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 ["C","E"]
Explanation
A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.
B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.
C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.
D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.
E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.
Correct Answer is A
Explanation
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.