The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

To gather information about the health status of the client.

To help the physician diagnose illness without further testing.

To decide on the best way to manage a client's illness based on the nurse's own views and beliefs.

To make judgments about the client's lifestyle and behaviors that contribute to the client's illness.

Answer and Explanation

The Correct Answer is A

Choice A reason:
The primary purpose of health assessment is to collect, analyze, and interpret data to identify the patient’s health status and needs, as well as to develop and implement appropriate nursing interventions to address these needs. It is a systematic process that is fundamental in promoting the health and well-being of patients. This involves a comprehensive evaluation of the patient's physical, psychological, and social health. Gathering this information is crucial for creating a care plan that addresses the individual needs of the client.
Choice B reason:
While health assessments can aid physicians in diagnosing illness, they are not solely for the purpose of diagnosis without further testing. Health assessments may indicate the need for additional tests to confirm a diagnosis. The nurse's role includes supporting the diagnostic process, but it is not the primary purpose of health assessment.
Choice C reason:
Health assessments are not meant to be subjective or based on the nurse's personal views and beliefs. The assessments are conducted to objectively determine the health status of a client, which then informs evidence-based practice and care planning. Personal biases should not influence the management of a client's illness.
Choice D reason:
Making judgments about a client's lifestyle and behaviors is not the primary purpose of health assessment. While lifestyle and behaviors may be assessed as part of understanding the client's overall health status, the goal is not to judge but to understand how these factors may impact the client's health and to provide education and support for healthy changes if needed.

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Correct Answer is C

Explanation

Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

A. Assist the client to a sitting position. B. Percuss the region before auscultating. C. Reduce all environmental noise. D. Palpate the region before auscultating.

Correct Answer is C

Explanation

Choice a reason:
Assisting the client to a sitting position is not the best action to ensure that bowel sounds can be heard. For abdominal auscultation, the patient should be lying down in a supine position to relax the abdominal muscles, which facilitates the hearing of bowel sounds.

Choice b reason:
Percussion of the abdomen before auscultation is not recommended as the best initial action. Percussion can stimulate bowel motility, which may alter the natural bowel sounds that the nurse is attempting to assess.

Choice c reason:
Reducing all environmental noise is the best action to ensure that bowel sounds can be heard clearly. Environmental noise can mask the subtle sounds of bowel motility, and minimizing distractions allows for a more accurate assessment of bowel activity.

Choice d reason:
Palpating the region before auscultating is not the best action because palpation can also stimulate bowel motility and potentially alter the bowel sounds. Auscultation should be performed before palpation during the abdominal examination to avoid this issue.

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The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Correct Answer is C

Explanation

The nurse working in an outpatient GI clinic is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Correct Answer is C

Explanation

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)

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The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

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