N-114 Exam #1
A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas? A. Physiologic, psychological, sociocultural, developmental, and spiritual data B. Focuses primarily on the client's physiologic development status C. Involves the client's musculoskeletal system and activities of daily living D. Focuses only on the client's psychological, sociocultural, and spiritual well-being
A. Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.
An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client? A.Speak slowly and clearly, using straightforward language B. Ask the client's daughter to be present during the interview C. Occupy a position close to the client and speak softly D. Direct the questions to the daughter to enhance communication
A.Speak slowly and clearly, using straightforward language Explanation: The nurse should speak slowly and clearly, using straightforward language, keeping the language as simple as possible for easy understanding. The nurse need not ask the client's daughter to be present during the interview, as the client is quite able except for the use of a hearing aid. The nurse should establish and maintain trust, privacy, and partnership with the older client for effectively collecting data and sharing concerns. The nurse should not occupy a position close to the client and speak softly, as the client has hearing loss; in such cases, the nurse should face the client at all times and speak loudly.
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. Collect subjective and objective data related to overall function. C. Take anthropometric measurements. D. Obtain a 24-hour diet recall.
B. Collect subjective and objective data related to overall function. Explanation: The nurse is responsible for collecting subjective and objective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietitian may take anthropometric measurements in addition to a subjective nutritional assessment, such as a 24-hour diet recall.
What are the types of nursing assessments? (Select all that apply.) A. Physical B. Focused C. Mental D. Emergency E. Comprehensive
B. Focused D. Emergency E. Comprehensive Explanation: Three types of nursing assessments are common: emergency, focused, and comprehensive. Physical and mental assessments are areas addressed in the various types of nursing assessments.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? A. Simple circle B. Simple square C. Circle with a cross D. Square with a cross
C. Circle with a cross Explanation:The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use? A. Rationale B. American Nurses Association recommendations C. Physical assessment skills D. Diagnostic reasoning
D. Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.
What is one of the broad goals within nursing? A. To provide cost effective care B. To form broad nursing diagnoses C. To promote self-care D. To treat human responses
D. To treat human responses Explanation: Four broad goals are within nursing: (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. The other options listed are not broad goals. Nursing, focuses on promoting health; while cost-effective care is strived for, is not a part of the broad goal, therefore, this is not a broad goal within nursing. Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not correctly answer the question.
