Deck 12: Assessing

Question 1

A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase will teach the student to:

A) implement a standardised care plan.
B) develop a list of nursing and collaborative problems.
C) assess whether patient goals have been met.
D) organise and validate data.

Answer 1

develop a list of nursing and collaborative problems.

Question 2

A client has been using the call light routinely throughout the evening. Upon now entering the room, the nurse becomes aware of an odour not observed previously. This is an example of:

A) objective data.
B) incomplete data.
C) secondary data.
D) subjective data.

Answer 2

objective data.

Question 3

A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client's past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The second nurse is following this process so as to:

A) validate and update the data.
B) reassess the patient's responses.
C) set priorities and goals.
D) interpret and analyse the data.

Answer 3

validate and update the data.

Question 4

A nurse has delegated to a student nurse to obtain vital signs for a newly admitted client. The student reports the following: temperature = 37.4 °C, respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is to:

A) report the findings to the Clinical Nurse Consultant.
B) call the physician.
C) reassess the vital signs.
D) continue with the physical assessment as soon as possible.

Question 5

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse states: "This is not his normal behaviour". The nurse documents this as which of the following?

A) Secondary subjective data.
B) Inference.
C) Subjective data.
D) Objective data.

Question 6

The nurse is taking information for the client's database. The client is not very talkative, is pale, diaphoretic, and restless in the bed and tells the nurse to, "Just leave me alone". Which of the following is subjective data?

A) Restlessness.
B) Not talkative.
C) "Just leave me alone."
D) Pale and diaphoretic.

Question 7

An infant has been admitted to the paediatric unit. The parents are quite worried and the grandmother is also present. In this situation, what would be the best source of data?

A) Parents.
B) Admitting physician.
C) Grandmother, since the parents are upset.
D) Medical record from the child's birth.

Question 8

Which of the following would be categorised as 'psychological data'?

A) Nausea and vomiting.
B) Relationships with family.
C) Major stressors.
D) Unemployment.

Question 9

A nurse has just been informed that a new admission is coming to the unit. According to the Australian Council on Healthcare Standards (2013), how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?

A) 48 hours.
B) 12 hours.
C) 24 hours.
D) 1 hour.

Question 10

When learning how to implement the nursing process into a plan of care for a client, the student nurse realises that part of the purpose of the nursing process is to:

A) make sure that standardised care is available to clients.
B) identify client needs and deliver care to meet those needs.
C) implement a plan that is close to the medical model.
D) deliver care to a client in an organised way.

Question 11

The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past two weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process?

A) Diagnosis.
B) Assessment.
C) Implementation.
D) Evaluation.

Question 12

A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow. What type of assessment would be necessary in this situation?

A) Initial assessment.
B) Emergency assessment.
C) Problem-focused assessment.
D) Time-lapsed assessment.

Question 13

A nurse is performing an initial assessment on a new admission. Which of the following is not a part of the database?

A) Information on how the client manages health care needs.
B) Documentation of the nurse's physical assessment.
C) Physician's orders.
D) Information about the client's cultural preferences.

Question 14

A nurse is undertaking an initial nursing assessment of a client who has been recently admitted to the ward. The purpose of this initial assessment is to:

A) establish a baseline database.
B) evaluate a previous database.
C) monitor emergency problems.
D) complete the paperwork on time.

Question 15

A nurse is providing a back rub to a client just after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse applying?

A) Evaluation.
B) Diagnosis.
C) Assessment.
D) Implementation.

Question 16

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?

A) Assessment.
B) Diagnosis.
C) Evaluation.
D) Implementation.

Question 17

The nurse makes this entry in the client's chart: "Client avoids eye contact and gives only vague, non-specific answers to direct questioning by the professional staff. However, the client is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." This is an example of which method of data collection?

A) Listening.
B) Examining.
C) Interviewing.
D) Observing.

Question 18

One critical-thinking activity that a nurse can develop during the assessment phase of the nursing process is that of:

A) comparing patterns with norms.
B) hypothesising.
C) making inferences.
D) categorising data according to a framework.

Question 19

The nurse uses critical-thinking skills when using the nursing process to diagnose after an initial assessment. This is reflected when the nurse:

A) makes reliable observations.
B) makes interdisciplinary connections.
C) performs client-focused interventions.
D) finds patterns among cues.

Question 20

The nursing process enables the nurse to respond to:

A) the moaning of a client in pain.
B) the changing health status of the patient.
C) a client with audible breathing.
D) co-workers discussing their clients' conditions.

Question 21

A client is coming into the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, the nurse should:

A) sit behind a desk.
B) stand at the counter to take notes during the interview.
C) stand at the side of the client's chair.
D) sit next to the client, a metre apart.

Question 22

A client comes to the emergency department with injuries to her upper shoulders and back area. When questioned about how the injuries occurred, the client becomes less talkative and states that she "fell". The client has a history of frequent ED visits, always with believable excuses about how her injuries occurred. The nurse begins to suspect that this client is a victim of abuse. This is an example of the nurse making which of the following?

A) Observation of cues.
B) Inference.
C) Judgment.
D) Validation.

Question 23

A nursing student is meeting an assigned client for the first time. In order to begin the establishment of rapport, the best statement by the student is:

A) "You're lucky, you have students and nurses taking care of you today."
B) "Hi. If you need anything, either your nurse or I will get it for you."
C) "Hello, I'm Jessie Young, a nursing student and I'll be helping to take care of you today."
D) "Good morning, is there anything you need right now?"

Question 24

Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Open-ended questions allow the patient to:

A) answer easily.
B) give short, factual answers.
C) elaborate.
D) restrict their answers.

Question 25

During an assessment interview, the nurse understands that the client has decided not to take the physician's advice about an elective surgical procedure. The client shares that, "This is just not part of what I have in mind for my life's goals". This would fall into which of Gordon's functional health patterns?

A) Cognitive/perceptual pattern.
B) Coping/stress-tolerance pattern.
C) Value/belief pattern.
D) Health-perception/health-management pattern.

Question 26

A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families and other people in the waiting room. The best way for the nurse to conduct an interview with this client is to:

A) have the client wait until the department quiets down, since the wound is not too serious.
B) draw curtains around the client and nurse to provide as much privacy as possible.
C) make sure the client's back is to the rest of the room so as not to be heard by passers-by.
D) tell the client to wait in the waiting room and fill out the paperwork.

Question 27

A nurse has been assigned a new client who cannot speak English. In order that the client receives accurate information, the nurse should:

A) make sure a family member who does speak English is available.
B) conduct the interview using hand gestures.
C) have a member of the housekeeping staff who speaks the same language translate.
D) use the translation services supplied by the hospital.

Question 28

The nurse has just completed an admission interview with a new client. Which response by the nurse is an example of a remark used during the closing phase of the interview?

A) "I'm going to set up your physical assessment now. Do you have any questions?"
B) "Tell me more about how you feel."
C) "Is there anything you're worried about?"
D) "Could you give examples of what types of other treatments you've had?"

Question 29

A client has been admitted for acute dehydration, secondary to nausea and diarrhoea. When is the best time for the nurse to conduct this client's interview?

A) After the client has been medicated.
B) After the client has settled in and been oriented.
C) When the family is available to help.
D) As soon as the client gets to the floor.

Question 30

The nurse is taking a health history from a client who has complications from chronic asthma. The nurse is asking closed questions so as to:

A) obtain specific information.
B) direct the client's answers.
C) explore the client's feelings.
D) seek clarification from the client.