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

Explanation

A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.

B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.

C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.

D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.

A. Texture B. Tachypnea C. Turgor D. Temperature E. Tympany

Correct Answer is ["A","C","D"]

Explanation

A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.

B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.

C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.

E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.

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What is the main purpose of the health assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows to auscultate the tricuspid valve at which location?

Correct Answer is C

Explanation

The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerve is the nurse assessing?

The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

What is the most reliable indicator of pain?

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 skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

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

The client's respiratory rate is 9 breaths per minute, and they deny feeling short of breath. The nurse will document this finding as:

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What will the nurse do next?