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. Refer the client for medical follow-up in two weeks. B. Document the benign findings. C. Perform a random blood sugar test per order. D. Ask the client about a family history of cancer.

Correct Answer is C

Explanation

A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.

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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

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

Correct Answer is C

Explanation

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?