Jensen Ch. 1

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) "I'm sorry, but assessment is ongoing and continuous." b) "Fortunately, assessment only needs to be done at the beginning of your stay." c) "I'll just need to evaluate you once more, at the end of your stay." d) "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end."

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

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 effectiveness of interventions b) A baseline for comparison with future findings c) Information on the nurse's cultural competence d) Data on the patient's prognosis for recovery

A baseline for comparison with future findings

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

Airway

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) Circulation b) Airway c) Breathing d) Disability

Airway

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? a) Appearance b) History of present health concern c) Occupation d) Family history

Appearance

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? a) History of present health concern b) Appearance c) Occupation d) Family history

Appearance

The nurse is collecting data from a client. Which of the following best reflects objective data? a) Age b) Occupation c) Religion d) Appearance

Appearance

What are nurses able to detect through the health assessment? a) Areas in need of health adjustments b) Areas that need in-hospital care c) Areas that need referral to a specialist d) Areas that need continuous care

Areas in need of health adjustments

What are nurses able to detect through the health assessment? a) Areas that need continuous care b) Areas that need referral to a specialist c) Areas in need of health adjustments d) Areas that need in-hospital care

Areas in need of health adjustments

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

Ask the client about the most recent experiences of pain.

How does a nurse best facilitate the nursing health assessment? a) Maintaining privacy b) Formulating a nursing diagnosis c) Asking the appropriate questions d) Creating a nursing care plan

Asking the appropriate questions

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 most important? a) Evaluation b) Implementation c) Assessment d) Planning

Assessment

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 most important? a) Implementation b) Assessment c) Evaluation d) Planning

Assessment

Which assessment finding should the nurse document as objective data? a) Personal relationships b) Lifestyle practices c) Body functions d) Biographical information

Body functions

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? a) Collect subjective data b) Document the data c) Validate the data d) Collect objective data

Collect subjective data

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? a) Validate the data b) Document the data c) Collect subjective data d) Collect objective data

Collect subjective data

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) Perform a musculoskeletal examination b) Obtain a 24-hour diet recall c) Take anthropometric measurements d) Collect subjective data related to overall function

Collect subjective data related to overall function

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? a) Identifying pain management interventions with input from the client b) Collecting data regarding the nature of the pain c) Teaching the client to draw knees to chest to help minimize the pain d) Planning care to help minimize the client's pain

Collecting data regarding the nature of the pain

What is a required component of a health assessment? a) Critical judgment b) Critical thinking c) Critical decision making d) Critical analysis

Critical thinking

What is a required component of a health assessment? a) Critical thinking b) Critical analysis c) Critical judgment d) Critical decision making

Critical thinking

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) Perform a rapid assessment for prompt treatment b) Evaluate whether outcomes of treatment are met c) Collect subjective data related to the client's overall health d) Determine any changes from the baseline data

Determine any changes from the baseline data

During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation? a) Determining whether the client wants to stop smoking b) Educating the client on the detrimental effects smoking has on the entire body. c) Sharing with the client that there are various smoking cessation methods available. d) Identifying smoking as a modifiable risk factor for the client.

Determining whether the client wants to stop smoking

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? a) Admissions clerk b) Diagnostic technician c) ED nurse d) Gastroenterologist

ED nurse

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) Inspection b) Palpation c) Empathy d) Sympathy

Empathy

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

Empathy

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) Evaluation b) Implementation c) Diagnosis d) Assessment

Evaluation

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) Implementation b) Evaluation c) Assessment d) Diagnosis

Evaluation

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 whether the client has achieved the outcome criteria of the treatment? a) Implementation b) Evaluation c) Diagnosis d) Assessment

Evaluation

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) Public mistrust of physicians b) Expansion of health care networks c) Decrease in client participation in care d) The shrinking cost of medical care

Expansion of health care networks

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) The shrinking cost of medical care b) Public mistrust of physicians c) Decrease in client participation in care d) Expansion of health care networks

Expansion of health care networks

A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? a) Focused assessment b) Comprehensive assessment c) Emergency assessment d) Ongoing assessment

Focused assessment

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) Omission of pertinent data needed to make a diagnosis b) Formation of judgments that may interfere with the interview c) Performance of unnecessary diagnostic tests d) Initiation of a referral that the client doesn't want

Formation of judgments that may interfere with the interview

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) Formation of judgments that may interfere with the interview b) Performance of unnecessary diagnostic tests c) Omission of pertinent data needed to make a diagnosis d) Initiation of a referral that the client doesn't want

Formation of judgments that may interfere with the interview

For which client should a nurse perform a focused assessment? a) Elevated blood pressure with no previous history of heart problems b) Right upper abdominal pain that radiates into the groin area c) Four-day history of sore throat and fever with enlarged lymph nodes d) Diabetic with elevated blood sugars for the past two weeks

Four-day history of sore throat and fever with enlarged lymph nodes

An assessment that concentrates on patterns of role performance that all humans share is called what? a) Body systems b) Focused c) Head-to-toe d) Functional

Functional

An assessment that concentrates on patterns of role performance that all humans share is called what? a) Head-to-toe b) Body systems c) Focused d) Functional

Functional *A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

Which of the following is an example of a recent trend in nursing roles? a) Gathering forensic evidence for a legal proceeding b) Using palpation to assess the abdomen of a pregnant woman c) Performing visual inspection of a client's eyes to detect illness d) Using auscultation to examine heart sounds

Gathering forensic evidence for a legal proceeding

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) Functional b) Body system c) Focused d) Head-to-toe

Head-to-toe

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) Functional b) Head-to-toe c) Focused d) Body system

Head-to-toe

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of a) the Department of Health and Human Services b) Healthy People 2020 c) the nursing process d) the three levels of preventative care

Healthy People 2020

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of a) the nursing process b) the three levels of preventative care c) the Department of Health and Human Services d) Healthy People 2020

Healthy People 2020

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 what level of prevention the patient is at c) Identify in what areas the patient needs the most care d) Identify the patient's medical diagnosis

Identify in what areas the patient needs the most care

As part of the nursing profession, nurses function as client advocates. What is one way in which a nurse advocates for a client? a) Providing client teaching about the family history of disease b) Keeping the client disease free c) Identifying the side effects of treatment d) Assisting families to optimal states of client interaction

Identifying the side effects of treatment *Nurses advocate for clients in many ways: keeping them safe, communicating their needs, identifying the side effects of treatment and finding better options, and helping clients to understand their diseases and treatments so that they can optimize self-care. Advocacy does not include teaching about a family's history of disease, assisting the family to optimal states of client interaction, or keeping the client disease free.

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) Interviewing b) Therapeutic communication c) Active listening d) Inspection

Inspection

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) Therapeutic communication b) Inspection c) Interviewing d) Active listening

Inspection

The nurse is performing a health assessment on a client. Which of the following would be most important for the nurse to do? a) Gather information from a variety of sources b) Focus the assessment on the client as an individual c) Interpret the information about the client in context d) Rely primarily on the client's statements

Interpret the information about the client in context

The nurse is performing a health assessment on a client. Which of the following would be most important for the nurse to do? a) Gather information from a variety of sources b) Focus the assessment on the client as an individual c) Rely primarily on the client's statements d) Interpret the information about the client in context

Interpret the information about the client in context

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) Corroborate the client's statements with trusted sources. c) Gather information from a variety of sources. d) Interpret the information about the client in context.

Interpret the information about the client in context.

When describing a focused assessment to a group of students, which of the following would the instructor include? a) It assesses a particular client problem. b) It is done before the physical exam. c) It replaces the comprehensive data base. d) It is done after gathering subjective data.

It assesses a particular client problem.

As a nurse becomes more proficient and comfortable in his or her role, what increases? a) Knowledge base and expertise b) Time management and confidence c) Expertise and time management d) Confidence and knowledge base

Knowledge base and expertise

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient? a) Acute pain b) Nutrition: less than body requirements c) Knowledge deficit d) Ineffective coping

Knowledge deficit

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient? a) Ineffective coping b) Nutrition: less than body requirements c) Knowledge deficit d) Acute pain

Knowledge deficit

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? a) Validating previous data b) Making clinical judgments c) Assisting the primary care provider d) Collecting accurate data

Making clinical judgments

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) Making incorrect nursing judgments or diagnoses b) Interjection of the nurse's thoughts or feelings into the data c) Relying on objective and subjective information d) Validating information that is already correct

Making incorrect nursing judgments or diagnoses

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) Interjection of the nurse's thoughts or feelings into the data d) Relying on objective and subjective information

Making incorrect nursing judgments or diagnoses

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

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

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

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

How does a nurse decide what health-promotion activities are necessary for a particular client? a) Nurses collaborate with clients to identify areas in which clients are willing to make changes b) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes c) Nurses assess areas in which clients are willing to make changes only d) Nurses address areas associated with healthy behaviors only

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

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 evaluation b) Nursing assessment c) Nursing intervention d) Nursing goal

Nursing intervention

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 intervention b) Nursing assessment c) Nursing goal d) Nursing evaluation

Nursing intervention

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable? a) Effective b) Objective c) Subjective d) Affective

Objective

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) Ongoing or partial c) Emergency d) Initial comprehensive

Ongoing or partial

Nurses provide both direct and indirect care. What is an example of indirect care? a) Participating in a client care conference b) Adjusting an IV rate c) Calculating a medication dosage d) Completing a nursing assessment

Participating in a client care conference

Nurses provide both direct and indirect care. What is an example of indirect care? a) Participating in a client care conference b) Completing a nursing assessment c) Calculating a medication dosage d) Adjusting an IV rate

Participating in a client care conference

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

Performing a focused assessemt on a client who is complaining of shortness of breath.

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

Performing a focused assessemt on a client who is complaining of shortness of breath.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? a) Secondary b) Holistic c) Tertiary d) Primary

Primary

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this? a) Primary prevention b) Secondary prevention c) Tertiary prevention d) Nursing prevention

Primary prevention

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is a) primary prevention b) tertiary prevention c) secondary prevention

Primary prevention

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason? a) Reassess previously detected problems b) Provide information for the client's record c) Determine the need for crisis intervention d) Address areas previously omitted

Reassess previously detected problems

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) Determine the need for crisis intervention b) Provide information for the client's record c) Reassess previously detected problems d) Address areas previously omitted

Reassess previously detected problems

Before meeting the client and performing a comprehensive health assessment, which of the following would be most important for the nurse to do? a) Consult essential resources. b) Validate information with the client. c) Review the client's medical record. d) Obtain basic biographic data.

Review the client's medical record.

In which situation should a nurse perform an emergency assessment of a client? a) Ear pain b) Shortness of breath c) Body rash d) Broken arm

Shortness of breath

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 affect b) The client's posture c) The client's feelings of happiness d) The client's behavior

The client's feelings of happiness

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 b) The client's affect c) The client's posture d) The client's behavior

The client's feelings of happiness

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? a) Focused assessment b) Ongoing assessment c) Emergency assessment d) Comprehensive assessment

The focused assessment addresses a particular client problem.

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2020 indicator of responsible sexual behavior? a) The importance of using a condom when engaging in sexual activity b) The importance of abstaining from sexual activity unless in a monogamous relationship c) The need for frequent diagnostic testing for sexually transmitted infections d) The need to reduce the percentage of adolescents who are HIV positive

The importance of using a condom when engaging in sexual activity

Why is the nurse always reassessing the patient for changes? a) To achieve the best results b) To always have the best nursing care plan c) To never make a mistake when providing care d) To update the nursing diagnosis

To achieve the best results

Four broad goals describe the role of a professional nurse. What is one of these goals? a) To advocate for individuals, families, communities, and populations b) To counsel about human responses to health or illness c) To prescribe medication d) To diagnose illness

To advocate for individuals, families, communities, and populations *(1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. Nursing goals do not include diagnosing illness, counseling about human responses to health or illness, or prescribing medications

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 evaluate whether outcomes of treatment are met b) To determine any changes from the baseline data c) To perform a rapid assessment for prompt treatment d) To collect subjective data related to the client's overall health

To determine any changes from the baseline data

A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision? a) Healthy People 2020 b) Health Belief Model c) Pender Health Promotion Model d) U.S. Preventive Services Task Force

U.S. Preventive Services Task Force

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is a) continuous. b) linear. c) performed only by nurses. d) completed on admission.

continuous.

A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? a) comprehensive b) focused c) ongoing partial d) emergency

focused

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) focused or problem-oriented assessment. c) ongoing or partial assessment. d) emergency assessment.

focused or problem-oriented assessment.

The result of a nursing assessment is the a) documentation of the need for a referral. b) prescription of treatment. c) client's physiologic status. d) formulation of nursing diagnoses.

formulation of nursing diagnoses.

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.

physiologic status

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

review the client's health care record.

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) make a list of appropriate nursing diagnoses b) collect all home medications brought to the hospital c) take a complete health history d) formulate a plan of care

take a complete health history

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply. a) "I feel so tired sometimes" b) Lungs clear to auscultation c) "My father died of a heart attack" d) Client complains of a headache e) Weight—145 lb f) Pupils equal, round, and reactive to light

• "I feel so tired sometimes" • "My father died of a heart attack" • Client complains of a headache

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. a) "I feel so tired sometimes." b) Pupils equal, round, and reactive to light c) Weight: 145 lbs d) Lungs clear to auscultation e) "My father died of a heart attack." f) Client complains of a headache

• "I feel so tired sometimes." • "My father died of a heart attack." • Client complains of a headache

What are the primary frameworks used in conducting a health assessment? Select all that apply. a) Body systems b) Head to toe c) Gordon's d) Analytical e) Functional

• Body systems • Head to toe • Functional

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply. a) Client complains of a headache b) Lungs clear to auscultation c) "I feel so tired sometimes" d) Pupils equal, round, and reactive to light e) Weight—145 lb f) "My father died of a heart attack"

• Client complains of a headache • "I feel so tired sometimes" • "My father died of a heart attack"

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) Formulation of nursing diagnosis(es) b) Development of a nursing care plan c) Identification of collaborative problems d) Identification of the need for referrals e) Assessment of the outcome of the care plan

• Identification of collaborative problems • Identification of the need for referrals • Formulation of nursing diagnosis(es)

What is paramount in health promotion? (Select all that apply.) a) Emphasizing the risks of poor health practices b) Working with the individual patient c) Demonstrating authority d) Limiting the involvements of the patient's friends and family e) Developing the nursing care plan

• Working with the individual patient • Developing the nursing care plan