Health Assessment Chapter 1

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"

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

A. Assessment

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.

A. Identify medical problems that require immediate referral. B. Identify client problems that require nursing care. D. Identify collaborative problems that require interdisciplinary care. E. Identify need for client teaching and health promotion.

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

A. Palpation B. Inspection C. Percussion D. Auscultation

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

A. Reassess previously detected problems

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.

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

A. Spiritual B. Physiologic D. Sociocultural E. Psychological F. Developmental

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

A. The client's feelings of happiness

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

A. focused assessment

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

A. the client's medical diagnosis B. recent abnormal laboratory findings E. recent changes in the client's blood pressure readings

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

B. Nurse

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?"

B. "Are you aware of any allergies that you may have?"

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

B. A 45-year-old man with chest pain and diaphoresis for 1 hour

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

B. A 50-year-old client newly diagnosed with diabetes

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

B. ED nurse

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

B. Effect of health on functional status

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.

B. Interpret the information about the client in context

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.

B. It is ongoing and continuous.

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

B. Step 2

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

B. health care practices C. personal medical history D. number of pregnancies

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

B. physician's report C. B/P 135/78, heart rate 74 beats/min, respirations 16 breaths/min

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

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

C. Assuring valid conclusions from analyzed data

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

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

C. Collect subjective data

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

C. Focused assessment

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

C. The client's acuity

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.

C. The focused assessment addresses a particular client problem.

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)

C. the Alzheimer's Association (AA)

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

D. Making clinical judgments

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.

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

D. Make a clinical judgment

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.

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

D. enlarged lymph node in the neck

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

D. ongoing or partial assessment