Correct Questions & Rationales
nurse's role in health assessment: 4 goals - ---✔✔✔ANSWER----promote
health
prevent illness
treat human responses to health or illness
advocate for individuals, families, communities, and populations
types of assessment - ---✔✔✔ANSWER----Emergency (center on
immediate and highest priority problem)
Comprehensive
General Survey
Focused
emergency assessment - ---✔✔✔ANSWER----involves a life-threatening or
unstable situation
A—Airway (with cervical spine protection if an injury is suspected)
B—Breathing—rate and depth, use of accessory muscles
,C—Circulation—pulse rate and rhythm, skin color
D—Disability—level of consciousness, pupils, movement
E—Exposure
comprehensive assessment - ---✔✔✔ANSWER----broad and complete;
includes a complete health history and physical assessment and all body systems
and areas; a patient's perception of health, strengths to build upon, risk factors for
illness, functional abilities, methods of coping, and support systems
general survey assessment - ---✔✔✔ANSWER----begins immediately upon
meeting client and continues throughout assessment; no measurements are done
-overall appearance, hygiene and dress, skin color, body structure and
development, behavior, facial expressions, posture, ROM, gait, speech, LOC
focused assesssment - ---✔✔✔ANSWER----based on the patient's health
issues; usually involves one or two body systems and is smaller in scope than the
comprehensive assessment, but more in-depth on the specific issue or issues
example is a patient who presents to the clinic with a cough.
levels of intervention to promote healthy change - ---✔✔✔ANSWER----
Primary prevention
Secondary prevention
Tertiary prevention
, primary prevention - ---✔✔✔ANSWER----involves strategies aimed at
preventing problems and focuses on people and groups. Examples: Immunizations,
health teaching, safety precautions, and nutrition counseling, family planning
services, providing poison-control information, and accident-prevention education
secondary prevention - ---✔✔✔ANSWER----focus on screening for early
detection of disease with prompt diagnosis and treatment
examples: Vision screening, Pap smears, BP screening, hearing testing, scoliosis
screening, and tuberculin skin testing
tertiary prevention - ---✔✔✔ANSWER----focuses on preventing
complications of an existing disease and promoting health to the highest level
examples: Diet teaching, exercise programs, physical therapy, medication, surgical
treatment
what is health assessment? - ---✔✔✔ANSWER----gathering information
about the health status of the patient, analyzing and synthesizing those data,
making judgments about nursing interventions based on the findings, and
evaluating patient care outcomes
health assessment includes - ---✔✔✔ANSWER----healthy history and
physical assessment
critical thinking in nursing - ---✔✔✔ANSWER-----Purposeful, outcome-
directed (result-oriented) thinking
-Is driven by patient, family, and community needs