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 ["C","E"]

Explanation

A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.

B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.

C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.

D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.

E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.

A. Lordosis B. Scoliosis C. Kyphosis D. Normal curve

Correct Answer is A

Explanation

A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.

B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.

C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.

D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.

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What is the main purpose of the health assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply.

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

Explanation

The nurse notes an exaggerated cervical curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record?

Correct Answer is A

Explanation

The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?

Which of the following is the rationale for the nurse to reassess the patient's pain after treatment?

The nurse is admitting a client to the acute care unit. Which should the nurse consider when regarding the confidentiality of the client?

The nurse is assessing a client admitted with severe back pain. Which are essential components of the pain assessment? Select all that apply.

The nurse is planning teaching for a client diagnosed with peripheral neuropathy. What should the nurse include in this teaching?

When conducting a peripheral vascular assessment on the upper extremities of a client, the nurse should include which assessments? Select all that apply

When assessing the abdomen, the nurse would expect to auscultate which sounds?

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more focused neurological assessment of this client?