Chapter 1 PrepU

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

A) formulation of nursing diagnoses.

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? A) Disability B) Airway C) Circulation D) Breathing

B) Airway

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) Diagnosis B) Evaluation C) Assessment D) Implementation

B) Evaluation

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

D) Nursing intervention

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Which findings will require follow-up? 1) Client is awake, alert, and oriented . 2) Client walks with a cane. 3) Abdomen is soft and nontender, 4) last bowel movement was charted 7 days ago . 5) No urine output has been charted in the last 24 hours . 6) Skin is warm, dry, pink, and intact . 7) Vital signs: temperature, 97.9°F (36.6°C); 8) heart rate 120 beats/min and irregular ; 9) oxygen saturations 88% on room air .

4, 5, 8, 9

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) Ask the client about the most recent experiences of pain. B) Meet with the client's spouse and daughter to discuss the client's pain. C) Collaborate with the physician who is treating the client. D) Review the client's medication administration record for analgesic use.

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

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

A) Head-to-toe

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

B) Body functions

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

B) Objective

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) Emergency B) Ongoing C) Initial D) Focused

B) Ongoing

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 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) Information on the nurse's cultural competence B) Information on the effectiveness of interventions C) Data on the client's prognosis for recovery D) A baseline for comparison with future findings

D) A baseline for comparison with future findings

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

D) Evaluation

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) Listening to a favorite song to relax in the evening D) Taking the dog for a walk in the park to get exercise

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

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? A) To perform a rapid assessment for prompt treatment B) To collect subjective data related to the client's overall health C) To evaluate whether outcomes of treatment are met D) To determine any changes from the baseline data

D) To determine any changes from the baseline data

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) creating an environment that encourages client autonomy C) developing an effective, respectful nurse-client relationship D) stabilizing the client's physical condition

A) collecting information regarding the client's health status

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) Head to toe D) Emergency

B) Body systems

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Diversification B) Technology C) Documentation D) Informatics

B) Technology

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? A) Assess the client. B) Administer IV fluids. C) Evaluate the outcome. D) Reevaluate the nursing plan.

A) Assess the client.

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? A) Evaluate outcome. B) Identify client concerns. C) Cluster client cues. D) Implement an intervention.

A) Evaluate outcome.

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

A) Expansion of health care networks

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) Active listening C) Therapeutic communication D) Interviewing

A) Inspection

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take? A) Perform an emergency assessment. B) Develop a nursing diagnosis. C) Conduct a partial assessment. D) Review the client's chart.

A) Perform an emergency assessment.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next? A) Validate that the client understands how to use the inhalers. B) Provide privacy for the client to administer the inhalers. C) Ask the client if they need any assistance with the inhalers. D) Leave the inhalers with the client to self-administer.

A) Validate that the client understands how to use the inhalers.

After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years. A) analysis of assessment findings B) development of priority nursing diagnosis C) documentation of subjective assessment findings D) implementation of interventions

A) analysis of assessment findings

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) Validating information that is already correct D) Relying on objective and subjective information

B) Making incorrect nursing judgments or diagnoses

A client admitted with a pulmonary embolism has been receiving continuous IV Heparin for the past 48 hours. The nurse reviews the client's chart containing the following information: ● 0800 VS: temperature 98.7F, blood pressure 120/74, heart rate 88, SpO2 95% 2L NC ● 1200 VS: temperature 98.6F, blood pressure 100/60, heart rate 99, SpO2 94% 2L NC ● Laboratory values on admission: hemoglobin 15 g/dL, hematocrit 40%, platelets 275,000 mm3 ● Laboratory values today: hemoglobin 11 g/dL, hematocrit 33%, platelets 175,000 mm3 What step of the nursing process should the nurse perform next? A) planning B) diagnosis C) intervention D) assessment

B) diagnosis