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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Correct Answer is D
Explanation
A) Inflammation of the lamina of the involved vertebra: While inflammation can contribute to pain, it is not the primary cause in the context of a herniated disc. The pain associated with a herniated disc is typically related to nerve compression rather than inflammation of the lamina itself.
B) Shifting of two adjacent vertebrae out of alignment: This describes a different condition, such as spondylolisthesis. A herniated disc primarily involves the displacement of disc material, rather than a significant misalignment of the vertebrae.
C) Increased pressure of cerebral spinal fluid within the vertebral column: Increased cerebrospinal fluid pressure is not typically associated with herniated discs and does not directly cause the pain related to this condition.
D) Compression of the spinal cord by the extruding disc: This is the most accurate explanation for the patient's pain. A cervical herniated disc can protrude and compress nearby nerve roots or the spinal cord itself, leading to significant pain, weakness, and other neurological symptoms. This compression is the primary cause of pain in patients with this diagnosis.
Correct Answer is B
Explanation
A) "Attempt to rotate your head in a circular manner": This instruction is focused on rotation rather than lateral flexion. While rotation assesses different neck movements, it does not specifically evaluate lateral flexion.
B) "Lean your head to the side and attempt to touch your ear to your shoulder": This instruction directly assesses lateral flexion of the neck. It encourages the client to bend their head to the side, effectively demonstrating the range of motion in that direction.
C) "Attempt to raise your shoulders up toward your ears": This instruction assesses shoulder elevation and shrugging rather than lateral flexion of the neck. It does not provide information about the lateral movement of the head.
D) "Tilt your head back and look at the ceiling": This instruction assesses extension of the neck rather than lateral flexion. It evaluates the ability to move the head backward.