What is the main purpose of the health assessment?
To establish a rapport with the client and family
To establish a data base against which subsequent assessments can be measured
To gather information for specialists to whom the client may be referred
To qualify the degree of pain the client may be experiencing
The Correct Answer is B
A) To establish a rapport with the client and family: While building rapport is an important aspect of the health assessment process, it is not the primary purpose. Establishing a trusting relationship can enhance communication and the quality of care, but the overarching goal of the assessment extends beyond interpersonal dynamics.
B) To establish a database against which subsequent assessments can be measured: This is the primary purpose of a health assessment. By collecting comprehensive baseline data regarding a client's health status, the nurse creates a reference point for future evaluations. This allows for the monitoring of changes in the patient's condition over time, facilitating timely interventions when necessary.
C) To gather information for specialists to whom the client may be referred: Although gathering relevant information for potential referrals is beneficial, it is not the main purpose of the health assessment. The assessment primarily serves to inform the current healthcare team about the patient's status rather than focusing solely on future consultations.
D) To qualify the degree of pain the client may be experiencing: Assessing pain is an important component of a comprehensive health assessment, but it is just one aspect among many. The overall purpose of the health assessment encompasses a broader evaluation of physical, emotional, and social factors affecting the client's health.
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View Related questions
Correct Answer is A
Explanation
A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.
B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.
C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.
D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.
Correct Answer is D
Explanation
A) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.
B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.
C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.
D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.