Deck 6: Nursing Assessment

Question 1

What must the nurse do to identify actual or potential health problems?

A) Evaluate care implemented.
B) Meet with significant others.
C) Call the physician.
D) Gather data from sources.

Answer 1

Gather data from sources.

Question 2

The phase of the nursing process when the nurse gathers data about the client to establish a plan of care is the:

A) assessment.
B) goals.
C) interventions.
D) evaluation.

Answer 2

assessment.

Question 3

A client has been discharged from an acute care facility. The first task a home health nurse must accomplish is:

A) care of the client's physical pain.
B) establish the client's database.
C) evaluate the care previously provided.
D) receive a report from the nursing staff.

Answer 3

establish the client's database.

Question 4

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

A) Focus
B) Psychosocial
C) Physical
D) Initial

Question 5

A nurse practitioner (NP) has a private practice in conjunction with a physician. The NP is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in 2 weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

A) Complete
B) Focus
C) Time-lapsed
D) Emergency

Question 6

A nurse is asking questions about a client's sexual history. It is important for the nurse to:

A) evaluate the client's past history of sexual dysfunction.
B) provide a time that enhances openness.
C) collect data in a quiet, private environment.
D) pull the curtains in a semiprivate room.

Question 7

When collecting subjective and objective data for a database in a client's home, it is important to:

A) ask the client to turn off the television.
B) ask the social worker to verify the collected data.
C) collect a 24-hour diet recall.
D) evaluate the care provided by the physician.

Question 8

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

A) Explanatory
B) Subjective
C) Objective
D) Severe

Question 9

When assessing an infant, it is important to involve the:

A) parents.
B) siblings.
C) physician.
D) infant.

Question 10

What would be a nursing priority when assessing a client who weighs 250 lbs and stands 5 feet, 3 inches tall?

A) Assess the HDL/LDL levels.
B) Obtain an electrocardiogram daily.
C) Assess blood pressure with a large cuff.
D) Begin client education regarding a low-fat diet.

Question 11

A client is a poor historian of his or her past medical history. Whom should the nurse consult about the client's past history?

A) Physician
B) Old chart
C) Social worker
D) Family

Question 12

Which cultural group may interpret touch by another as an invasion of privacy?

A) Chinese American
B) Spanish American
C) European American
D) African American

Question 13

The purpose of obtaining a nursing history is to:

A) assist the physician to establish a medical diagnosis.
B) minimize the time required to establish a nursing diagnosis.
C) focus on objective physical data specific to the client.
D) identify actual and potential nursing diagnoses.

Question 14

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

A) clarify the client's health status.
B) review as much information as possible.
C) identify actual and potential nursing diagnoses.
D) develop the nursing plan of care.

Question 15

During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

A) review literature pertinent to the client's attributes.
B) assess personal feelings regarding similar clinical situations.
C) inform the client of the maintenance of confidentiality.
D) implement supportive nursing interventions.

Question 16

When assessing the client's pulse, the nurse should use which assessment technique?

A) Inspection
B) Palpation
C) Percussion
D) Auscultation

Question 17

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

A) Assess the client's diet.
B) Assess the client's activity level.
C) Assess the client's blood pressure.
D) Assess the client's medication regimen.

Question 18

Before conducting a health assessment on a client, what should the nurse do first?

A) Ask a family member to be present for the assessment.
B) Tell the client the amount of time for the assessment.
C) Inform the client of the procedure done in the assessment.
D) Introduce him- or herself to the client.

Question 19

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

A) Nodding frequently during the interview
B) Sitting at eye level with the client
C) Standing next to the client while interviewing
D) Limiting questions to those with yes or no answers

Question 20

The nurse has identified a priority problem on the unit. Which statement is true regarding addressing a priority problem?

A) Setting priorities involves skipping interventions.
B) Priorities are set at predetermined intervals throughout the shift.
C) A priority problem requires a nursing intervention before another problem is addressed.
D) Priority of problems is established and continued according to the nursing plan of care.
E) The physician is responsible for determining priority of client needs.

Question 21

Which would be considered examples of subjective data? Select all that apply.

A) Comments made by the client's family.
B) Description of a symptom by a client.
C) A mother telling a nurse what the baby looked like when he or she was very ill.
D) A nursing assessment of the client's vital signs.
E) The physical exam notes made by the physician.

Question 22

Which of the following are examples of objective data?

A) Client describing his or her pain
B) Laboratory results
C) Breath sounds
D) Mother describing her child's asthma attack
E) A client's temperature

Question 23

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

A) Size of the liver
B) Presence of peristalsis
C) Pupil reaction
D) Skin temperature

Question 24

The RN is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while he or she collects data. After completing the admission process, the client complains of a severe headache, so the nurse reassesses the vital signs to find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

A) The company that made the blood pressure equipment
B) The nurse
C) The UAP
D) The charge nurse

Question 25

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

A) "When I perform the nursing history, I will need to ask your family to leave the room."
B) "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."
C) "I will perform a physical assessment while I am obtaining the nursing history."
D) "I will leave a form with you to complete the nursing history information I need."

Question 26

While performing the nursing history, the nurse notes that the client reports having very little pain but is occasionally grimacing and rubbing the shoulder throughout the interview. The nurse acknowledges this behavior and questions the client and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview?

A) Preparatory
B) Introductory
C) Maintenance
D) Concluding

Question 27

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

A) Validate inferences with the client.
B) Do not share inferences with the client.
C) Document all inferences.
D) Avoid making any inferences.

Question 28

During data collection, the nurse may validate data by which method? Select all that apply.

A) Comparing cues to normal function
B) Referring to textbooks, journals, and research reports
C) Checking consistency of cues
D) Clarifying the client's statements
E) Seeking consensus with colleagues about inferences