Exam 1

9. A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewıng a client from a minority culture, the nurse has enlisted the assistance of culture broker How can this individual best facilitate the client's care ?

A) By interpreting the client's language and culture culturally

16. A nurse is assessing a client who is exhibiting decorticate posturing. Which of the following would the nurse observe

B) Internally rotated lower extremities

15. A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status?

B) Obtain 24-hour diet recall.

19. 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

5. Which of the following client situations would the nurse interpret as requiring an emergency assessment?

C) A client who overdosed on acetaminophen

18. A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression?

C) ilt usually takes me over an hour to fall asleep.

15. A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following?

A) Harardous and harmful alcohol use

17. 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 whic of the following?

A) Heart sounds

13. A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the "P"?

A) What makes it worse?"

20. A nurse is appraising a colleague's assessment technique as part of a continuing performing which of the following actions?

B) Feeling the surface structures using a circular motion

14. A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

C) "Menarche at age 13

12. A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

C) "What is your major health concern at this time?

3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?

C) "You must quit smoking because it affects others, not only you." D)

17 A nurse 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?

C) Assuring valid conclusions from analyzed data

18. 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?

C) Collect subjective data.

22. The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lowea 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?

C) Severity

29. 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?

C) The client's acuity

7. 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

21. A nurse is providing care for a client who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. As well, the client makes statements that are not grounded in reality. What nursing diagnosis is suggested by these assessment data?

B) Acute Confusion related to hepatic encephalopat

6. 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?

B) Effect of health on functional status

2. A nurse is interpreting and validating information from an older adult client who has been experiencing functional decline. The nurse is in which phase of the interview?

B) Working

15. 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?

D) Technology

22. A client has presented to the emergency department (ED) with a lower leg laceration that she suffered ìwhile I was on a bender last night.î The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment?

D) ìHave you ever felt guilty about your alcohol use?î

16. 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?

D) Blunt percussion

16. 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

21. 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) ìI feel so tired sometimes.î B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) ìMy father died of a heart attack.î F) Pupils equal, round, and reactive to light

A.D.E

5. A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted chent. Which of the followıng would the nurse identify as an example of a closedLended.cuestion or statement?

C) "Are you allergic to any medications?"

23. The nurse is obtaining information about a client's past health history. Which statement would best reflect this component of assessment?

C) "I had surgery 5 years ago to repair an inguinal hernia.

11. 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?

C) Appearance

11. A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?

D) "This helps us have an appropriate focus for the physical examination."

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

ED Nurse

Health History 1. A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the murse prioritize?

Establishing a trusting relationship

1. A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client?,

Making clinical judgement

12. 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?

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

25. The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginnıng with the section obtained first.

A) Family health history B) Reason for seeking care C) Biographic data Dy Review of body systems E) History of present concern F) Past health history

26. A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best respond to this assessment finding?

A) Identify a nursing diagnosis of Ineffective Health Maintenance.

23. 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

14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession?

A) Natural senses

7. 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) Promise to find out the information for the client.

8. 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

27. A nurse in the emergency department is utilizing the SAD PERSONAS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool?

A) The client may have a high risk for suicide.

27. 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

8. The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

A) The client's sensory abilities

24. 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

9. 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?

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

13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

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

17. The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the cars. The nurse would most likely interperet this to indicate that the client is experiencing which of the following?

B) Anxiety

30. 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?

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

3. 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? others

B) It is ongoing and continuous.

6. A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint?

B) Provide a laundry list of descriptive words.

19. A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment?

B) The diaphragm should be held firmly against the body part.

4. A nurse is interviewing 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?

B) Using a moderate amount of eye contact client

10. 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?

C) Avoid biases and judgments

25. 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

C) Focused assessment

24. 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?

C) Providing a laundry list of descriptors when needed

24. The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eye

C) Speak to the client clearly from a close distance.

20. 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?

C) The focused assessment addresses a particular client problem.

23. A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the client's mental status?

C) The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

18. 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?

C) iWhen using the bell, push on it lightly î

22. The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes B) Determining client's nursing problem C) Collecting information about the client D) Determining outcome achievement E) Carrying out interventions

C,B, A,E,D

10. 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?

D) "You're certainly justified in being upset, but I am ready to begin your exam now."

28. 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?

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

15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions?

D) Use both hands to depress the skin 1 to 2 inches.

4. 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?

Review the client medical records.