Chapters 1-4
A nurse is interpreting and validating information from the client. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing
b
A 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. B) Ignore the question by changing the subject. C) Tell the client to only take prescribed medication. D) Encourage the client to ask the pharmacist.
a
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "No! I will not let you do that to me!" Which response by the nurse would be most appropriate? A) Respect the client's wishes and omit the pelvic exam. B) Tell the client that she needs to have the Pap smear to check for cancer. C) Ask the client if she would like someone else to do the exam. D) Proceed with the pelvic exam even if the client protests.
a
A group of nursing students are 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. B) It creates a data base for care that was not rendered to the client. C) It replaces the client acuity classification system. D) It directly formulates the nursing diagnoses.
a
A group of students is reviewing information about the potential opportunities for nurses with advanced assessment skills. The students demonstrate that they understand the information when they identify which of the following as helping to promote this role? A) Expansion of health care networks B) Decrease in client participation in care C) Restraints in the cost of medical care D) Broadening of the base of biomedical data
a
A nurse is creating a genogram for a client's family health history. The nurse would use which of the following to denote the client's female relatives? A) Circle B) Square C) Triangle D) Rectangle
a
A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? A) Feelings of happiness B) Posture C) Mood D) Behavior
a
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 include as the purpose of this type of documentation? A) It helps cluster data B) It provides lines for comments. C) It includes specialized data D) It standardizes data collection.
a
A nurse is starting a new job at a long-term care facility. Which initial assessment documentation form would the nurse most likely expect to use? A) Nursing minimum data set B) Cued or checklist forms C) Integrated cued checklist D) Open-ended forms
a
A nurse is using a cardiovascular assessment documentation form. The nurse understands that this is an example of which type of form? A) A focused area assessment form B) An ongoing assessment form C) A frequent assessment form D) An initial assessment form
a
A nurse obtains the following information from a client. Which statement would the nurse need to validate? A) "I've recently lost 20 pounds." B) "I feel very weak and tired." C) "I've had two cesarean deliveries." D) "I am generally healthy and happy."
a
After explaining the skills used to gather subjective and objective data, the instructor determines that additional teaching is needed when the students identify which of the following as a skill necessary for collecting subjective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening
a
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following? A) Subjective data and objective data B) Interpretation and inference C) Observation and inspection D) Data and results
a
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) Assessment B) Planning C) Implementation D) Evaluation
a
An instructor is describing the four basic physical examination techniques and their sequence. The instructor determines that the teaching was successful when the students identify which technique as always being done first? A) Inspection B) Palpation C) Percussion D) Auscultation
a
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 on to perform assessment? A) Natural senses B) Biomedical knowledge C) Technology D) Critical pathways
a
Before meeting the client and performing a comprehensive health assessment, which of the following would be most important for the nurse to do? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult essential resources. D) Validate information with the client.
a
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) Address areas previously omitted D) Determine the need for crisis intervention
a
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 B) Providing a comfortable, warm room temperature C) Arranging exam equipment on a bedside tray table D) Explaining why standard precautions are being used
a
The nurse is preparing to assess a client's near vision. Which of the following would be most appropriate for the nurse to use? A) Newspaper B) Snellen chart C) Ophthalmoscope D) Penlight
a
The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first? A) Sensory abilities B) General intelligence C) Severe phobias D) Irrational cognition
a
The nurse is using the bell of a stethoscope to assess which of the following? A) Heart murmurs B) Bowel sounds C) Breath sounds D) Femoral pulses
a
When beginning the collection of the client data base, which of the following would be most important for the nurse to do? A) Establish a trusting relationship B) Determine the client's strengths C) Identify health problems D) Make inferences
a
When interviewing a Hispanic client, the nurse enlists the assistance of a "culture broker," based on the understanding that this person's primary function is to: A) Interpret the language and culture. B) Evaluate the client's health practices. C) Teach the client about health care. D) Make the client feel comfortable and safe.
a
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? A) Objective data B) A genogram C) Past health history D) Family history data
a
When using the mnemonic COLDSPA, which question would be most appropriate to use to evaluate the "P"? A) "What makes it worse?" B) "When did it start?" C) "How does it feel?" D) "What does it look like?"
a
Which method of validation would be most appropriate when the nurse is unsure if a murmur is heard when assessing heart sounds? A) Verify with another health care professional. B) Recheck through reassessment. C) Compare objective data with subjective data. D) Clarify data with the client.
a
The activities below reflect the steps of the nursing process. Place the activities 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
a b c d e
Selected sections of a health history are listed below. Place them in the correct sequence, beginning with the section that is obtained first. A) Family health history B) Reason for seeking care C) Biographic data D) Review of body systems E) History of present concern F) Past health history
a b c d e f
A nurse is preparing an in-service education program for a group of staff nurses about documentation, including documentation of assessment data. The nurse demonstrates understanding of the significance of documentation by including a discussion of which of the following as playing a role in this area? Select all that apply. A) Joint Commission B) State nurse practice act C) Medicare D) Local city government E) Institutional agency
a b c e
The nurse is evaluating the setting for a client's physical examination. The nurse ensures that the setting has which of the following? Select all that apply. A) Adequate lighting B) Cool room temperature C) Quiet surroundings D) Soft chair or table E) Table for equipment F) Door or curtain
a c e f
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) Weight—145 lb C) Lungs clear to auscultation D) Client complains of a headache E) "My father died of a heart attack" F) Pupils equal, round, and reactive to light
a d e
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Swelling
a e f
A client is having difficulty describing a chief complaint of chest pain. Which action by the nurse would be most appropriate? A) Ignore the complaint for now and return to it later. B) Provide a laundry list of descriptive words. C) Restate the question using simple terms. D) Wait in silence until the client can determine the correct words.
b
A client states, "My wife died two months ago today." Which of the following responses would be most appropriate? A) "What did she die of?" B) "How does that make you feel?" C) "You probably must be sad." D) "Are you feeling sad, depressed, angry, or upset?"
b
A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can detect bowel sounds. D) The binaurals connect the tubing to the chest piece.
b
A new graduate nurse asks another more experienced nurse about the best way to assess a client's dietary habits. Which suggestion would be most appropriate? A) Ask the client to explain the food pyramid. B) Obtain a 24-hour diet recall. C) Ask about the contents of one meal. D) Determine how often the client eats.
b
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions
b
After performing an anal exam for prostate enlargement/tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? A) Parasites B) Blood C) Bacteria D) Fungus
b
In comparison with the physician's medical exam, the comprehensive health assessment performed by the nurse focuses on which aspect? A) Current physiologic status B) Effect of health on lifestyle C) Past medical history D) Motivation for compliance
b
The nurse demonstrates the proper technique for light palpation by which of the following? A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the nondominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure
b
The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) A 3-year-old child with an acute ear infection D) A teenager seeking information about contraception
b
The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? A) Extremity edema B) Joint flexion/extension C) Two-point discrimination D) Vibratory sensation
b
The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate? A) Collaborating with the client to identify problems B) Explaining the purpose of the interview C) Determining the client's reason for seeking care D) Obtaining family health history data
b
The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness
b
The nurse is performing a health assessment on client. Which of the following would be most important for the nurse to do? A) Focus the assessment on the client as an individual B) Interpret the information about the client in context C) Rely primarily on the client's statements D) Gather information from a variety of sources
b
The nurse is preparing to assess a client's peripheral pulses. The nurse would place the client in which position? A) Sitting B) Supine C) Sims D) Prone
b
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? A) Complete the examination as quickly as possible. B) Speak clearly and slowly when explaining a procedure. C) Begin the examination with auscultation instead of inspection. D) Maintain the supine position for each part of the examination.
b
The nurse is using a Wood's light for a client complaining of itching, burning, and peeling of the skin between the toes. The nurse is assessing for which of the following? A) Parasitic infection B) Fungal infection C) Bacterial infection D) Allergic reaction
b
The nurse is working in an ambulatory care clinic. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 35-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg
b
The nurse obtains the following information. The nurse would need to validate the data for which client? A) A new mother who says she is tired B) A client who is laughing and talking with a temperature of 104°F C) A young girl with a small right lower quadrant scar who reports she had an appendectomy D) A man who has been a diabetic for 25 years
b
When discussing the nursing process with a group of students, which of the following statements best describes it? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.
b
When performing a physical examination of an older adult client, which of the following would be most appropriate? A) Omit intrusive parts of the exam. B) Try to minimize position changes. C) Allow client to remain dressed. D) Dim the room light.
b
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment? A) Physician B) Nurse C) Secretary D) Technician
b
Which method would be most appropriate to determine a client's medication and substance use? A) Ask the client to identify which medications he or she is taking every day. B) Ask the client to bring all the medications and supplements to the interview. C) Ask the caregiver whether the client is taking the prescribed medications. D) Ask the client whether he or she takes any over-the-counter medications.
b
Which of the following would be most important to ensure accurate data when gathering client information? A) Documenting the data B) Validating the data C) Identifying client support systems D) Determining client needs
b
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) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment
c
A client who had a mastectomy is being discharged home. The client lives alone. Which data would be most important to validate for this client? A) If the client has transportation for follow-up appointments B) If the client usually functions independently C) What support systems are in place to assist the client D) If the client has a religious belief regarding illness
c
A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication? A) Attitude B) Silence C) Laundry list D) Facial expression
c
A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation? A) Client appears upset about upcoming surgery. B) Client was interviewed about previous history of hypertension C) Skin pale, warm, and dry without evidence of lesions D) Client's oral intake is satisfactory
c
A nurse has completed gathering some basic data about a client and then reflects on personal feelings about the client. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care
c
A nurse is explaining the facility's open-ended form for documentation to a group of new nursing employees. Which of the following would the nurse give as the primary reason for using this form? A) Prevents missed questions B) Combines assessment data with nursing diagnosis C) Individualizes information D) Meets needs of multiple data users
c
After teaching a group of students about the review of systems component of the health history, the instructor determines that the teaching was successful when the students identify which data as an example? A) "High school diploma plus 2 years of college" B) "Caregiver reliable source of information" C) "Menarche at age thirteen" D) "Lungs clear to auscultation bilaterally"
c
After teaching a group of students about verbal communication techniques, the instructor determines that the teaching was successful when the students identify which of the following as an example of a closed-ended question/statement? A) "What is your relationship with your children?" B) "Tell me what you eat in a normal day." C) "Are you allergic to any medications?" D) "What is your typical day like?"
c
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? A) Plastic tubing should be longer than 3 feet. B) The bell is used after using the diaphragm. C) When using the bell, push on it lightly. D) A diaphragm picks up low-pitched sounds.
c
During an in-service presentation, the presenter stresses the importance of accurate and thorough documentation for which reason? A) Guarantee a continual assessment process. B) Identify abnormal data. C) Assure valid conclusions from analyzed data. D) Allow for drawing inferences and identifying problems.
c
For which of the following would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? A) Mid-arm circumference B) Client's height C) Skin lesion size D) Pupillary size
c
The instructor is describing the various types of initial assessment documentation forms. The instructor determines that the teaching was successful when the students identify which form helping to standardize data collection? A) Open-ended B) Integrated cued checklist C) Cued/checklist D) Nursing minimum data set
c
The nurse is applying standard precautions by performing which of the following? A) Washes the hands between examination of each body part B) Discards in the trash can the safety pin that was used to assess sensory perception C) Wears gloves to palpate the tongue and buccal membranes D) Wears gown, gloves, and mask during the physical exam
c
The nurse is assessing the client's activity and exercise level. Which client statement would indicate to the nurse that the client is getting the recommended amount of exercise? A) "I walk on the treadmill once or twice a week." B) "I play basketball with a team each week." C) "I go to an aerobics class for 1 hour three times a week." D) "I swim for 30 minutes each Saturday morning."
c
The nurse is collecting data from a client. Which of the following best reflects objective data? A) Religion B) Occupation C) Appearance D) Age
c
The nurse is explaining the role of documenting the initial and ongoing assessment data base. Which of the following would the nurse emphasize as major reason? A) Reduce fragmentation of care B) Minimize incorrect conclusions from data C) Promote communication between disciplines D) Facilitate achievement of professional standards
c
The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. Which of the following would the nurse obtain? A) Penlight B) Tongue depressor C) Tuning fork D) Otoscope
c
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this aspect? A) "My mom's still alive but my dad died 10 years ago of heart failure." B) "I have a brother with leukemia and a sister with hypertension." C) "I had surgery 5 years ago to repair an inguinal hernia." D) "I have been having some pain when I urinate for the last several days."
c
The nurse is using the fingerpads of the hand to palpate a body part. Which of the following would the nurse be able to detect? A) Temperature B) Vibrations C) Crepitus D) Fremitus
c
The nurse is using the mnemonic, COLDSPA, to assess a client's complaint of abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset C) Severity D) Pattern
c
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 information? A) Finger pad surface B) Palmar hand surface C) Dorsal hand surface D) Ulnar hand surface
c
When describing a focused assessment to a group of students, which of the following would the instructor include? A) It is done before the physical exam. B) It replaces the comprehensive data base. C) It assesses a particular client problem. D) It is done after gathering subjective data.
c
When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? A) Collect objective data B) Validate the data C) Collect subjective data D) Document the data
c
Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A client with severe sunburn B) A client needing an employment physical C) A client who took a drug overdose D) A client who wants a pregnancy test
c
Which of the following questions would be most important for the nurse to ask first when obtaining the health history? A) "Do you have adequate health insurance coverage?" B) "Are you generally fairly healthy?" C) "What is your major health concern at this time?" D) "Did you bring all your medications with you?"
c
Which of the following statements best reflects appropriate documentation? A) "Client depressed because of fear of breast biopsy" B) "Client with lower back pain" C) "Client unkempt appearance, avoids eye contact" D) "Client has clear lung sounds in right and left lungs"
c
Which statement by the nurse could be construed as judgmental? A) "How often do your adult children visit?" B) "Your husband's death must have been difficult for you." C) "You must quit smoking because it is offensive to others." D) "How do you feel about getting older?"
c
A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process? A) Evaluation B) Implementation C) Planning D) Analysis.
d
A nurse is working in a health care facility that using charting by exception. Which of the following would the nurse expect to document? A) Liver palpation normal B) No tenderness on palpation C) Bowel sounds normoactive D) Aching, burning pain in lower back
d
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use? A) A screening tool that assesses specific risks B) An integrated cued checklist C) An abbreviated admission data sheet D) An assessment flow chart
d
An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose? A) Collect accurate data B) Assist the physician C) Validate previous data D) Make a clinical judgment
d
An instructor is explaining the technique for deep palpation, describing it as which of the following? A) Using one hand and depressing the skin 1 centimeter B) Using the dominant hand to depress the skin one-half to three-quarters of an inch C) Using both hands to depress the skin one-half of an inch D) Using both hands to depress the skin 1 to 2 inches
d
The nurse compares subjective data and objective data to achieve which of the following? A) Formulation of nursing diagnoses B) Identification of missing data C) Determination of documentation form to use D) Validation of data
d
The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data? A) "Do you always wear your seatbelt when driving?" B) "How much beer, wine, or alcohol do you drink?" C) "Do you use condoms with each sexual encounter?" D) "Could you describe how you perform self-breast exams?"
d
The nurse is preparing to perform a physical examination on a client. The nurse would begin with which of the following examinations? A) Head and neck B) Lymph glands C) Breast exam D) Vital signs
d
The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which of the following? A) Eye goggles B) Face mask C) Cover gown D) Face shield
d
The nurse places a client complaining of back pain in the dorsal recumbent position. Which area would the nurse be least likely to assess with the client in this position? A) Chest B) Head C) Peripheral pulses D) Abdomen
d
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? A) "Our schedule is very busy also. We got to you as soon as we could." B) "No one is holding you captive, you are free to leave at any time." C) "Would you like to speak to the office manager about your complaint?" D) "You seem very angry. I am ready to begin your exam now."
d
When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would be identified as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology
d
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? A) Health care institutions have established policies regarding documentation. B) Incorrect conclusions may be made without documentation of initial data. C) It satisfies legal standards established by health care organizations and institutions. D) It becomes the foundation for the entire nursing process.
d
When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary? A) Completes the client's health record. B) Assures a trusting interpersonal relationship. C) Evaluates the seriousness of the client's risk factors. D) Provides a focus for the physical exam.
d
Which of the following would be most important for the nurse to do immediately before beginning the physical exam? A) Practice interviewing skills. B) Construct the client's family genogram. C) Establish the client's reliability as historian. D) Collect necessary equipment essential to the exam.
d
Which of the following would the nurse implement in response to a collaborative problem? A) Encouraging oral fluids B) Providing bedtime protein snack C) Assisting with personal hygiene D) Taking blood glucose twice daily
d
Which technique would be best for the nurse to use to evaluate kidney tenderness in a client complaining of dysuria and back pain? A) Light palpation B) Indirect percussion C) Moderate palpation D) Blunt percussion
d
