What is the main purpose of the health assessment?

To establish a rapport with the client and family

To establish a data base against which subsequent assessments can be measured

To gather information for specialists to whom the client may be referred

To qualify the degree of pain the client may be experiencing

Answer and Explanation

The Correct Answer is B

A) To establish a rapport with the client and family: While building rapport is an important aspect of the health assessment process, it is not the primary purpose. Establishing a trusting relationship can enhance communication and the quality of care, but the overarching goal of the assessment extends beyond interpersonal dynamics.

B) To establish a database against which subsequent assessments can be measured: This is the primary purpose of a health assessment. By collecting comprehensive baseline data regarding a client's health status, the nurse creates a reference point for future evaluations. This allows for the monitoring of changes in the patient's condition over time, facilitating timely interventions when necessary.

C) To gather information for specialists to whom the client may be referred: Although gathering relevant information for potential referrals is beneficial, it is not the main purpose of the health assessment. The assessment primarily serves to inform the current healthcare team about the patient's status rather than focusing solely on future consultations.

D) To qualify the degree of pain the client may be experiencing: Assessing pain is an important component of a comprehensive health assessment, but it is just one aspect among many. The overall purpose of the health assessment encompasses a broader evaluation of physical, emotional, and social factors affecting the client's health.

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Correct Answer is D

Explanation

A) Symmetry of lesions: While asymmetry can be a concern when assessing moles, it is not the most critical indicator when a lesion has already shown signs of burning and bleeding. Symmetry is one aspect of the overall assessment but does not immediately indicate danger in this scenario.
B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.

A. Alert and oriented B. Cyanosis C. Anxiety and restlessness D. Oxygen saturation 96% E. Capillary refill 5 seconds

Correct Answer is ["B","C","E"]

Explanation

A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.

B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.

C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.

D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.

E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia

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What is the main purpose of the health assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client tells the nurse that he has noticed that one of his moles has started to burn and bleed. The nurse should pay close attention to danger signs for pigmented lesions, and would be concerned with which additional finding?

Correct Answer is D

Explanation

What signs and symptoms indicate hypoxia? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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