Coursepoint Ch 1: Nurse's Role in HA: Collecting and Analyzing Data
7. After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases? A) Assessment B) Planning C) Implementation D) Evaluation
ANS: A) Assessment
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways
ANS: A) Natural senses
The client has a headache. What type of data is this? A) Subjective B) Objective C) Focused D) Comprehensive
ANS: A) Subjective
31. How does a nurse decide what health-promotion activities are necessary for a particular client? A) Nurses address areas associated with healthy behaviors only B) Nurses collaborate with clients to identify areas in which clients are willing to make changes C) Nurses assess areas in which clients are willing to make changes only D) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes
ANS: B) Nurses collaborate with clients to identify areas in which clients are willing to make changes
49. During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client? A) physical B) environmental C) social well-being D) developmental level
ANS: environmental
44. The client has a murmur. This is what type of data? A) Subjective B) Objective C) Focused D) Comprehensive
ANS: B) Objective
54. When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying? A) the client's ability to communicate verbally B) the nurse's ability to ask relevant questions C) the type and degree of physical issues the client is experiencing D) the rapport that exists between the nurse and the client
ANS: D) the rapport that exists between the nurse and the client
35. A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? A) To establish a database against which subsequent assessments can be measured B) To establish rapport with the client and family C) To gather information for specialists to whom the client might be referred D) To quantify the degree of pain a client may be experiencing
ANS: A To establish a database against which subsequent assessments can be measured
2. A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician
ANS: B) ED nurse
20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.
ANS: C) The focused assessment addresses a particular client problem.
52.After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client? A) Healthy People 2020 B) the client's family history C) organization standards of care D) the client's past medical history
ANS: A) Healthy People 2020
48. A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? A) Breathing B) Airway C) Circulation D) Disability
ANS: Airway
39. A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse? A) Interjection of the nurse's thoughts or feelings into the data B) Making incorrect nursing judgments or diagnoses C) Relying on objective and subjective information D) Validating information that is already correct
ANS: B) Making incorrect nursing judgments or diagnoses
59. The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should A) analyze data that have already been collected. B) review any past collaborative problems. C) avoid premature judgments about the client. D) consult with the client's family members.
ANS: C) avoid premature judgments about the client.
22. The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes B) Determining client's nursing problem C) Collecting information about the client D) Determining outcome achievement E) Carrying out interventions
ANS: C, B, A, E, D C) Collecting information about the client B) Determining client's nursing problem A) Identifying outcomes E) Carrying out interventions D) Determining outcome achievement
58. An assessment that concentrates on patterns of role performance that all humans share is called what? A) Head-to-toe B) Body systems C) Focused D) Functional
ANS: D) Functional
40. Which of the following is the best example of assessment in everyday life? A) Taking the dog for a walk in the park to get exercise B) Listening to a favorite song to relax in the evening C) Texting a friend to let her know that you made it home safely D) Measuring the remaining tread on a car tire to determine whether it is time to replace it
ANS: D) Measuring the remaining tread on a car tire to determine whether it is time to replace it
66. Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? A) "Do you have family who visit you regularly?" B) "What amount of cleaning have you been doing in the past?" C) "Have you tried to schedule a cleaning service?" D) "Are you friendly with your neighbors?"
ANS: A) "Do you have family who visit you regularly?"
61. When assisting a client with health promotion, what must the nurse also nurture? A) A healthy environment B) Knowledge of the Healthy People 2020 indicators C) Family communication D) School/work attendance
ANS: A) A healthy environment
16. A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians
ANS: A) Expansion of health care networks
26. A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is a bit sporadic. How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.
ANS: A) Identify a nursing diagnosis of Ineffective Health Maintenance.
23. A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening
ANS: A) Inspection
33. An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? A) Nursing intervention B) Nursing goal C) Nursing evaluation D) Nursing assessment
ANS: A) Nursing intervention
67. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map
ANS: A) Nursing process
8. 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, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention
ANS: A) Reassess previously detected problems
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client.
ANS: A) Review the client's medical record.
19. A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior
ANS: A) The client's feelings of happiness
27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery
ANS: A) The client's motivation for change
38. A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? A) To determine any changes from the baseline data B) To collect subjective data related to the client's overall health C) To perform a rapid assessment for prompt treatment D) To evaluate whether outcomes of treatment are met
ANS: A) To determine any changes from the baseline data
55. Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility? A) collecting information regarding the client's health status B) stabilizing the client's physical condition C) developing an effective, respectful nurse-client relationship D) creating an environment that encourages client autonomy
ANS: A) collecting information regarding the client's health status
21. The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) I feel so tired sometimes. B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) My father died of a heart attack. F) Pupils equal, round, and reactive to light
ANS: A, D, E
56. The nurse recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply A) living a healthy lifestyle B) disease prevention C) improving one's quality of life D) providing affordable health care services E) increasing the longevity of one's life
ANS: A-C, E
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg
ANS: B) A 45-year-old man with chest pain and diaphoresis for 1 hour
13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception
ANS: B) A 50-year-old client newly diagnosed with diabetes
30. A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.
ANS: B) Ask the client about the most recent experiences of pain.
69. What is one way nurses use critical thinking in regard to the nursing process? A) Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client B) Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions C) Nurses do not need to think critically; they just need to follow the doctor's orders D) Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions
ANS: B) Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions
6. In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment
ANS: B) Effect of health on functional status
24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.
ANS: B) Interpret the information about the client in context.
3. The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.
ANS: B) It is ongoing and continuous.
41. Which of the following is the best example of holistic data collection by a nurse? A) Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate B) Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings C) Performing an x-ray, ECG, exercise stress test, and complete blood count D) Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test
ANS: B) Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
51. The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? A) Follows the ABC approach B) Uses evidence-based techniques C) Asks unlicensed staff to measure vital signs D) Focuses on the system that caused the hospitalization
ANS: B) Uses evidence-based techniques
47. An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) A) ongoing or partial assessment. B) focused or problem-oriented assessment. C) emergency assessment. D) initial comprehensive assessment.
ANS: B) focused or problem-oriented assessment.
34. The purpose of a health assessment includes what? (Select all that apply.) A) Identifying the client's major disease process B) Collecting information about the health status of the client C) Clarifying the client's ability to pay for health care D) Evaluating client outcomes E) Synthesizing collected data
ANS: B, D, E
5. Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test
ANS: C) A client who overdosed on acetaminophen
11. The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern
ANS: C) Appearance
17. A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems
ANS: C) Assuring valid conclusions from analyzed data
10. A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care
ANS: C) Avoid biases and judgments
18. A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.
ANS: C) Collect subjective data.
37. What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? A) Teaching the client to draw knees to chest to help minimize the pain B) Planning care to help minimize the client's pain C) Collecting data regarding the nature of the pain D) Identifying pain management interventions with input from the client
ANS: C) Collecting data regarding the nature of the pain
25. A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? A) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment
ANS: C) Focused assessment
45. When doing an overall assessment of a client, the nurse is able to utilize findings and do what? A) Identify what level of prevention the client is at B) Identify in what areas the client can educate his or her family C) Identify in what areas the client needs the most care D) Identify the client's medical diagnosis
ANS: C) Identify in what areas the client needs the most care
57. A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care? A) Request that the health care team revise the plan of care. B) Notify the primary health care provider of the change in the client's health status. C) Recognize the need to reevaluate the client's plan of care. D) Monitor the client frequently for other changes in health status.
ANS: C) Recognize the need to reevaluate the client's plan of care.
29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability
ANS: C) The client's acuity
62. What are nurses able to detect through the health assessment? A) Areas that need continuous care B) Areas that need in-hospital care C) Areas that need a referral to a specialist D) Areas in need of health adjustments
ANS: D) Areas in need of health adjustments
68. A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use? A) Rationale B) American Nurses Association recommendations C) Physical assessment skills D) Diagnostic reasoning
ANS: D) Diagnostic reasoning
32. An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform? A) Focused B) Comprehensive C) None, the cardiac catheterization will provide all needed information D) Emergency
ANS: D) Emergency
64. A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment? A) Inspection B) Palpation C) Sympathy D) Empathy
ANS: D) Empathy
28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.
ANS: D) Establish a baseline for the comparison of future health changes.
36. A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? A) Assessment B) Diagnosis C) Implementation D) Evaluation
ANS: D) Evaluation
43. Revising the plan as needed occurs in what part of the nursing process? A) Assessment B) Diagnosis C) Planning D) Evaluation
ANS: D) Evaluation
65. Which of the following statements best conveys the rationale for health promotion in a school setting? A) Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. B) Children younger than 13 years are some of the most common consumers of acute health care services. C) Children contract numerous communicable diseases in the school environment. D) Healthy child development is a critical health determinant because of its implications for lifelong health.
ANS: D) Healthy child development is a critical health determinant because of its implications for lifelong health.
1. A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? A) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments
ANS: D) Making clinical judgments
12. An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.
ANS: D) Measure the client's blood glucose four times daily.
50. After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing? A) Planning B) Evaluation C) Implementation D) Nursing diagnosis
ANS: D) Nursing diagnosis
42. The nurse is exhibiting critical thinking in which client care situation? A) Transcribing medication orders onto the nurse's medication administration record. B) Notifying the healthcare provider of a critical lab result. C) Answering the client's call bell alarm while the nursing assistant is at lunch. D) Performing a focused assessment on a client who is complaining of shortness of breath.
ANS: D) Performing a focused assessment on a client who is complaining of shortness of breath.
15. When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology
ANS: D) Public mistrust of physicians
60. When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A) entry. B) exploratory. C) focused. D) comprehensive.
ANS: D) comprehensive.
46. The result of a nursing assessment is the A) prescription of treatment. B) documentation of the need for a referral. C) client's physiologic status. D) formulation of nursing diagnoses.
ANS: D) formulation of nursing diagnoses.
53. The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? A) cluster the data B) document the findings C) determine a problem list D) perform a physical examination
ANS: D) perform a physical examination
