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:
The facial nerve, or cranial nerve VII, is responsible for the taste sensation in the anterior two-thirds of the tongue, not the posterior third. It carries taste sensations from the front part of the tongue via the chorda tympani branch.

Choice B Reason:
The abducens nerve, or cranial nerve VI, has no role in taste sensation. It is primarily involved in controlling the lateral rectus muscle of the eye, which abducts the eye.

Choice C Reason:
The glossopharyngeal nerve, or cranial nerve IX, provides special sensory innervation for taste to the posterior third of the tongue. This enables the sensation of various tastes like salty, sweet, sour, and bitter in this region.

Choice D Reason:
The hypoglossal nerve, or cranial nerve XII, is responsible for motor control of the tongue muscles but does not provide sensory innervation for taste.

A. Temperature B. Vibrations C. Pulses D. Fremitus

Correct Answer is C

Explanation

Choice A Reason:
The dorsal aspect of the hand, rather than the finger pads, is more sensitive to temperature due to its thinner skin. Therefore, while the finger pads can detect temperature, they are not the best tool for this purpose.

Choice B Reason:
Vibrations, such as those produced by vocal fremitus, are typically assessed using the ulnar edge or the palmar aspect of the hand, not the finger pads. The finger pads are sensitive but do not provide the best surface for detecting vibrations.

Choice C Reason:
The finger pads are densely innervated and are the most sensitive part of the hand, making them ideal for palpating pulses. Pulses are subtle and require a fine touch to assess properly, which is why the finger pads are the preferred area for this assessment.

Choice D Reason:
Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as someone speaks. It is best felt with the ball of the hand or the ulnar edge, not the finger pads.

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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

What cranial nerve is responsible for the taste sensation of the posterior third of the tongue?

Correct Answer is C

Explanation

The nurse is using the finger pads of the hand to palpate a body part. Which finding would the nurse be best able to detect?

Correct Answer is C

Explanation

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

The nurse working in the eye doctor's office is completing an assessment on an elderly client. Which of the following would a nurse expect to assess in a client with esotropia?

The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

The nurse knows the importance of assessing vital signs is to:

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

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?