Ch 1 Nurse's Role, Ch 2 Subjective Data, Ch 3 Objective Data, Ch 4 Validating and Documenting Data

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?"

A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?

A) Analysis

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

A) By interpreting the client's language and culture

A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?

A) Circle

While performing the initial assessment of a client, the client tells the nurse that this is his first hospitalization and that he has no previous surgeries. The nurse should document which of the following?

A) Client denies prior hospitalizations and surgeries

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate?

A) Ensuring client's privacy by providing an examination gown

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 nurse prioritize?

A) Establishing a trusting relationship

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says Absolutely not! There's no way I'll let you do that to me! Which response by the nurse would be most appropriate?

A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

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 which of the following?

A) Heart sounds

A nurse is assessing a female client whose worsening sciatica has prompted her to seek care. Which of the client's following statements would the nurse most likely need to validate?

A) I don't generally have problems with pain.

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first?

A) Inspection

A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse identify as a major advantage of this type of documentation?

A) It helps nurses to cluster assessment data.

A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?

A) It provides a chronologic source of client assessment data.

The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use?

A) Newspaper

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.

A surgical client's pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information?

A) Read the order back to the surgeon for confirmation.

A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?

A) Subjective data and objective data

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

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?

ANS: A) Assessment

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?

ANS: A) Expansion of health care networks

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 a bit sporadic. How should the nurse best respond to this assessment finding?

ANS: A) Identify a nursing diagnosis of Ineffective Health Maintenance.

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?

ANS: A) Inspection

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?

ANS: A) Natural senses

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?

ANS: A) Reassess previously detected problems

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?

ANS: A) Review the client's medical record.

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?

ANS: A) The client's feelings of happiness

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?

ANS: A) The client's motivation for change

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.

ANS: A, D, E

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?

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

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?

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

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?

ANS: B) ED nurse

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?

ANS: B) Effect of health on functional status

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?

ANS: B) Interpret the information about the client in context.

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?

ANS: B) It is ongoing and continuous.

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

ANS: C) A client who overdosed on acetaminophen

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?

ANS: C) Appearance

A nurse has 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?

ANS: C) Assuring valid conclusions from analyzed data

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?

ANS: C) Avoid biases and judgments

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?

ANS: C) Collect subjective data.

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?

ANS: C) Focused assessment

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?

ANS: C) The focused assessment addresses a particular client problem.

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.

ANS: C, B, A, E, D C) Collecting information about the client B) Determining client's nursing problem A) Identifying outcomes E) Carrying out interventions D) Determining outcome achievement

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?

ANS: D) Making clinical judgments

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?

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

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?

ANS: D) Public mistrust of physicians

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?

B) "How does that make you feel right now?"

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

B) Ask the client to bring all the medications and supplements to an interview.

A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?

B) Blood

A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following?

B) Documentation provides a permanent legal record of care given and not given.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

B) Explain the purpose of the interview.

A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions?

B) Feeling the surface structures using a circular motion

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?

B) Focused assessment form

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

B) Fungal infection

A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements?

B) I think this client would benefit from an antiemetic.

The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing?

B) Joint flexion/extension

A nurse is using a nursing minimum data set to document findings following the assessment of a client. This nurse is most likely providing care in which setting?

B) Long-term care facility

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 a 24-hour diet recall.

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.

The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination?

B) Speak clearly and slowly when explaining a procedure.

The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position?

B) Supine

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.

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate?

B) Try to minimize position changes.

A nurse is interviewing a 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

A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which of the following nursing actions would be most important to ensure accurate data when gathering the resident's information?

B) Validating the data

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

B) Working

A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?

C) "Are you allergic to any medications?"

A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?

C) "I go to a step class for an hour three times a week."

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

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

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"

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?"

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."

A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse?

C) Client has unkempt appearance and avoids eye contact

A task force has been established at a hospital with the aim of overhauling the assessment forms that are used throughout the facility. Which of the following options is most likely to help standardize the process of data collection?

C) Cued or checklist form

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data?

C) Dorsal hand surface

An instructor is describing various ways that a nurse can validate data to a group of nursing students. The instructor determines that additional teaching is necessary when the students identify which of the following as a reliable method?

C) Having the client repeat what was said

The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. Which of the following would the nurse emphasize as the major rationale for this action?

C) Promoting communication between disciplines

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

The nurse is using her fingerpads to palpate a client's body part during the physical examination. Which of the following would the nurse best be able to detect?

C) Pulses

The nurse is using the mnemonic "COLDSPA" to assess a client's complaint of lower 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

A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement?

C) Skin lesion size

The nurse is gathering the necessary equipment preparatory to examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain?

C) Tuning fork

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions?

C) Wearing gloves to palpate the tongue and buccal membranes

A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?

C) What support systems are in place to assist the client

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) When using the bell, push on it lightly.

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, beginning with the section obtained first.

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

The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment?

D) "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?

D) "Could you describe how you perform self-breast exams?"

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."

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."

The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position?

D) Abdomen

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

A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam?

D) Collect necessary equipment essential to the exam.

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?

D) Decreased range of motion in right shoulder

The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment?

D) Face shield

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?

D) It becomes the foundation for the entire nursing process.

A client has illuminated his call light and tells the nurse that he is having ten out of ten pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?

D) Perform further assessments addressing various aspects of the client's pain.

A small, rural hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?

D) The man had an inguinal hernia repair in 2008.

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.

A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?

D) Validation of data

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?

D) Vital signs