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:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.

Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.

Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.

Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.

A. Left temporal bone B. Both ears equally C. Right ear D. Left ear

Correct Answer is C

Explanation

Choice a reason:
The left temporal bone would be the expected site of lateralization for sound in a Weber test if the patient had conductive hearing loss in the left ear. However, with unilateral sensorineural hearing loss, the sound typically lateralizes to the opposite ear, which is the ear with better hearing.
Choice b reason:
Lateralization to both ears equally during the Weber test would suggest either normal hearing or symmetrical hearing loss. In the case of unilateral sensorineural hearing loss, the sound is not perceived as equal in both ears because the affected ear does not hear as well as the unaffected ear.
Choice c reason:
In a patient with unilateral sensorineural hearing loss in the left ear, the Weber test will lateralize to the right ear, which is the ear with normal hearing. This occurs because the inner ear on the affected side is not able to transmit the sound as effectively as the unaffected side, making the sound seem louder in the ear with better hearing.
Choice d reason:
Lateralization to the left ear in the Weber test would indicate conductive hearing loss in the left ear, not sensorineural hearing loss. In sensorineural hearing loss, the sound vibrates to the ear with better cochlear function, which would be the right ear in this case.

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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

The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use?

Correct Answer is C

Explanation

A patient is diagnosed with left ear unilateral sensorineural hearing loss. During the performance of the Weber test, the nurse expects lateralization of the sound/vibration to the:

Correct Answer is C

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

During a health history assessment, where is the symptoms description/narrative typically documented?

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

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?

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should be included in the section about preventing gingivitis?

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?