What is the primary purpose of a nursing health assessment?

Collect client data in order to make a professional clinical judgment of the client's overall level of functioning.

Provides information about chronic diseases and medications to identify how a present illness is impacting the client.

Compile data during a step-by-step physical examination.

Focuses on the client's physiologic status in order to implement provider decisions.

Answer and Explanation

The Correct Answer is A

A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.

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Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

A. Air being diverted from the trachea to the bronchi B. Air passing through constricted passageways C. Air increasing in turbulence in a wide passage D. Air leaking from the alveoli into the pleural space

Correct Answer is B

Explanation

A. Air being diverted from the trachea to the bronchi does not explain the cause of a wheeze. This is a normal part of airflow distribution.
B. Air passing through constricted passageways is correct. A wheeze is a high-pitched, musical sound that occurs when air flows through narrowed or obstructed airways, as seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
C. Air increasing in turbulence in a wide passage is incorrect. Wheezing occurs due to airway narrowing, not widening.
D. Air leaking from the alveoli into the pleural space describes pneumothorax, which presents with absent breath sounds rather than wheezing.

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What is the primary purpose of a nursing health assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

Correct Answer is B

Explanation

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?