The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

To gather information about the health status of the client.

To help the physician diagnose illness without further testing.

To decide on the best way to manage a client's illness based on the nurse's own views and beliefs.

To make judgments about the client's lifestyle and behaviors that contribute to the client's illness.

Answer and Explanation

The Correct Answer is A

Choice A reason:
The primary purpose of health assessment is to collect, analyze, and interpret data to identify the patient’s health status and needs, as well as to develop and implement appropriate nursing interventions to address these needs. It is a systematic process that is fundamental in promoting the health and well-being of patients. This involves a comprehensive evaluation of the patient's physical, psychological, and social health. Gathering this information is crucial for creating a care plan that addresses the individual needs of the client.
Choice B reason:
While health assessments can aid physicians in diagnosing illness, they are not solely for the purpose of diagnosis without further testing. Health assessments may indicate the need for additional tests to confirm a diagnosis. The nurse's role includes supporting the diagnostic process, but it is not the primary purpose of health assessment.
Choice C reason:
Health assessments are not meant to be subjective or based on the nurse's personal views and beliefs. The assessments are conducted to objectively determine the health status of a client, which then informs evidence-based practice and care planning. Personal biases should not influence the management of a client's illness.
Choice D reason:
Making judgments about a client's lifestyle and behaviors is not the primary purpose of health assessment. While lifestyle and behaviors may be assessed as part of understanding the client's overall health status, the goal is not to judge but to understand how these factors may impact the client's health and to provide education and support for healthy changes if needed.

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Correct Answer is C

Explanation

Choice a reason:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.

Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.

Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.

Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.

A. Angular cheilitis B. Herpes simplex C. Angioedema

Correct Answer is B

Explanation

Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.

Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.

Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.

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The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use?

Correct Answer is C

Explanation

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Correct Answer is B

Explanation

A client reports experiencing chronic headaches after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?

The nurse is preparing to percuss a client's anterior chest area. Which approach will the nurse use for this assessment?

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

The nurse read the patient's health history and noted cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?