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NUR 104 Health Assessment Final Exam Bay State College Verified Tests
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NUR 104 Health Assessment Final Exam Bay StateCollege Verified Tests
Holistic Care ANS health care that takes into account the whole person interacting in the environment
Steps of the Nursing Process ANS 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Types of Assessments ANS o Initial Comprehensive
o Ongoing or Partial
o Emergency
Preparing for Assessment ANS o Review client's record (learn basic info.)
o Review client's status with other health care team members
o Reflect on own personal biases
o Educate about client's diagnosis and tests performed
Steps in Data Analysis ANS 1. Identify abnormalities
2. Cluster data
3. Draw inferences
4. Propose nursing diagnoses
5. Check defining characteristics
6. Confirm or rule out diagnoses
7. Document
Data Clustering ANS occurs when related cues are grouped together, also assists in identification of nursing
diagnosis
,The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of
care. Which statement describes a nursing diagnosis?
a. The collection of subjective and objective data
b. A clinical judgment about client responses to health difficulties ANS b; A clinical judgment about client
responses to health difficulties
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? ANS Critical Thinking
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 actions for the client?
a. Healthy People 2020
b. the client's past medical history ANS a; Healthy People 2020
Phases of an Interview ANS o Preparatory
o introductory
o working
o termination
Working Phase ANS The nurse then listens, observes cues, and uses critical thinking skills to interpret and
validate information received from the client. The nurse and client collaborate to identify the client's problems and
goals.
Types of Nonverbal Communication ANS o Appearance
o Demeanor
o Facial Expression
o Attitude
o Silence
o Listening
Types of Verbal Communication ANS o Open-ended questions
o Close-ended questions
o Laundry List
, o Rephrasing
o Well-placed phrases
o Inferring
o Providing info.
Health History Components ANS o Biographical data
o Reasons for seeking health care
o History of present health concern
o Personal health history
o Family health history
o ROS for current health problems
o Lifestyle and health practices profile
o Developmental level
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before
auscultating? ANS Disinfect the stethoscope before touching the client
During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals.
This occurs during the phase of the interview termed... ANS working
A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse
document this information in the comprehensive assessment? ANS Review of Systems
Standard Precautions ANS Assume that every person is potentially infected or colonized with an organism that
could be transmitted in the health care setting, and apply the following infection control practices during the delivery
of health care.
Dorsal Recumbent Position ANS
Sim's Position ANS
Knee-to-Chest Position ANS
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