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. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.

A. In the left lower quadrant. B. At the symphysis pubis. C. In the right upper quadrant. D. Above the umbilicus.

Correct Answer is B

Explanation

A. The left lower quadrant contains portions of the small and large intestines but is not the starting point for palpating the bladder.
B. The nurse should begin palpating at the symphysis pubis because the bladder is located in the lower abdomen. When distended, it rises above the pubic symphysis and can extend toward the umbilicus.
C. The right upper quadrant contains the liver and gallbladder but is not relevant to bladder assessment.
D. A significantly distended bladder may extend above the umbilicus, but the nurse should begin palpation at the symphysis pubis and move upward to assess for distention.

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What is the primary purpose of a nursing health assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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?

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

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?

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

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?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?