Health Assessment Ch. 1

15. When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology

D

14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways

A

16. A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

A

8. The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention

A

13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception

B

2. 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) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician

B

3. The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? 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

30. A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.

B

9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-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

10. A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? 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

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

C

12. An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.

D

28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.

D

19. A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

A

23. A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening

A

4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client.

A

7. After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases? A) Assessment B) Planning C) Implementation D) Evaluation

A

6. In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment

B

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

C,B,A,E,D

26. A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.

A

27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery

A

21. The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) I feel so tired sometimes. B) Weight- 145 lbs 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

24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.

B

17. 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? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems

C

18. A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.

C

20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.

C

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

C

29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability

C

5. Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test

C

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) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments

D