Nurs 224 Chapter 1 CoursePoint

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

a) A healthy environment

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

c) Appearance

Revising the plan as needed occurs in what part of the nursing process? a) Assessment b) Diagnosis c) Planning d) Evaluation

d) Evaluation

A nurse is conducting a health assessment. How will the information collected from the client be used? a) As a basis for the nursing process b) To illustrate nursing competence c) To facilitate nurse-client caring d) As one component of medical care

a) As a basis for the nursing process

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is a) Primary prevention b) Secondary prevention c) Tertiary prevention

a) Primary prevention

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.

a) The client's motivation for change.

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.

b) Focused or problem-oriented assessment.

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.

b) Making incorrect nursing judgments or diagnoses.

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) Provide information for the client's record b) Reassess previously detected problems c) Address areas previously omitted d) Determine the need for crisis intervention

b) Reassess previously detected problems

The nurse is collecting data from a client. Which of the following best reflects objective data? a) Religion b) Occupation c) Appearance d) Age

c) Appearance

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

c) Avoid biases and judgments

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

d) Empathy

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment? a) Inspection b) Observation c) Sympathy d) Empathy

d) Empathy

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.

d) Establish a baseline for the comparison of future health changes.

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

d) Evaluation

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

d) Formulation of nursing diagnoses

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

a) "I feel so tired sometimes." d) Client complains of a headache e) "My father died of a heart attack."

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.

a) Collecting information regarding the client's health status.

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? a) Feelings of happiness b) Posture c) Mood d) Behavior

a) Feelings of happiness

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of a) Healthy People 2020 b) The nursing process c) The Department of Health and Human Services d) The three levels of preventative care

a) Healthy People 2020

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

a) Inspection

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

a) Nursing intervention

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

d) Comprehensive

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.

a) Review the client's medical record.

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

a) The client's feelings of happiness

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.

b) Ask the client about the most recent experiences of pain.

How does a nurse best facilitate the nursing health assessment? a) Maintaining privacy b) Asking the appropriate questions c) Formulating a nursing diagnosis d) Creating a nursing care plan

b) Asking the appropriate questions

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

b) Environmental

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful? a) Physical assessment and health history. b) Individual student interview and questionnaire. c) Review of literature and consultation with faculty. d) Walk-through of education facility and faculty questionnaire.

b) Individual student interview and questionnaire.

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

c) Collect subjective data

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? a) Collect subjective data related to the client's overall health. b) Perform a rapid assessment for prompt treatment. c) Determine any changes from the baseline data. d) Evaluate whether outcomes of treatment are met.

c) Determine any changes from the baseline data.

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? a) Functional b) Focused c) Head-to-toe d) Body system

c) Head-to-toe

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? a) Initial b) Focused c) Ongoing d) Emergency

c) Ongoing

The nurse is exhibiting critical thinking in which client care situation? a) Notifying the healthcare provider of a critical lab result. b) Answering the client's call bell alarm while the nursing assistant is at lunch. c) Performing a focused assessment on a client who is complaining of shortness of breath. d) Transcribing medication orders onto the nurse's medication administration record.

c) Performing a focused assessment on a client who is complaining of shortness of breath.

A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client? a) The client's latest CD4 cell count b) The client's current body weight c) The client's pain level d) Presence of bacterial pneumonia on blood test results

c) The client's pain level

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.

c) The focused assessment addresses a particular client problem.

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.

d) Measure the client's blood glucose four times daily.

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.

d) Measuring the remaining tread on a car tire to determine whether it is time to replace it.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a) Holistic wellness status b) Developmental history c) Level of functioning d) Physiologic status

d) Physiologic status