate Action:
A toddler is clinging to the client’s leg.
The person reports being in pain.
The client is clutching their abdomen.
Review Feedback
Immediate action is required for findings that indicate the client
is in danger of losing their life. This includes an individual who is
unresponsive, is having difficulty breathing, or does not have
a pulse.
Privacy of Health Information
How do health professionals protect the client's private information
when using a hard copy medical record? Select all that apply.
Lock records in your desk drawer when not in use.
Allow the client’s children to review the medical record.
Shield identifying information from view by visitors.
Return the medical record to the designated storage
area.
Close the medical record when entering the client's room.
Review Feedback
,Safeguarding the privacy of health information is a fundamental
responsibility of all health providers. Although hard copy, paper, or
medical records are not used frequently, the health professionals
who use them have the responsibility to protect the private health
information they contain. To do this, open records should be
shielded from the view of others, the record should be
closed when entering the client’s room and remain closed
unless being actively used. All physical medical records should
be returned to a designated storage area.
Only those directly involved in caring for the client should review the
medical record. The client has a right to look at their own record, but
that right is not extended to family or friends without consent from
the client. The exception to this is for custodial caregivers and
parents or legal guardians of minors.
Although the security of health records is a high priority, they must
remain available to the entire care team. Locking records in an
individual’s desk may limit access, delay care, and negatively
impact client safety.
Health Assessment Components
Identify the major components of the complete health assessment
by dragging the correct options from the left side to the right side
column.
Health Assessment Components Correct Major
Components
Health history Health history
Physical assessment Physical assessment
Discharge teaching Interpretation of data
Setting realistic goals
Interpretation of data
Review Feedback
The complete health assessment includes a health
history, physical assessment, and interpretation of data to
determine if further assessment is needed.
,Although the information collected during the complete health
assessment is used to set goals for the client’s health and identify
teaching needs, those aspects of care are not part of the complete
health assessment.
Self-Check: Emergency Recognition
Emergency Recognition
When entering the room to perform a complete health assessment
on a new client, the nurse finds the client and family standing
around an unlicensed assistive personnel (UAP) who is lying on the
floor.
What is the priority action for the nurse?
Assess the UAP.
Ask what happened.
Move the client to another room.
Phone for an emergency response.
Review Feedback
In this situation, you may have struggled to select one of two
answers: assess the UAP or ask what happened. The key to deciding
which to select is often to answer this question, “If I can only do one
thing to help, what would it be?” When a person appears to be
unresponsive, the one action to take is to assess the person who
may be experiencing a health emergency, even if is not the client.
Of course, most health professionals would be assessing the UAP
while asking the client what happened. The correct answer is based
on the fact that only asking what happened while not assessing is
not in the individual’s best interest.
Self-Check: Is This Assessment?
Is This Assessment?
, In which situations does the nurse collect data as part of an
assessment? Select Yes if data is being collected or No if data is not
being collected.
Yes
Yes
Yes
During the complete health
assessment.
Yes
When administering medications.
When asking questions from the
client’s partner.
Yes
While reading the nurse
practitioner’s admission note.
Review Feedback
Healthcare providers assess
As they pass the individual needs and current status
walking in the hallway. during every encounter with
the client and family members.
Assessment is not limited to the initial or follow-up assessments, but
to any time when cues to the client’s health, health-related needs,
and current status can be observed or collected. These include when
administering medications (focused assessment related to the need
for the medication and if it is safe to administer at that time); when
gathering data about client preferences and unique needs (speaking
with a partner); while reviewing notes from the health team
members involved with care (such as the primary care provider);
and when you observe the client when out of the room (assessing
strength, stability, and activity tolerance).
& Immediate Actions | Practice Questions & Verified Answers
Clinical Judgment in Health
Assessment
Which assessment findings require immediate action by the nurse?
Drag the choices from the bottom and drop them under the
appropriate category of requiring or not requiring immediate action.
Require Immediate Action:
The person is breathing so quickly they are unable to speak.
The individual is unresponsive.
Not Require Immediate Action:
A toddler is clinging to the client’s leg.
The person reports being in pain.
The client is clutching their abdomen.
Review Feedback
Immediate action is required for findings that indicate the client
is in danger of losing their life. This includes an individual who is
unresponsive, is having difficulty breathing, or does not have
a pulse.
Privacy of Health Information
How do health professionals protect the client's private information
when using a hard copy medical record? Select all that apply.
Lock records in your desk drawer when not in use.
Allow the client’s children to review the medical record.
Shield identifying information from view by visitors.
Return the medical record to the designated storage
area.
Close the medical record when entering the client's room.
Review Feedback
,Safeguarding the privacy of health information is a fundamental
responsibility of all health providers. Although hard copy, paper, or
medical records are not used frequently, the health professionals
who use them have the responsibility to protect the private health
information they contain. To do this, open records should be
shielded from the view of others, the record should be
closed when entering the client’s room and remain closed
unless being actively used. All physical medical records should
be returned to a designated storage area.
Only those directly involved in caring for the client should review the
medical record. The client has a right to look at their own record, but
that right is not extended to family or friends without consent from
the client. The exception to this is for custodial caregivers and
parents or legal guardians of minors.
Although the security of health records is a high priority, they must
remain available to the entire care team. Locking records in an
individual’s desk may limit access, delay care, and negatively
impact client safety.
Health Assessment Components
Identify the major components of the complete health assessment
by dragging the correct options from the left side to the right side
column.
Health Assessment Components Correct Major
Components
Health history Health history
Physical assessment Physical assessment
Discharge teaching Interpretation of data
Setting realistic goals
Interpretation of data
Review Feedback
The complete health assessment includes a health
history, physical assessment, and interpretation of data to
determine if further assessment is needed.
,Although the information collected during the complete health
assessment is used to set goals for the client’s health and identify
teaching needs, those aspects of care are not part of the complete
health assessment.
Self-Check: Emergency Recognition
Emergency Recognition
When entering the room to perform a complete health assessment
on a new client, the nurse finds the client and family standing
around an unlicensed assistive personnel (UAP) who is lying on the
floor.
What is the priority action for the nurse?
Assess the UAP.
Ask what happened.
Move the client to another room.
Phone for an emergency response.
Review Feedback
In this situation, you may have struggled to select one of two
answers: assess the UAP or ask what happened. The key to deciding
which to select is often to answer this question, “If I can only do one
thing to help, what would it be?” When a person appears to be
unresponsive, the one action to take is to assess the person who
may be experiencing a health emergency, even if is not the client.
Of course, most health professionals would be assessing the UAP
while asking the client what happened. The correct answer is based
on the fact that only asking what happened while not assessing is
not in the individual’s best interest.
Self-Check: Is This Assessment?
Is This Assessment?
, In which situations does the nurse collect data as part of an
assessment? Select Yes if data is being collected or No if data is not
being collected.
Yes
Yes
Yes
During the complete health
assessment.
Yes
When administering medications.
When asking questions from the
client’s partner.
Yes
While reading the nurse
practitioner’s admission note.
Review Feedback
Healthcare providers assess
As they pass the individual needs and current status
walking in the hallway. during every encounter with
the client and family members.
Assessment is not limited to the initial or follow-up assessments, but
to any time when cues to the client’s health, health-related needs,
and current status can be observed or collected. These include when
administering medications (focused assessment related to the need
for the medication and if it is safe to administer at that time); when
gathering data about client preferences and unique needs (speaking
with a partner); while reviewing notes from the health team
members involved with care (such as the primary care provider);
and when you observe the client when out of the room (assessing
strength, stability, and activity tolerance).
