MODULE 1 ( CHAPTERS 1-3,8)
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? A. Standing while the client is seated B. Using a moderate amount of eye contact C. Sitting across the room from the client D. Minimizing facial expressions
Answer: B
A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing? A. The client's family relationships B. The client's current level of social and relational stability C. The client's critical thinking and problem-solving abilities D. The client's stress management and coping strategies
Answer: D
A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client? A. focused assessment B. comprehensive assessment C. emergency assessment D. ongoing assessment
Answer: A
A community health nurse is assessing an older adult client in their home. When 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
Answer: A
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "No! I will not let you do that to me!" Which response by the nurse would be most appropriate? A. Respect the client's wishes and omit the pelvic exam. B. Tell the client that she needs to have the Pap smear to check for cancer. C. Ask the client if she would like someone else to do the exam. D. Proceed with the pelvic exam even if the client protests.
Answer: A
A nurse is creating a genogram for a client's family health history. The nurse would use which of the following to denote the client's female relatives? A. Circle B. Square C. Triangle D. Rectangle
Answer: A
A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? A. Explain that you will find out the information for the client. B. Change the subject and return to this topic later. C. Teach the client to only take prescribed medications. D. Encourage the client to ask the pharmacist or primary care provider.
Answer: A
A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A. Inspection B. Palpation C. Percussion D. Auscultation
Answer: A
A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care? A. By interpreting the client's language and culture B. By evaluating the client's culturally based health practices C. By teaching the client about health care D. By making the client feel comfortable and safe
Answer: A
A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam? A. Ensuring client's privacy by providing an examination gown B. Providing a comfortable, warm room temperature C. Arranging exam equipment on a bedside tray table D. Explaining why standard precautions are being used
Answer: A
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
Answer: A
During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." What would the nurse do next? A. Briefly describe some of the potential benefits of regular exercise. B. Ask the client if he understands the risk factors for heart disease and diabetes. C. Tell the client to exercise 30 minutes at least 3 days a week. D. Document the client's current activity level as minimal.
Answer: A
In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A. Heart sounds B. Bowel sounds C. Breath sounds D. Femoral pulses
Answer: A
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
Answer: A
The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first? A. Sensory abilities B. General intelligence C. Severe phobias D. Irrational cognition
Answer: A
The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial? A. Family history B. Social concerns C. Current problem D. Past medical problems
Answer: A
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.
Answer: A
When beginning the collection of the client data base, which of the following would be most important for the nurse to do? A. Establish a trusting relationship B. Determine the client's strengths C. Identify health problems D. Make inferences
Answer: A
When interviewing a client who does not speak English, the nurse enlists the assistance of a "culture broker," based on the understanding of what as this person's primary function? A. to interpret the language and culture B. to evaluate the client's health practices
Answer: A
The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply. A. Palpation B. Inspection C. Percussion D. Auscultation E. The medical record
Answer: A, B, C, D
The nurse is nearing the end of the interview. Which question(s) about the client's extracurricular activities will the nurse ask to determine the client's level of social development? Select all that apply. A. "Are you involved in any community groups?" B. "How do you feel about your community?" C. "Have you had any major changes in the past year?" D. "What do you do for fun and relaxation?" E. "What things do you do to stay healthy?"
Answer: A, B, D
To assess the client's self-concept and self-care responsibilities, the nurse will ask which of the following question(s)? Select all that apply. A. "How would you describe yourself?" B. "How often do you have medical checkups?" C. "Are you having any family problems?" D. "Do you practice safe sex?" E. "What gives your family hope in times of trouble?"
Answer: A, B, D
The nurse has gathered objective and subjective data during the initial client assessment at an acute care facility. At the end of the assessment, the nurse will make informed clinical judgments. Which statement(s) reflects what the nurse will do next? Select all that apply. A. Identify medical problems that require immediate referral. B. Identify client problems that require nursing care. C. Identify how the family is affected by the client's health status. D. Identify collaborative problems that require interdisciplinary care. E. Identify need for client teaching and health promotion.
Answer: A, B, D, E
The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply. A. Spiritual B. Physiologic C. Recreational D. Sociocultural E. Psychological F. Developmental
Answer: A, B, D, E, F
The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply. A. the client's medical diagnosis B. recent abnormal laboratory findings C. the client's recent divorce D. the client's tonsillectomy 45 years ago E. recent changes in the client's blood pressure readings
Answer: A, B, E
The nurse is performing bimanual palpation. Which parts of the body might the nurse be examining? Select all that apply. A. Breasts B. Umbilicus C. Spleen D. Uterus E. Sinuses
Answer: A, C, D
The nurse is engaged in the working phase of a client interview. Which activities will the nurse complete during this phase? Select all that apply. A. Family history B. Validates goals C. Biographical data D. Developmental level E. Reasons for seeking care
Answer: A, C, D, E
The nurse is evaluating the setting for a client's physical examination. The nurse ensures that the setting has which of the following? Select all that apply. A. Adequate lighting B. Cool room temperature C. Quiet surroundings D. Soft chair or table E. Table for equipment F. Door or curtain
Answer: A, C, E, F
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
Answer: A, D, E
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A. Joint stiffness B. Rhinorrhea C. Shortness of breath D. Chest pain E. Muscle strength F. Swelling
Answer: A, E, F
A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? A. "In general, it's necessary for us to gather as much information about each client as possible." B. "We want to make sure your nursing care matches your needs as closely as possible." C. "The care team needs to cross-reference your diagnostic testing with your medical history." D. "We don't want to focus solely on the medical problem that brought you here."
Answer: B
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
Answer: B
A client is having difficulty describing a chief complaint of chest pain. Which action by the nurse would be most appropriate? A. Ignore the complaint for now and return to it later. B. Provide a laundry list of descriptive words. C. Restate the question using simple terms. D. Wait in silence until the client can determine the correct words.
Answer: B
A client states, "My wife died two months ago today." Which of the following responses would be most appropriate? A. "What did she die of?" B. "How does that make you feel?" C. "You probably must be sad." D. "Are you feeling sad, depressed, angry, or upset?"
Answer: B
A new graduate nurse asks another more experienced nurse about the best way to assess a client's dietary habits. Which suggestion would be most appropriate? A. Ask the client to explain the food pyramid. B. Obtain a 24-hour diet recall. C. Ask about the contents of one meal. D. Determine how often the client eats.
Answer: B
A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action? A. Depressing the skin 1 to 2 centimeters with the dominant hand B. Feeling the surface structures using a circular motion C. Placing the nondominant hand on top of the dominant hand D. Using one hand to apply pressure and the other hand to feel the structure
Answer: B
A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A. Standing while the client is seated B. Using a moderate amount of eye contact C. Sitting across the room from the client D. Minimizing facial expressions
Answer: B
A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment? A. Auscultation can be performed through clothing. B. The diaphragm should be held firmly against the body part. C. The bell of the stethoscope can detect bowel sounds. D. The binaurals connect the tubing to the chest piece.
Answer: B
After assessing a type 1 diabetic client who states they are unable to pay for their prescribed insulin, the nurse includes this information in the cluster of cues collected during the assessment. In which phase of the nursing process will this take place? A. Step 1 B. Step 2 C. Step 3 D. Step 4
Answer: B
During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential? A. Preintroductory B. Introductory C. Working D. Summary and closing
Answer: B
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
Answer: B
The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client 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
Answer: B
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.
Answer: B
The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate? A. Collaborating with the client to identify problems B. Explaining the purpose of the interview C. Determining the client's reason for seeking care D. Obtaining family health history data
Answer: B
The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? A. Flatness B. Resonance C. Tympany D. Dullness
Answer: B
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.
Answer: B
The nurse is preparing to assess a client's peripheral pulses. The nurse would place the client in which position? A. Sitting B. Supine C. Sims D. Prone
Answer: B
The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination? A. Complete the examination as quickly as possible. B. Speak clearly and slowly when explaining a procedure. C. Begin the examination with auscultation instead of inspection. D. Maintain the supine position for each part of the examination.
Answer: B
The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate? A. Omit intrusive parts of the exam. B. Try to minimize position changes. C. Allow client to remain dressed. D. Dim the room light.
Answer: B
The nurse is reviewing the medical record of a newly admitted client to the rehabilitation center. Which subjective question should the nurse confirm with the client? A. "What would you like for lunch today?" B. "Are you aware of any allergies that you may have?" C. "Do you have family coming to visit today?" D. "Would you prefer a bed by the window or a bed by the door?"
Answer: B
The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? A. Parasitic infection B. Fungal infection C. Bacterial infection D. Allergic reaction
Answer: B
The nurse prepares to complete a comprehensive assessment on a client. Which skill is the most important for the nurse to use at this time? A. Inferring B. Listening C. Observing D. Validating
Answer: B
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment? A. Physician B. Nurse C. Secretary D. Technician
Answer: B
A nurse is completing an assessment that will involve gathering subjective and objective information. Which data would the nurse identify as objective? Select all that apply. A. review of systems (ROS) B. physician's report C. B/P 135/78, heart rate 74 beats/min, respirations 16 breaths/min D. family history E. client's name, age, and occupation
Answer: B, C
The obstetric nurse is performing an initial assessment of a pregnant woman. Which subjective data will the nurse include in the assessment? Select all that apply. A. fundal height 28 cm (11 inches) B. health care practices C. personal medical history D. number of pregnancies E. elevated blood pressure
Answer: B, C, D
In interviewing an older adult client, the nurse detects a hearing loss. Which interviewing skill(s) will the nurse employ to promote trust and a collaborative relationship with the client? Select all that apply. A. Speak very loudly. B. Face the client when speaking. C. Use intermittent eye contact. D. Show respect. E. Validate the client's health concern.
Answer: B, C, D, E
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
Answer: C
A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication? A. Attitude B. Silence C. Laundry list D. Facial expression
Answer: C
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
Answer: C
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
Answer: C
A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A. preintroductory B. introductory C. working D. summary and closing
Answer: C
A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A. Maintaining an open attitude B. Using silence appropriately C. Providing a laundry list of descriptors when needed D. Maintaining an open and encouraging facial expression
Answer: C
A nurse on the 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.
Answer: C
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
Answer: C
After teaching a group of students about the review of systems component of the health history, the instructor determines that the teaching was successful when the students identify which data as an example? A. "High school diploma plus 2 years of college" B. "Caregiver reliable source of information" C. "Menarche at age thirteen" D. "Lungs clear to auscultation bilaterally"
Answer: C
After teaching a group of students about verbal communication techniques, the instructor determines that the teaching was successful when the students identify which of the following as an example of a closed-ended question/statement? A. "What is your relationship with your children?" B. "Tell me what you eat in a normal day." C. "Are you allergic to any medications?" D. "What is your typical day like?"
Answer: C
The nurse is assessing a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A. Character B. Onset C. Severity D. Pattern
Answer: C
The nurse is assessing the client's activity and exercise level. Which client statement would indicate to the nurse that the client is getting the recommended amount of exercise? A. "I walk on the treadmill once or twice a week." B. "I play basketball with a team each week." C. "I go to an aerobics class for 1 hour three times a week." D. "I swim for 30 minutes each Saturday morning."
Answer: C
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
Answer: C
The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client's cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability? A. the American Diabetic Association (ADA) B. the American Heart Association (AHA) C. the Alzheimer's Association (AA) D. the American Ophthalmology Association (AAO)
Answer: C
The nurse is gathering subjective data to complete a health history on a 68- year-old client. During the interview, the client mentions their frequent use of alcohol and recreational drugs. This information belongs in which section of the health history? A. chief complaint B. past medical history C. lifestyle and health practices D. review of systems
Answer: C
The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain? A. Penlight B. Tongue depressor C. Tuning fork D. Otoscope
Answer: C
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? A. "My mom's still alive, but my dad died 10 years ago of heart failure." B. "I have a brother with leukemia and a sister with hypertension." C. "I had surgery 5 years ago to repair an inguinal hernia." D. "I have been having some pain when I urinate for the last several days."
Answer: C
The nurse is questioning a 19-year-old client about personal relationships with family members or significant others in order to assess problems and potential support from the client's family of origin. Which question would be the best question for the nurse to ask? A. "What do you hope to accomplish in your life?" B. "What gives you strength and hope?" C. "Who is the most important person in your life?" D "Are you satisfied with the level of education you have?"
Answer: C
The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which piece of protective equipment? A. Face mask B. Cover gown C. Gloves D. Eye goggles
Answer: C
The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding? A. Temperature B. Vibrations C. Pulses D. Fremitus
Answer: C
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information? A. Finger pad surface B. Palmar hand surface C. Dorsal hand surface D. Ulnar hand surface
Answer: C
When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? A. Collect objective data B. Validate the data C. Collect subjective data D. Document the data
Answer: C
Which of the following questions would be most important for the nurse to ask first when obtaining the health history? A. "Do you have adequate health insurance coverage?" B. "Are you generally fairly healthy?" C. "What is your major health concern at this time?" D. "Did you bring all your medications with you?"
Answer: C
Which statement by the nurse could be construed as judgmental? A. "How often do your adult children visit?" B. "Your husband's death must have been difficult for you." C. "You must quit smoking because it is offensive to others." D. "How do you feel about getting older?"
Answer: C
A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy. 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
Answer: D
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.
Answer: D
An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose? A. Collect large quantities of data B. Assist the physician C. Validate previous data D. Make a clinical judgment
Answer: D
An instructor is explaining the technique for deep palpation, describing it as which of the following? A. Using one hand and depressing the skin 1 centimeter B. Using the dominant hand to depress the skin one-half to three-quarters of an inch C. Using both hands to depress the skin one-half of an inch D. Using both hands to depress the skin 1 to 2 inches
Answer: D
An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? A. Plastic tubing should be longer than 3 feet. B. The bell is used after using the diaphragm. C. When using the bell, push on it lightly. D. A diaphragm picks up low-pitched sounds.
Answer: D
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.
Answer: D
During the interview, the client informs the nurse that their abdominal pain has caused them to be fearful. The client worries that they may have ulcers or cancer. The nurse is aware that rephrasing is an excellent way to clarify subjective information. Which is the best response from the nurse? A. "How is your pain right now?" B. "When did your pain start?" C. "Is the pain sharp, dull, or radiating?" D. "You are thinking that you may have a serious illness?"
Answer: D
The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A. Deep palpation B. Indirect percussion C. Moderate palpation D. Blunt percussion
Answer: D
The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data? A. "Do you always wear your seatbelt when driving?" B. "How much beer, wine, or alcohol do you drink?" C. "Do you use condoms with each sexual encounter?" D. "Could you describe how you perform self-breast exams?"
Answer: D
The nurse notes that an intervention provided to a client for a specific health problem was not effective. The nurse continues to monitor and care for the client. Which type of assessment is the nurse performing? A. initial comprehensive B. focused or problem oriented C. emergency D. ongoing or partial assessment
Answer: D
The nurse places a client complaining of back pain in the dorsal recumbent position. Which area would the nurse be least likely to assess with the client in this position? A. Chest B. Head C. Peripheral pulses D. Abdomen
Answer: D
The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic? A. Criteria, opportunity, label, direction, stamina, progress, action B. Category, occasion, length of time, decision, strength, plan, attitude C. Choices, outcomes, learning, determination, status, protrusion, activity D. Character, onset, location, duration, severity, pattern, associated factors
Answer: D
When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary? A. Completes the client's health record. B. Assures a trusting interpersonal relationship. C. Evaluates the seriousness of the client's risk factors. D. Provides a focus for the physical exam.
Answer: D
When the nurse collects objective data, which finding requires immediate follow-up? A. cerumen in the ear B. acne lesions on the face and upper chest C. moist nasal mucosa D. enlarged lymph node in the neck
Answer: D
Which of the following would be most important for the nurse to do immediately before beginning the physical exam? A. Practice interviewing skills. B. Construct the client's family genogram. C. Establish the client's reliability as historian. D. Collect necessary equipment essential to the exam.
Answer: D
While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies any complications. How would the nurse best document the subjective portion of the assessment? A. "Client's gastrointestinal health is within normal limits. " B. "Client denies gastrointestinal signs and symptoms." C. "Gastrointestinal problems are not present at this time." D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."
Answer: D
The nurse has completed collecting primary data and is finishing a health history for a newly admitted client on the medical-surgical unit. Which statement best reflects primary data? A. information exclusively provided by the client's family B. information exclusively provided by the client C. information exclusively provided by the health care provider D. information taken from the chart by the nurse prior to the interview
Answer:B
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
Answer:B
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 what action? A. Performing hand hygiene between examinations of each body part B. Discarding in the trash can the safety pin that was used to assess sensory perception C. Wearing gloves to palpate the tongue and buccal membranes D. Wearing a gown, gloves, and mask during the physical exam
Answer:C
Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? A. "Our schedule is very busy also. We got to you as soon as we could." B. "No one is holding you captive, you are free to leave at any time." C. "Would you like to speak to the office manager about your complaint?" D. "You seem very angry. I am ready to begin your exam now."
Answer:D