Deck 1: Health Assessment

Question 1

The novice nurse working on a medical-surgical unit is preparing a plan of care for a client admitted for irritable bowel syndrome. The goal statement is, "The client will resume normal bowel elimination patterns." When reviewing the plan of care with the novice nurse, which statement by the preceptor is the most appropriate?

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 admitting diagnosis."
D) "This care plan is accurate and will be placed in the client's medical record."

Answer 1

"This goal statement requires a time frame to be appropriate."

Question 2

The nurse educator is discussing Healthy People 2020 with a group of nursing students. One of the students questions the instructor how this work will impact hospitalization. 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 health care costs for hospitalized clients."
D) "Healthy People 2020 is seen as a tool by hospitals to reduce length of stay."

Answer 2

"Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death."

Question 3

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 health care providers to lobby legislators for more funding."
B) "The primary goal of Healthy People 2020 is to assist health care 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."

Answer 3

"Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death."

Question 4

A novice nurse is conducting a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which action by the novice nurse is appropriate?

A) Obtaining a urine sample to send for a urinalysis.
B) Monitoring the client's vital signs.
C) Questioning the client about dietary preferences.
D) Assessing the characteristics of the client's pain.

Question 5

The nurse is preparing a teaching plan for a client diagnosed with hypertension. Which objective is appropriate when addressing the psychomotor domain for the client?

A) The client will discuss measures to take when experiencing dizziness.
B) The client will describe signs and symptoms of an elevated blood pressure.
C) The client will demonstrate how to monitor own blood pressure.
D) The client will define the dimensions of hypertension.

Question 6

The community health nurse is preparing to conduct a program for a group of nursing students concerning health and wellness. Which statement by a participant indicates the most comprehensive and accurate understanding of health?

A) "Health is the absence of illness, disease, and symptoms."
B) "Health is a state of well-being and the use of every power the person possesses to the fullest extent."
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 7

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which are appropriate goals for the initial health assessment?

A) Determine the client's current state of health and ongoing health-promotion activities.
B) Predict risks to current health status.
C) Use only objective data to determine client allergies.
D) Determine how frequently the client is able to change positions.
E) Identify health-promoting activities.

Question 8

The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective?

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 very pale.
E) The client appears nervous during the data collection period.

Question 9

The nurse is reviewing a client's medical record while planning care. Which data from the medical record is an example of objective data?

A) "I hurt my head."
B) "I am 6 years old and I'm here because I fell."
C) "Six-year-old Hispanic female sitting on examination table holding a towel to her forehead."
D) "Client states that she fell at the playground."

Question 10

The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention is most appropriate 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 3 hours.
D) Assist the client with guided imagery to manage pain levels.

Question 11

The nurse educator is presenting information about the nursing process to a group of students. Which statement by a student reflects the appropriate sequence when implementing the nursing process?

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

Question 12

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

A) The client will verbalize pain relief using an intensity rating in 4 hours.
B) The client will state that he feels fine in 4 hours.
C) The nurse will observe fewer signs of pain in the client's demeanor.
D) The nurse will reevaluate the client's pain level every 2 hours.

Question 13

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 by the nurse is the most appropriate?

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 14

While conducting a health history, a client states, "I am healthy, I don't know why I have to be here to get a check-up." However, the client reports, type 2 diabetes mellitus and an unhealed ulcer on the left foot. Based on this information, 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 15

Which statement best describes the active role of the professional nurse as an educator?

A) Nurses must consider learning needs, goals, objectives, content, teaching methods, and evaluation when carrying out client education.
B) Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized.
C) In the role of educator, the nurse should refer the client to other health care providers who specialize in the area of need.
D) Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.

Question 16

While conducting a physical assessment for a client with asthma, the nurse notes that the client is wheezing and documents this finding in the medical record. Which phase of critical thinking is represented by this nurse's actions?

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

Question 17

The nurse is admitting a client to a mental health unit for an exacerbation of bipolar disorder. When conducting the health history for this client, which is important to keep in mind regarding the client's confidentiality?

A) Confidentiality means that information sharing is limited to those directly involved in the client care.
B) Complete client confidentiality means that all members of the health care team may have access to the chart.
C) The Health Insurance Portability and Accountability Act (HIPAA) helps to maintain client confidentiality and dictates who is to be communicating with the client.
D) The medical records are open to any hospital employee, including administration.

Question 18

The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which is an appropriate source for the nurse to 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.

Question 19

The nurse is assessing a client who presents in the emergency department (ED) with abdominal pain, nausea, and vomiting. Vital signs are within normal limits. The client's health history indicates pelvic inflammatory disease, mitral valve prolapse, and childbirth. When analyzing the available data, what items should be clustered together?

A) Vital signs, complaints of pain, history of childbirth.
B) Abdominal pain, nausea, vomiting, and history of pelvic inflammatory disease.
C) Gender, history of mitral valve prolapse, and vital signs.
D) History of pelvic inflammatory disease, mitral valve prolapse, and pain scale reports.

Question 20

The nurse is reviewing a client's medical records and notes various forms of information. Which is an example of subjective data from this client's medical record?

A) The client states, "My abdomen hurts on the left side after eating."
B) The nurse notes 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 21

The nurse is developing a plan of care for a recently admitted client to the medical-surgical unit. Which is the basis for the plan and implementation of the client's care?

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

Question 22

The nurse is preparing the care plan for a client who admitted to the unit after an abdominal hysterectomy to manage endometriosis. Which goal statements reflect the need for further development by the nurse?

A) The nurse will assess the vital signs every 2 hours.
B) The client will walk Q2h on the first postoperative day.
C) The client will report feeling better.
D) The client will begin a clear liquid diet on the first postoperative day.
E) The healthcare provider will prescribe oral analgesics on the first postoperative day.

Question 23

The health care organization is planning to change the type of documentation done on the client care units. The nurses have requested a system that will reduce time spent writing out routine tasks and will still allow for documentation of exceptions. Which type of documentation will best meet the needs of the nursing staff?

A) Focus documentation.
B) Flow sheets.
C) SOAP charting.
D) APIE charting.

Question 24

The nurse is reviewing flow chart entries for a client experiencing pain. Which chart entries represent subjective data?

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 5.6.
D) The client demonstrates guarding behaviors during the assessment of the affected extremity.
E) The client complains leg cramps.

Question 25

When using Leavall and Clark's model as a framework for preparing a community health program, which program objective best reflect the concepts presented by this model?

A) The participants will recognize health as the absence of disease.
B) The participants will verbalize the role of self-actualization achievement in relation to health.
C) The participants will define health as the interrelationships between the agent, host, and the environment.
D) Internal harmony is the foundational basis for health achievement.

Question 26

During step 3 of the nursing process, which activity is performed?

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

Question 27

The nurse educator is presenting information about the APIE method of charting as it will be implemented by the facility in a few weeks. Which statements by the participants indicate an appropriate understanding of this method of charting?

A) "I will only need to chart by exception with this method."
B) "Only subjective data are included in the assessment portion."
C) "The 'P' refers to the chief problem of the client."
D) "The activities implemented to manage the client's needs will be documented in the 'I' section."
E) "The 'E' refers to the evaluation that occurs after an intervention is implemented."

Question 28

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?

A) S: The client states, "I am so nauseated."
B) O: The client reports feeling fatigued.
C) A: Bowel sounds are high-pitched in all abdominal quadrants.
D) P: The client will remain NPO.

Question 29

The student nurse is preparing a care plan for an assigned client. When writing the nursing diagnose for this client, which elements are required?

A) Medical diagnosis.
B) Risk or related factors.
C) Defining characteristics.
D) A diagnostic label.
E) A definition.