Deck 1: Health Assessment

Question 1

The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which source should the nurse use?

A) The client's physical assessment.
B) The client's self-reports.
C) The client's healthcare provider.
D) The client's significant other.

Answer 1

The client's self-reports.

Question 2

The nurse is obtaining an admission assessment. Which should the nurse document as subjective data? Select all that apply.

A) The client's mother informs the nurse that her daughter has not been sleeping due to pain.
B) The client states, "I have pain in my belly that is 7 out of 10."
C) Abdominal assessment reveals a firm, hard abdomen.
D) The client is weak and looks pale.
E) The client appears nervous during the data collection period.

Answer 2

The client's mother informs the nurse that her daughter has not been sleeping due to pain.
The client states, "I have pain in my belly that is 7 out of 10."

Question 3

The preceptor is reviewing the effective use of the nursing process with a new nurse. Which statement by the nurse indicates an understanding of the information?

A) "The correct order of the nursing process is diagnosis, assessment, planning, implementation, and evaluation."
B) "The correct order of the nursing process is assessment, diagnosis, planning, implementation, and evaluation."
C) "The correct order of the nursing process is planning, assessment, diagnosis, implementation, and evaluation."
D) "The correct order of the nursing process is assessment, planning, diagnosis, implementation, and evaluation."

Answer 3

"The correct order of the nursing process is assessment, diagnosis, planning, implementation, and evaluation."

Question 4

The nurse is admitting a client to the unit. Which should the nurse consider when regarding the confidentiality of the client?

A) Information sharing is limited to those directly involved in the client care.
B) All members of the unit's healthcare team may have access to the chart.
C) The Health Insurance Portability and Accountability Act (HIPAA)determines who can communicate with the client.
D) The medical records are open to any hospital employee, including administration.

Question 5

The preceptor has created a teaching plan about the concepts of health and wellness for a new nurse. Which statement by the nurse indicates an understanding of health?

A) "Health is the absence of illness, disease, and symptoms."
B) "Health is a state of well-being and when the client feels good."
C) "Health is the state when a person is viewed as a holistic being."
D) "Health is a state of complete physical, mental, and social well-being."

Question 6

The nurse recognizes that there needs to be a change in practice on the unit to improve the client outcomes. Which is the quickest method the nurse should consider to change current practice?

A) Research.
B) Literature review.
C) Quality improvement project.
D) Document patient outcomes.

Question 7

The nurse is caring for a client who is recovering from abdominal surgery. Which goal should the nurse include in this client's plan of care?

A) The client will verbalize pain relief using an intensity rating in 1 hour.
B) The client will state that they feel fine in 1 hour.
C) The nurse will observe fewer signs of pain in the client's every 1 hour.
D) The nurse will re-evaluate the client's pain level every 1 hour.

Question 8

A new nurse asks the preceptor how the Healthy People 2020 goals can affect a hospitalized client. Which response by the educator is the most appropriate?

A) "Healthy People 2020 is a tool for the healthcare providers to offer information to their clients."
B) "Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death."
C) "The purpose of Healthy People 2020 is to reduce healthcare costs for hospitalized clients."
D) "Healthy People 2020 is seen as a tool by hospitals to reduce length of stay."

Question 9

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which goals should the nurse include in the initial health assessment? Select all that apply.

A) Determine the client's current state of health.
B) Predict risks to current health status.
C) Use only objective data to determine client allergies.
D) Identify the client's ongoing health activities.
E) Identify the client's ability to adhere to treatment.

Question 10

The nurse is reviewing the role of the nurse practitioner. Which should the nurse recognize is the primary role?

A) Manage complex patient care areas.
B) Attend to the health of women of all ages.
C) Engagement in quality improvement.
D) Provide primary care in acute settings.

Question 11

The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention should the nurse implement to address this client's pain?

A) The healthcare provider will prescribe additional analgesics.
B) The client will have reduced pain after administration of analgesics.
C) The client will vocalize reduced levels of pain within 1 hour.
D) The client will be assisted with guided imagery to manage pain levels.

Question 12

The nurse is preparing to provide teaching to a client at risk for diabetes. During which time should the nurse recognize is the most effective moment for teaching?

A) During health promotion.
B) When the client is ready to learn.
C) During the discussion of disease prevention.
D) When a knowledge deficit has been identified.

Question 13

The nurse is reviewing the advanced practice roles in nursing. Which role should the nurse recognize is most likely to provide indirect patient care?

A) Nurse Researcher.
B) Nurse Administrator.
C) Nurse Educator.
D) Nurse Anesthetist.

Question 14

The nurse is reviewing a client's medical record. Which documented data should the nurse recognize is objective?

A) The client states, "fell and hurt myself."
B) The client states, "I am six years old."
C) "Six-year-old child observed holding a towel to her forehead."
D) "Client states that she was running and fell at the playground."

Question 15

The nurse is reviewing a client's medical records. Which should the nurse recognize as subjective data?

A) The client tells the nurse their abdomen hurts on the left side after eating.
B) The client's abdomen is tender on the left side during palpation.
C) The CAT scan reveals a large mass in the left lower quadrant of the abdomen.
D) The client's hemoglobin is 14.1 gm/dL.

Question 16

The preceptor is reviewing a new nurse's goal statement of, "The client will resume normal bowel elimination patterns," created for the care plan of a client with irritable bowel syndrome. Which feedback should the preceptor provide the nurse?

A) "This plan of care has an appropriate goal statement which meets criteria."
B) "This goal statement requires a time frame to be appropriate."
C) "This goal statement is not reflective of the client's diagnosis."
D) "This care plan is accurate and should be entered in the client's medical record."

Question 17

During a physical assessment of a client, the nurse notes wheezing and documents the findings in the medical record. Which phase of critical thinking is represented by the nurse's actions?

A) Collection of information.
B) Evaluation.
C) Generation of alternatives.
D) Analysis of the situation.

Question 18

A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound on the left foot states to the nurse, "I am healthy, I don't know why I have to be here to get a check-up." Which statement by the nurse is the most appropriate?

A) "I feel that you are in denial about your health status."
B) "Tell me about your definition of being healthy."
C) "Do you understand what diabetes is?"
D) "Is there anything else you are not telling me?"

Question 19

The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives?

A) "It will allow healthcare providers to lobby legislators for more funding."
B) "The primary goal of Healthy People 2020 is to assist healthcare providers in determining risk factors for premature birth."
C) "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death."
D) "The initiatives will outline standards of care for providers in managing diseases."

Question 20

The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action should the nurse take?

A) Report the lack of achievement of the goals to the healthcare provider.
B) Review the data and modify the plan.
C) Reformulate the nursing diagnosis to a more realistic one.
D) Request a consult for the client to be seen by a pulmonologist.

Question 21

The nurse is evaluating the risk factors for health disparity. Which social determinant should the nurse consider places the clients in the community at risk?

A) Lack of access to healthcare services.
B) Nonadherence to health prevention.
C) Lack of participation in exercise.
D) Chronic substance abuse.

Question 22

The nurse is preparing to obtain a health history. Which should the nurse understand is the main purpose of obtaining a health history before a physical assessment?

A) Allows the nurse to gather objective data.
B) Provides a systematic means of gathering information.
C) Enables a nursing diagnosis to be generated.
D) Assists the examiner in accurately conducting a physical assessment.

Question 23

The preceptor is assessing a new nurse's ability to critically think. Which should the preceptor include in the assessment? Select all that apply.

A) Application of logic.
B) Use of resources.
C) Ability to problem solving.
D) Use of the nursing process.
E) Use of cognitive skills.

Question 24

The nurse is preparing to conduct a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which initial action should the nurse take?

A) Obtain a urine sample.
B) Monitor the client's vital signs.
C) Assess the client's about dietary preferences.
D) Assess the characteristics of the client's pain.

Question 25

The nurse is preparing to focus on the third step of the nursing process. Which should the nurse anticipate obtaining?

A) Statement of client goals.
B) Collection of subjective data.
C) Performance of care activities.
D) Review of client's achievement of goals.

Question 26

The nurse is reviewing the client's record for reports of pain. Which should the nurse consider subjective data? Select all that apply.

A) The client's leg is red and swollen.
B) The client complains of leg tenderness.
C) The client's white blood cell count is elevated
D) The client demonstrates guarding behavior during the assessment
E) The client states they have leg cramps.

Question 27

The nurse administrator is explaining their role to a new nurse. Which statement made by the new nurse indicates further teaching is required?

A) "You are available for consultation."
B) "You will be conducting research."
C) "You are responsible for staffing."
D) "You will be monitoring the goals of the organization."

Question 28

The new nurse is reviewing a client's plan of care with the preceptor. Which statement made by the nurse should the preceptor be concerned with?

A) "I have created one goal per nursing diagnosis."
B) "I have created my goals based on the nursing diagnosis."
C) "I identified measurable goals during the planning."
D) "I have written the interventions based on my goals."

Question 29

The nurse is developing a client's plan of care. Which should the nurse base the plan of care on?

A) The nursing diagnosis.
B) The objective data.
C) The subjective data.
D) Client goals.

Question 30

The nurse is reviewing a client's care plan. Which part of the nursing process should the nurse use to determine if new problems exist?

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

Question 31

Which should the nurse understand is the main focus of the Agency for Health Research and Quality?

A) Nursing practice guidelines.
B) Health promotion.
C) Produce evidence-based reports.
D) Address healthcare disparity.

Question 32

The nurse is reviewing the advanced practice roles of the nurse. Which should the nurse recognize as the primary responsibility of the clinical nurse specialist?

A) Identify problems in regards to patient care, designs plans of study, and develops tools.
B) Provide generalized healthcare services, such as family planning, obstetric, and gynecological care.
C) Provide direct patient care, direct and teach other team members providing care, and conduct research within an area of specialization.
D) Combine expertise in diagnosis and illness with a nurse's understanding of health promotion and prevention.

Question 33

The nurse is reviewing the goal statements for a postoperative client. Which goal statements should the nurse recognize needs further development? Select all that apply.

A) The nurse will assess the vital signs every 2 hours.
B) The client will ambulate every 6 hours on the first postoperative day.
C) The client will report feeling better by the end of the day.
D) The client will begin a clear liquid diet on the first postoperative day.
E) The nurse will administer oral analgesics as prescribed.