Foundations Exam 1 Chapter 11 Prep U

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment? Client Medical record Primary physician Charge nurse

Client

The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following? Perform a review of the problem areas Complete an exam of all body systems Focus on only the systems that the client is comfortable with Examine certain body systems

Complete an exam of all body systems

A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information? Read the client's chart. Consult with the client. Consult with the client's doctor. Consult nursing and medical literature.

Consult nursing and medical literature.

The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview? Focus on the computer so as not to make a mistake. Focus full attention on the client. Focus on notes so as not to make the client uncomfortable. Focus on interventions being planned for this client.

Focus full attention on the client.

The nurse is conducting a nursing/health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply. Strengths Health status Health problems Financial status Health risks

Health status Strengths Health problems Health risks

A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information? If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the patient is in bed, the nurse stands at the side of the bed. If both the nurse and patient are seated, their chairs are at right angles to each other, 1 foot apart. If the patient is in bed, the nurse stands at the foot of the bed.

If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

The nursing student is learning how to do a complete assessment by organizing the data into the different body systems. This is an example of which of the following types of assessment? Maslow's hierarchy model Medical model Prevention model Gordon's framework model

Medical model

The nurse records the name, age, and race of the client. These data are components of which of the following? Nursing or health history Physical assessment Patient interview Physical exam

Nursing or health history

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data? Objective Intuitive Hunches Subjective

Objective

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? Intuitive Objective Subjective Hunches

Objective

The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is mostly likely the cause of this action by the client? Pain Sleepiness Low anxiety Hunger

Pain

The nursing instructor is teaching about physical assessment and the best methods used for performing such an assessment. The instructor identifies a need for further education when one of the students makes which statement? Physical assessment is not routinely performed in a hospital setting. Physical assessment is the examination of the client for subjective data. Physical assessment is the examination of the client for objective data. Physical assessment is done only once and that's when the client is first seen.

Physical assessment is the examination of the client for subjective data.

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? Working phase Termination phase Preparatory phase Introductory phase

Termination phase

After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment? The results of the client's bone scan indicate decreased bone density. The client demonstrates an unsteady gait and spinal kyphosis. The client claims her mobility and independence have declined in recent years. The client's serum calcium levels are below the reference range.

The client claims her mobility and independence have declined in recent years

The nurse is conducting an admission assessment on a client who informs the nurse that dyspnea follows the exertion the client is experiencing. What would be the best way for the nurse to chart this data? I think the client needs to rest more to prevent dyspnea I think the client is having a problem with breathing The client seems to have trouble breathing at times The client reports feeling dyspneic after exertion

The client reports feeling dyspneic after exertion

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs the client's temperature is 102. 9 F. What should be the nurse's priority action? Inform the unlicensed assistant personnel to document the finding Verbally report the finding immediately to the client's physician Verbally report the finding to the charge nurse at the change of shift Reassess the client's temperature in 2 hours and chart this data

Verbally report the finding immediately to the client's physician

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? "Is there anything else we should know in order to care for you better?" "What do you envision for your care while you're here at the facility?" "What practices have you found especially helpful in other settings?" "What are your expectations from us and from yourself in your care?"

"Is there anything else we should know in order to care for you better?"

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply. A client describes his pain as an 8 on the pain assessment scale. A nurse observes a client wringing her hands before signing a consent for surgery. A client reports being cold and requests an extra blanket. A client's blood pressure is elevated following physical activity. A nurse observes redness and swelling at an IV site. A client feels nauseated after eating his breakfast.

A client describes his pain as an 8 on the pain assessment scale. A client reports being cold and requests an extra blanket. A client feels nauseated after eating his breakfast.

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment? Adds depth to existing information Provides breadth for future comparisons Gives a comprehensive volume of data Suggests possible problems

Adds depth to existing information

A nursing student is assisting with taking nursing, or health histories of all clients. The student identifies when is the best time to do a nursing/health history? After the client is settled and feels ready As soon as possible after a client presents for care Anytime before the client is discharged Within 24 hours of admission

As soon as possible after a client presents for care

The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview? Focus mainly on verbal comments Fill in the words for the client Fill in quiet spaces and pauses Avoid the impulse to interrupt

Avoid the impulse to interrupt

The nursing student has learned that when doing an assessment on any client, it is essential to get the most important information first. By doing so the nurse's action is an example of which of the following? Being factual Being able to prioritize Being complete Being purposeful

Being able to prioritize

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? During the collection of data only In the middle of the data-gathering process At the end of the data-gathering process Both during the collection and at the end of the collection

Both during the collection and at the end of the collection

Who or what is the primary source of information for a nursing history? Other health care personnel Previous medical records Family members The client

The client

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured his leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. The nurse prepares to meet the client by reading current and past records and reports. The nurse ensures that the interview environment is private and comfortable. The nurse recapitulates the interview, highlighting key points. The nurse initiates the interview by stating his/her name and status. The nurse assesses the client's comfort and ability to participate in the interview. The nurse arranges the seating in the interview room to facilitate an easy exchange of information.

The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports.

The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction? The nurse should introduce herself and give name and position. The nurse should show her name badge to the client so he can identify the nurse. The nurse should verify the client's name. The nurse should ask the client what name he would like to be called. The nurse should sit on eye level with the client.

The nurse should show her name badge to the client so he can identify the nurse.

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data? A client with inner ear infections reports dizziness. A client receiving chemotherapy reports nausea. A client states that she is feeling very anxious about her tests. The skin of a client who has liver failure has a yellowish tint.

The skin of a client who has liver failure has a yellowish tint.

When performing an assessment, the nurse should focus on the developmental stage for which client? Young adult Adolescent Toddler Middle-age adult

Toddler

The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action? asking the client whether the client has cultural preferences determining if the client's goals for wellness have been met developing a plan to manage the client's health problems coming up with the nursing diagnosis based on potential health risk

asking the client whether the client has cultural preferences

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: agrees with each of the client's statements. uses broad, open statements to communicate with the client. attempts to write down everything the client says. reassures the client of good outcomes.

uses broad, open statements to communicate with the client.

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? Focused Emergency Head-to-toe Time-lapse

Focused

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation? "Client states, 'I don't see the point in trying anymore.'" "Client makes statements indicating a loss of hope." "Client states that his rehabilitation will be unsuccessful." "Client is demonstrating signs and symptoms of depression."

"Client states, 'I don't see the point in trying anymore.'"

While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses? Documentation Listening Observation Caring

Observation

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? Client's wife Test reports Client's friends Client himself

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side". This statement is an example of which of the following? An inference A misinterpretation duplicate data A cue

A cue

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to: Body systems. Functional health patterns. Human response patterns. Human needs.

body systems.

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: develop the nursing plan of care. clarify the client's health status. review as much information as possible. identify actual and potential nursing diagnoses.

review as much information as possible.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The client reports eating all of today's breakfast." "The client's right leg is cold to the touch, from the knee to the foot." "The client's sister reports that the client has unrelieved pain." "The UAP reports blood in the client's stool."

"The client's right leg is cold to the touch, from the knee to the foot."

A nurse is assessing an energetic 80-year-old, admitted to the hospital with complaints of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this patient? Obtaining a detailed assessment of the patient's sexual history A full assessment of the urinary system A focused assessment of the specific problems identified Conducting a thorough systems review to validate data on the patient's record

A focused assessment of the specific problems identified

An unlicensed staff member asks the nurse what the difference is between a medical assessment and a nursing assessment. Which of the following is the nurse's best response? A nursing assessment looks at ways to cure the client's disease. A nursing assessment focuses on the client's response to health problems. A medical assessment focuses on cure. A medical assessment does not look at the pathology of health problems.

A nursing assessment focuses on the client's response to health problems.

The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which of the following statements made by a nursing student indicates a need for further instruction? Validation helps to keep data as free from error as possible Validation is the act of confirming or verifying Validation is an important part of assessment All data collected needs to be validated

All data collected needs to be validated

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of which of the following? A cue Duplicate data Erroneous data An inference

An inference

Which client situation most likely warrants a time-lapse nursing assessment? A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema. A client is being admitted to a general medicine unit after spending several days in the intensive care unit. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain.

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem from happening, which of the following should nurses do when beginning to collect assessment data? Organize all questions into categories Tell the client you will be quick Carefully review the client's record Make the questions short

Carefully review the client's record

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? Client has leukoplakia on her oral mucosa. Client is alert and oriented to person and place but not time or situation. Client has generalized myalgia or muscle pain. Client has ptosis, a drooping of the eyelid, on his right side. Client has a temperature of 102°F.

Client has generalized myalgia or muscle pain.

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment?

Client is unable to communicate basic needs and cannot perform hygiene measures with left

While caring for a client who has a problem related to digestion, a nurse has been referred by the primary care provider to be seen by a gastroenterologist. Which of the following parts of the client record should the nurse look at to see the recommendations made by the gastrointestinal specialist? Laboratory reports Medical history Progress notes Consultation

Consultation

An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? Focused assessment Emergency assessment Initial assessment Time-lapse assessment

Focused assessment

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? Initial assessment Emergency assessment Time-lapse assessment Focused assessment

Focused assessment

The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior? Pain High anxiety Sleepiness Hunger

High anxiety

A nursing student is conducting an interview with a client. Which of the following best demonstrates use of open-ended questions in an interview? Do you smoke? Do you participate in any illicit drugs? How are you feeling? Are you feeling well?

How are you feeling?

The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously? It makes the client feel as if the nurse is spending more time with them It is because the client's health status can change quickly It is because most facilities require it for reimbursement It gives the nurse more information to document on the client

It is because the client's health status can change quickly

Which statement defines the physical exam technique of auscultation? It is a technique in which one or both hands are used to strike the body surface in a precise manner to produce a sound. It is a visual examination of the client that is done in a methodical and deliberate manner. It is the specialized use of touch for data collection. I t is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify normal and abnormal sounds.

It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify normal and abnormal sounds.

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data? Physical Unreliable Subjective Objective

Objective

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? Subjective Objective Covert Symptomatic

Objective

he nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data? Pain rating is 7 Bilateral pedal edema 2+ Wheezing throughout lung fields Pupils equal and accommodate and react to light

Pain rating is 7

The nurse is preparing to perform an assessment on a newly admitted client. What should the nurse do prior to performing this initial assessment? Introduce the members of the healthcare team to the client Review the records available on the client Tell the client that you will do an assessment only if its convenient Report to the charge nurse what needs to be done on the client

Review the records available on the client

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? Limiting questions to those with yes or no answers Nodding frequently during the interview Sitting at eye level with the client Standing next to the client while interviewing

Sitting at eye level with the client

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg? Subjective Explanatory Severe Objective

Subjective

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? Limit the assessment to objective data. Perform the assessment in several short episodes rather than at one sitting. Obtain the client's records from admissions to other institutions. Supplement the client's information by speaking with family or friends.

Supplement the client's information by speaking with family or friends.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? The client tells the nurse that there is a burning sensation when voiding. The client's spouse reports the client experienced incontinence a few days ago. The provider orders the nurse to help the client void. The nurse tells the client to attempt to void.

The client tells the nurse that there is a burning sensation when voiding.

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that which of the following is the best place to get baseline data? The client recored from the physician's office The Medical record from a precious admission The initial comprehensive nursing assessment The focus assessment done when admitted to the ER

The initial comprehensive nursing assessment

While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate? The nurse should inform the client of these potential biases and obtain the client's opinion. The nurse should verify the information with one or two family members without informing the client. The nurse should consult with another nurse for that colleague's description of the assessment or observations. The nurse should document on the client's chart that the assessment data may be biased.

The nurse should consult with another nurse for that colleague's description of the assessment or observations.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment? The nurse's physical assessment will focus on pathologic conditions and their causes. The nurse's physical assessment will focus on the client's functional abilities. The physician's physical assessment will focus on the client's functional abilities. The physician's physical assessment will focus on pathologic conditions and their causes.

The nurse's physical assessment will focus on the client's functional abilities.

A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing? Complete Emergency Time-lapse Focus

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client? Time-lapsed assessment Focused assessment Emergency assessment Developmental stage assessment

Time-lapsed assessment

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next? Validate the data. Chart the data. Ignore the client's nonverbal behavior. Ignore the client's answer.

Validate the data

While admitting a teenage client who has a diagnosis of anorexia, the client informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? Record it in the client's record Inform the client that this cannot be correct Validate the weight loss with the client Ignore this information completely and continue collecting data

Validate the weight loss with the client

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value? Secondary Objective Subjective Primary

Objective

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply. 38-year-old man "My leg hurts." Height: 6' (1.82 m) Weight: 195 lb (89 kg) "I am afraid something serious is wrong".

38-year-old man Height: 6' (1.82 m) Weight: 195 lb (89 kg)

During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? Ask the client's husband to come in and answer the interview questions. Wait until the next day to obtain the answers to the interview questions. Ask the client to wake up and try to answer the interview questions. Ask the client if it is okay to interview her husband for the answers to the interview questions.

Ask the client if it is okay to interview her husband for the answers to the interview questions.

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. Types of data that the nurse should review before caring for this client include which of the following? Select all that apply. Consultations Salary history X-Ray reports Progress notes Medical history Lab reports

Consultations X-Ray reports Progress notes Medical history Lab reports

Which of the following is an example of a time-lapse reassessment? Bob is a nurse in a long-term skilled nursing facility. Noreen is a new client. Bob wants to gather information from Noreen, which includes her health status and any problematic health patterns, and to get a baseline for Noreen's overall functioning. Daren is a nurse in a hospital who happens to walk by a room and notices a client down on the floor. Daren immediately assesses the client for airway, breathing, and circulation. Once the presence of these three is established, Daren calls for help and begins a quick neurological exam. Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before. Joan is a nurse who is just coming on to her shift. She has received client reports from the nurse leaving the floor. To start off her day, she goes into each of her client's rooms and performs a focused physical assessment based on each individual's diagnosis.

Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before.

Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply. Competence Respect for client Caring Number of years in profession Professionalism

Respect for client Competence Professionalism Caring

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? The nursing supervisor The physician The nurse The case manager

The nurse