Chapter 1 - Nurse's Role in Health Assessment: Collecting & Analyzing Data

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order. 1. Identify abnormal data and strengths 2. Cluster the data 3. Draw inferences and identify problems 4. Propose possible nursing diagnoses 5. Check for defining characteristics of the diagnoses 6. Confirm or rule out nursing diagnoses

1. Identify abnormal data and strengths 2. Cluster the data 3. Draw inferences and identify problems 4. Propose possible nursing diagnoses 5. Check for defining characteristics of the diagnoses 6. Confirm or rule out nursing diagnoses

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides? A. A baseline for comparison with future findings B. Information on the effectiveness of interventions C. Data on the patient's prognosis for recovery D. Information on the nurse's cultural competence

A. A baseline for comparison with future findings

After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process? Select all that apply. A. Identification of the need for referrals B. Assessment of the outcome of the care plan C. Identification of collaborative problems D. Development of a nursing care plan E. Formulation of nursing diagnosis/es

A. Identification of the need for referrals C. Identification of collaborative problems E. Formulation of nursing diagnosis/es

In which situation should a nurse perform an emergency assessment of a client? A. Shortness of breath B. Ear pain C. Body rash D. Broken arm

A. Shortness of breath

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. Collecting data regarding the nature of the pain C. Planning care to help minimize the client's pain D. Identifying pain management interventions with input from the client

B. Collecting data regarding the nature of the pain

A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply. A. Development of a nursing care plan B. Identification of collaborative problems C. Assessment of the outcome of the care plan D. Formulation of nursing diagnosis(es) E.Identification of the need for referrals

B. Identification of collaborative problems E.Identification of the need for referrals D. Formulation of nursing diagnosis(es)

As a nurse becomes more proficient and comfortable in his or her role, what increases? A. Expertise and time management B.Knowledge base and expertise C. Time management and confidence D.Confidence and knowledge base

B. Knowledge base and expertise

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 patient'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. Relying on objective and subjective information B. Making incorrect nursing judgments or diagnoses C. Interjection of the nurse's thoughts or feelings into the data D. Validating information that is already correct

B. Making incorrect nursing judgments or diagnoses

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A.entry. B.comprehensive. C.focused. D.exploratory.

B.comprehensive.

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 rapport that exists between the nurse and the client C. the type and degree of physical issues the client is experiencing D.the nurse's ability to ask relevant questions

B.the rapport that exists between the nurse and the client

The client has a headache. What type of data is this? A. Objective B. Focused C. Subjective D.Comprehensive

C. Subjective

Which statement by the new nurse demonstrates an understanding of the nurse's responsibility to conduct an effective health assessment of the client? A. "A health assessment requires both a patient history as well as a physical examination." B. "The health assessment is the foundation of quality patient care." C. "I always allow sufficient time to conduct the history portion of the assessment effectively." D. "I am always trying to improve my assessment skills."

D. "I am always trying to improve my assessment skills."

Revising the plan as needed occurs in what part of the nursing process? A. Assessment B.Diagnosis C. Planning D. Evaluation

D. Evaluation

The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply. A. "Are you feeling dizzy now?" B. "Do you know what your blood pressure is usually?" C. "Do you know what may have caused you to fall?" D."What do you think will help you from falling again?" E. "Are you experiencing any pain at this time?"

E. "Are you experiencing any pain at this time?" A. "Are you feeling dizzy now?" B. "Do you know what your blood pressure is usually?"

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what? A. Functional status B.Only data involving the client complaint C. A focused assessment of the client complaint D. Family history for the past three generations

A. Functional status

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

A. Nursing process

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing? A. Formulating a discharge plan B. Assessing C. Diagnosing D. Intervening where necessary

B. Assessing

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? A. Holistic B. Primary C. Secondary D. Tertiary

B. Primary

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is A. performed only by nurses. B. linear. C. continuous. D. completed on admission.

C. Continuous.

What is one of the broad goals within nursing? A. To promote self-care B. To address mental health issues C. To treat human responses D. To form broad nursing diagnoses

C. To treat human responses

A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data? A. Subjective B. Realistic C. Concrete D. Objective

D. Objective

What is a required component of a health assessment? A. Critical thinking B. Critical decision making C. Critical judgment D. Critical analysis

A. Critical thinking

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to A. a healthy lifestyle B. the absence of disease C. changes in the environment D. stress reduction

A. a healthy lifestyle

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's A. physiologic status. B.level of functioning. C.developmental history. D. holistic wellness status.

A. physiologic status.

When assisting a patient with health promotion, what must the nurse also nurture? A. A healthy environment B. School/work attendance C. Family communication D. Knowledge of the Healthy E. People 2020 indicators

A. A healthy environment

How does a nurse best facilitate the nursing health assessment? A. Asking the appropriate questions B.Formulating a nursing diagnosis C. Creating a nursing care plan D. Maintaining privacy

A. Asking the appropriate questions

Data collection occurs where in the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

A. Assessment

Which assessment finding should the nurse document as objective data? A. Body functions B. Biographical information C. Lifestyle practices D. Personal relationships

A. Body functions

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client? A. Comprehensive B.Partial C. Emergency D. Focused

A. Comprehensive

What is a required component of a health assessment? A. Critical judgment B. Critical decision making C. Critical analysis D. Critical thinking

A. Critical Judgement

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse? A. Critical thinking B.Diagnostic reasoning C. Nursing care plan D.Physical assessment

A. Critical thinking

A patient 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 patient? A. Breathing B. Airway C. Circulation D. Disability

B. Airway

A young adult male nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what? A. Focused B. Head to toe C. Body systems D.Functional

B. Head to toe

The client has a murmur. This is what type of data? A. Subjective B. Objective C. Focused D.Comprehensive

B. Objective

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? A. "The health assessment will be more thorough if I wait until the client is pain free." B."I'm going to assess the client now so that I can begin formulating the care plan." C. "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." D. "I'll do the health assessment when the client's family leaves so that distractions will be minimal."

B."I'm going to assess the client now so that I can begin formulating the care plan."

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? A. Assessment B.Diagnosis C.Planning D.Evaluation

B.Diagnosis

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. "Have you tried to schedule a cleaning service?" B. "Are you friendly with your neighbors?" C. "Do you have family who visit you regularly?" D. "What amount of cleaning have you been doing in the past?"

C. "Do you have family who visit you regularly?"

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following? A. "Fortunately, assessment only needs to be done at the beginning of your stay." B. "I'll just need to evaluate you once more, at the end of your stay." C. "I'm sorry, but assessment is ongoing and continuous." D. "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end."

C. "I'm sorry, but assessment is ongoing and continuous."

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments? A. "The health care provider focuses on the treatment of human responses caused by diseases." B. "Both are the same and they serve to validate the information collected." C. "Nurses focus on the diagnosis and treatment of diseases." D. "Nurses focus on the diagnosis of actual human responses to disease or life events." SUBMIT ANSWER

C. "Nurses focus on the diagnosis and treatment of diseases."

A nurse performs a comprehensive assessment on a client. Which of the following components is included only in a comprehensive assessment? A. Circulatory assessment B. Assessment of the airway C. Complete health history D. Disability assessment

C. Complete health history

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A. A focused assessment involves all body systems, unlike a comprehensive assessment B. A focused assessment covers the body head to toe, unlike a comprehensive assessment C. A focused assessment occurs only in the clinic area, unlike a comprehensive assessment D. A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

D. A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings? A. Ambulatory care B. Public health C. Critical care D. Hospice

D. Hospice

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? A. The client's cooperation B. Onset of current symptoms C. How much time the nurse has D. The client's acuity

D. The client's acuity

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility? A. Take anthropometric measurements. B. Perform a musculoskeletal examination. C. Collect subjective and objective data related to overall function. D. Obtain a 24-hour diet recall.

C. Collect subjective and objective data related to overall function.

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first A. determine potential health care resources. B. plan for potential laboratory procedures. C. review the client's health care record. D. discuss the client's symptoms with other team members.

C. review the client's health care record.

What are the types of nursing assessments? (Select all that apply.) A.Physical B.Comprehensive C.Focused D. Mental E. Emergency

C.Focused E. Emergency B.Comprehensive

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.Synthesizing collected data D. Clarifying the client's ability to pay for health care E. Evaluating client outcomes

C.Synthesizing collected data E. Evaluating client outcomes B.Collecting information about the health status of the client

This type of assessment includes a health history and physical assessment. A. Emergency B. Focused C. Ongoing D. Comprehensive

D. Comprehensive

What is paramount in health promotion? (Select all that apply.) A. Working with the individual patient B.Emphasizing the risks of poor health practices C. Developing the nursing care plan D.Demonstrating authority E. Limiting the involvements of the patient's friends and family

A. Working with the individual patient C. Developing the nursing care plan

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data? A. Hemoglobin level 9.9 mg/dL B. Follows a Kosher diet C. Skin warm and dry D. Heart rate 72 and regular

B. Follows a Kosher diet

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. Focused B. Ongoing C. Initial D. Emergency

B. Ongoing

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. Initial comprehensive assessment. B. ongoing or partial assessment. C. focused or problem-oriented assessment. D. emergency assessment.

C. focused or problem-oriented assessment.

The result of a nursing assessment is the A. prescription of treatment. B. client's physiologic status. C. formulation of nursing diagnoses. D. documentation of the need for a referral.

C. formulation of nursing diagnoses.

What are the primary frameworks used in conducting a health assessment? Select all that apply. A. Body systems B.Analytical C.Head to toe D.Gordon's E. Functional systems

C.Head to toe A. Body systems E. Functional systems

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data? A. Whether the client is caring for any dependents at home B. What types of foods the client typically eats C. What type of work the client does D. The client's range of motion in her right arm

D. The client's range of motion in her right arm

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. developmental level B. physical C. social well-being D. environmental

D. environmental

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply. A. Gather assessment tools after meeting the client B. Determine knowledge of self-care based on age, education, and experience C. Check the client's status with the nurse of the previous shift D.Review the client's record before meeting the client E. Revise nursing care plans to reflect improvements in the clients condition

D.Review the client's record before meeting the client E. Revise nursing care plans to reflect improvements in the clients condition C. Check the client's status with the nurse of the previous shift

The RN is completing an admission database and must include priority nursing diagnoses for the plan of care. Which statement describes the purpose of nursing diagnosis? A. A clinical judgment about client responses to health difficulties. B.Identification of realistic, client-centered goals. C. To diagnose the condition and particular illness of the client. D. The collection of subjective and objective data.

A. A clinical judgment about client responses to health difficulties.

A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply. A. Declining numbers of medical students due to rising costs and focus on primary care B. Growing aging population with complex comorbidities C. Declining health care needs of single parents D. Increasing impact of children and the homeless on communities E. Increasing complexity of acute care

A. Declining numbers of medical students due to rising costs and focus on primary care E. Increasing complexity of acute care B. Growing aging population with complex comorbidities D. Increasing impact of children and the homeless on communities

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. Palpation B. Empathy C. Sympathy D. Inspection

B. Empathy

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? A. Subjective B. Objective C. Affective D. Effective

B. Objective

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to: A. validate the data collected. B. contribute to the medical diagnosis. C. document any physical symptoms the client may have. D. arrive at conclusions about the client's health.

D. arrive at conclusions about the client's health.

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas? A. Physiologic, psychological, sociocultural, developmental, and spiritual data B. Focuses only on the client's psychological, sociocultural, and spiritual well-being C.Focuses primarily on the client's physiologic development status D.Involves the client's musculoskeletal system and activities of daily living

A. Physiologic, psychological, sociocultural, developmental, and spiritual data

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

A. To establish a database against which subsequent assessments can be measured

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. avoid premature judgments about the client. C. consult with the client's family members. D. review any past collaborative problems.

B. avoid premature judgments about the client.

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be A. "each assessment is important and the nurse and doctor will get together to determine what orders need to be written." B. "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home." C. "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." D. "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately."

C. "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

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. Evaluation D.Implementation

C. Evaluation

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings? A. Critical care B. Ambulatory care C. Hospice D. Public health

C. Hospice

What are nurses able to detect through the health assessment? A. Areas that need in-hospital care B. Areas that need referral to a specialist C.Areas that need continuous care D. Areas in need of health adjustments

D. Areas in need of health adjustments

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. Evaluate whether outcomes of treatment are met B. Perform a rapid assessment for prompt treatment C. Collect subjective data related to the client's overall health D. Determine any changes from the baseline data

D. Determine any changes from the baseline data

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. Evaluation B. Planning C. Implementation D.Nursing diagnosis

D. Nursing diagnosis

Which of the following is the best example of assessment in everyday life? A. Measuring the remaining tread on a car tire to determine whether it is time to replace it B. Texting a friend to let her know that you made it home safely C. Taking the dog for a walk in the park to get exercise D. Listening to a favorite song to relax in the evening

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

An assessment that concentrates on patterns of role performance that all humans share is called what? A. Focused B. Functional C. Body systems D. Head-to-toe

B. Functional

The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient? A. Health history B. Physical examination C. Planning care D. Goal setting

B. Physical examination

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 construct their own theories to identify perceptions, barriers, and positive outcomes C. Nurses collaborate with clients to identify areas in which clients are willing to make changes D. Nurses assess areas in which clients are willing to make changes only

C. Nurses collaborate with clients to identify areas in which clients are willing to make changes

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. Asks unlicensed staff to measure vital signs B.Focuses on the system that caused the hospitalization C. Follows the ABC approach D. Uses evidence-based techniques

D. Uses evidence-based techniques

As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?". Based upon the client's behavior, which assessment will the nurse now focus upon? A. Mental B. Interpersonal C. Physical D. Spiritual

A. Mental

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks? A. Can you remember when you first started to feel dizzy?" B. "What do you mean by 'a little dizzy'?" C. "Have you ever been dizzy enough to fall?" D."Do you often feel dizzy?"

B. "What do you mean by 'a little dizzy'?"

When making rounds, the RN should prioritize follow-up care for which client? A. A client with strong, equal pedal pulses following catheterization. B. A client who is receiving intravenous antibiotics for pneumonia. C. A client who is due for a routine shift assessment. D. An oncology client with a cough but no fever.

D. An oncology client with a cough but no fever.

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment? A. Sympathy B.Observation C.Inspection D. Empathy

D. Empathy

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply. A. Wellness teaching B.Physical examination C. Medication administration D. Health history E.Outcome identification

D. Health history B.Physical examination

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? A. Emergency B. Focused C. Ongoing D. Comprehensive

C. Ongoing

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 goal B. Nursing intervention C. Nursing evaluation D. Nursing assessment

B. Nursing intervention

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? A. Focused or problem-oriented B. Emergency C. Ongoing or partial D. Initial comprehensive

C. Ongoing or partial

For which of the following clients should a nurse perform a focused assessment? A. Client with right upper abdominal pain that radiates into the groin area B. Client with elevated blood pressure with no previous history of heart problems C. Diabetic with elevated blood sugars for the past 2 weeks D. Client with 4-day history of sore throat and fever with enlarged lymph nodes

D. Client with 4-day history of sore throat and fever with enlarged lymph nodes

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? A. Comprehensive B. Body systems C. Functional D. Head to toe

B. Body systems

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. the client's family B.history organization C.standards of care D.Healthy People 2020 E. the client's past medical history

D.Healthy People 2020

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. Individual student interview and questionnaire B. Review of literature and consultation with faculty C. Physical assessment and health history D. Walk-through of education facility and faculty questionnaire

A. Individual student interview and questionnaire

Which of the following is the best example of holistic data collection by a nurse? A. Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings B. Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test C. Performing an x-ray, ECG, exercise stress test, and complete blood count D. Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate

A. Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

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

A. 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 pain level B. The client's latest CD4 cell count C. Presence of bacterial pneumonia on blood test results D. The client's current body weight

A. The client's pain level

What is the primary purpose of health assessment? A. To gather information about the health status of the client B. To decide on the best way to manage a client's illness based on the nurse's own views and beliefs C. To make judgments about the client's lifestyle and behaviors that contribute to the patient's illness D. To help the physician diagnose illness without further testing

A. To gather information about the health status of the client

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first A. take a complete health history B. collect all home medications brought to the hospital C. formulate a plan of care D. make a list of appropriate nursing diagnoses

A. take a complete health history

What is one way nurses use critical thinking in regard to the nursing process? A. Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions 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 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

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation? A. Performance of unnecessary diagnostic tests B. Formation of judgments that may interfere with the interview C. Initiation of a referral that the client doesn't want D. Omission of pertinent data needed to make a diagnosis

B. Formation of judgments that may interfere with the interview

Which of the following statements best conveys the rationale for health promotion in a school setting? A. Children contract numerous communicable diseases in the school environment. B. Healthy child development is a critical health determinant because of its implications for lifelong health. C. Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. D. Children younger than 13 years are some of the most common consumers of acute health care services.

B. Healthy child development is a critical health determinant because of its implications for lifelong health.

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: A. Ascertaining past and current use of health care services B. Using reputable health-education strategies to reduce risk behaviours C. Determining client stress levels related to lifestyle choices D. Understanding the health problems that clients experience in everyday life

B. Using reputable health-education strategies to reduce risk behaviours

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process? A. Validating information that is already correct B.Making incorrect nursing judgments or diagnoses C. Relying on objective and subjective information D.Interjection of the nurse's thoughts or feelings into the data

B.Making incorrect nursing judgments or diagnoses

A nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client? A. U.S. Preventive Services Task Force B. Healthy People 2020 C. Health Belief Model D. Pender Health Promotion Model

C. Health Belief Model

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. Body system B. Functional C. Focused D. Head-to-toe

D. Head-to-toe

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse? A. Begin CPR B. If the client is injured, protect the cervical spine C. Ensure that the client is safe D. Open the client's airway

D. Open the client's airway

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.) A. How will the client use her left arm? B. How will the client drive? C. How will the client get home from the hospital? D. Who will be there to help the client with ADLs? E. How will the client cook and eat?

D. Who will be there to help the client with ADLs? C. How will the client get home from the hospital? E. How will the client cook and eat?

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next A. document conclusions. B. draw inferences and identify problems. C. cluster the data collected. D. check for the presence of defining characteristics.

D. check for the presence of defining characteristics

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. None, the cardiac catheterization will provide all needed information B.Comprehensive C.Focused D.Emergency

D.Emergency

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what? A. Identify in what areas the patient can educate his or her family B. Identify in what areas the patient needs the most care C. Identify the patient's medical diagnosis D. Identify what level of prevention the patient is at

B. Identify in what areas the patient needs the most care

Reflection of the nurse upon personal feelings prior to the initial encounter with a client may help to avoid the occurrence of what situation? A. Initiation of a referral that the client doesn't want B. Omission of pertinent data needed to make a diagnosis C. Performance of unnecessary diagnostic tests D. Formation of judgments that may interfere with the interview

D. Formation of judgments that may interfere with the interview

Why is the nurse always reassessing the patient for changes? A. To never make a mistake when providing care B. To always have the best nursing care plan C. To achieve the best results D. To update the nursing diagnosis

C. To achieve the best results

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. developing an effective, respectful nurse-client relationship B. creating an environment that encourages client autonomy C. collecting information regarding the client's health status D. stabilizing the client's physical condition

C. collecting information regarding the client's health status