Deck 1: Health Assessment

Question 1

The charge nurse is discussing with the new graduate nurse the care planning process for clients admitted to the unit.The graduate nurse correctly identifies the order of the steps of the nursing process as:
1)Diagnosis,Assessment,Planning,Implementation,Evaluation
2)Assessment,Diagnosis,Planning,Implementation,Evaluation
3)Planning,Assessment,Diagnosis,Implementation,Evaluation
4)Assessment,Planning,Diagnosis,Implementation,Evaluation

Answer 1

2

Question 2

The nursing instructor is discussing Healthy People 2020 with a group of nursing students.One of the students questions the instructor how this work will impact hospitalization.The best response by the nursing instructor would be:
1)"Healthy People 2020 is a tool for the healthcare providers to offer information to their clients."
2)"Healthy People 2020 seeks to improve health and prevent illness,disability,and premature death."
3)"The purpose of Healthy People 2020 is to reduce health care costs for hospitalized clients."
4)"Healthy People 2020 is seen as a tool by hospitals to reduce length of stay."

Answer 2

2

Question 3

The nurse is preparing a teaching plan for a client diagnosed with type 1 diabetes mellitus.When developing the teaching plan the nurse addresses objectives in the psychomotor domain.Which of the following objectives best meets this criteria?
1)The client will discuss measures to take when experiencing the feeling of low blood glucose levels.
2)The client will describe signs and symptoms of low blood sugar.
3)The client will demonstrate how to draw up the correct dose of insulin.
4)The client will define the dimensions of diabetes mellitus.

Answer 3

3

Question 4

Which of the following statements best describes the active role of the professional nurse as an educator?
1)Nurses must consider learning needs,goals,objectives,content,teaching methods,and evaluation when carrying out client education.
2)Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized.
3)In the role of educator,the nurse should refer the client to other health care providers who specialize in the area of need.
4)Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator.

Question 5

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.What should the nurse do next in this situation?
1)Report the lack of achievement of the goals to the healthcare provider.
2)Review the data and modify the plan.
3)Reformulate the nursing diagnosis to a more realistic one.
4)Request a consult for the client to be seen by a pulmonologist.

Question 6

The nurse is admitting a client to the acute care facility.The health history form has a place for recording subjective data.The nurse understands that primary subjective data should be obtained from which of the following sources?
1)The client's physical assessment
2)The client's self-reports
3)The client's healthcare provider
4)The client's significant other

Question 7

A client with hepatitis B is admitted to the hospital.When obtaining the physical assessment,what should the nurse keep in mind regarding client confidentiality?
1)Confidentiality means that information sharing is limited to those directly involved in the client care.
2)Complete client confidentiality means that all members of the health care team may have access to the chart.
3)Health Insurance Portability and Accountability Act (HIPAA)helps to maintain client confidentiality and dictates who is to be communicating with the client.
4)The medical records are open to any hospital employee,including administration.

Question 8

The nurse is reviewing a client's medical records and notes various information.The nurse understands that which of the following is an example of objective data?
1)"I hurt my head."
2)"I am 6 years old and I'm here because I fell."
3)"Six-year-old Hispanic female sitting on examination table holding a towel to her forehead."
4)"Client states that she fell at the playground."

Question 9

The nurse is developing the plan of care for a client who is recovering from abdominal surgery.When planning interventions the nurse recognizes which of the following will best meet the needs of the client experiencing pain?
1)The healthcare provider will prescribe additional analgesics.
2)The client will have reduced pain after administration of analgesics.
3)The client will vocalize reduced levels of pain within 3 hours.
4)Assist the client with guided imagery to manage pain levels.

Question 10

A client is hospitalized with end stage liver failure secondary to many years of alcoholism.The nurse begins collection of information by first:
1)Organizing how to proceed with the client and generating alternatives to the approach.
2)Identifying assumptions that can misguide or misdirect the assessment and intervention process.
3)Collecting information and determining its relevance as far as impacting the client care.
4)Identifying any inconsistencies in the communication from the client and or significant others.

Question 11

The nurse is completing an admission assessment.The assessment form allows for the separation of subjective and objective data.Distinguish which of the following are examples of subjective data utilized by the nurse.
1)The client's mother informs the nurse that her daughter has not been sleeping due to pain.
2)The client states,"I have pain in my belly that is 7 out of 10."
3)Abdominal assessment reveals a firm,hard abdomen.
4)The client is weak and looks very pale.
5)The client appears nervous during the data collection period.

Question 12

While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD),the client becomes very short of breath.The nurse recognizes the need to stop the assessment to initiate respiratory support interventions.This is an example of which phase of critical thinking?
1)Collection of information
2)Evaluation
3)Generation of alternatives
4)Analysis of the situation

Question 13

The nurse is caring for a client who is recovering from abdominal surgery.When determining the best goal statement for the client concerning level of pain,which of the following is most appropriate?
1)The client will verbalize pain relief using an intensity rating in 4 hours.
2)The client will state that he feels fine in 4 hours.
3)The nurse will observe fewer signs of pain in the client's demeanor.
4)The nurse will reevaluate the client's pain level every 2 hours.

Question 14

The charge nurse has instructed the nurse to complete a focused interview on the client who has just been admitted to the facility with complaints consistent with kidney stones.Which of the following actions by the nurse indicates the best understanding of the assignment?
1)The nurse obtains a urine sample to send for a urinalysis.
2)The nurse takes the client's vital signs.
3)The nurse questions the client about dietary preferences.
4)The nurse asks the client about the characteristics of the pain being experienced.

Question 15

The nurse is presenting a workshop on wellness and health promotion and the initiatives of Healthy People 2020 as a resource for this topic.After the session,which of the following statements by a participant indicates an understanding concerning the initiatives proposed?
1)"It will allow health care providers to lobby legislators for more funding."
2)"The primary goal of Healthy People 2020 is to assist health care providers in determining risk factors for premature birth."
3)"Healthy People 2020 seeks to promotes health,prevent illness,disability,and premature death."
4)"The initiatives will outline standards of care for providers in managing diseases."

Question 16

The recent graduate nurse is orienting to the medical surgical care unit.The graduate nurse has prepared a nursing care plan for a client admitted for exacerbation of ulcerative colitis.The goal statement is,"The client will resume normal bowel elimination patterns." The graduate nurse has asked the charge nurse to review the care plan.What action by the charge nurse is indicated?
1)Express to the new nurse that the goal statement meets criteria.
2)Explain to the new nurse that the lack of time frame makes the goal inappropriate.
3)Express to the new nurse that the goal statement is not reflective of the client's admitting diagnosis.
4)Accept the care plan for inclusion into the client's medical record as it is accurate.

Question 17

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA).Which of the following are appropriate goals of the initial health assessment?
1)Determine the client's current state of health and ongoing health-promotion activities.
2)Predict risks to current health status.
3)Use only objective data to determine client allergies.
4)Determine how frequently the client is able to change positions.
5)Identify health-promoting activities.

Question 18

The nurse is reviewing a client's medical records and notes various forms of information.The nurse understands that which of the following are subjective data?
1)The client states,"My abdomen hurts on the left side after eating."
2)The nurse notes the client's abdomen is tender on the left side during palpation.
3)The CAT scan reveals a large mass in the left lower quadrant of the abdomen.
4)The client's hemoglobin is 14.1 gm/dL.

Question 19

The nurse is obtaining a health history from a client who reports that he is healthy and has no health concerns.As part of the health history,the nurse documents that the client reported that he has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months.Which of the following statements would be the best choice for the nurse to use at this point in the interview?
1)"I feel that you may be in denial about your health status."
2)"Tell me about your definition of being healthy."
3)"Do you understand what hypertension is?"
4)"Is there anything else you are not telling me?"

Question 20

The community health nurse is preparing to conduct a program for a group of nursing students concerning health and wellness.Which of the following statements by a participant indicates the most comprehensive and accurate understanding of health?
1)"Health is the absence of illness,disease,and symptoms."
2)"Health is a state of well-being and the use of every power the person possesses to the fullest extent."
3)"Health is the state when a person is viewed as a holistic being."
4)"Health is a state of complete physical,mental,and social well-being."

Question 21

The community health nurse is preparing a program about health maintenance.The nurse has decided to use the Leavall and Clark model as the framework for the programming.Which of the following program objectives best explain the concepts presented by this model?
1)The participants will recognize health as the absence of disease.
2)The participants will verbalize the role of self-actualization achievement in relation to health.
3)The participants will define health as the interrelationships between the agent,host,and the environment.
4)Internal harmony is the foundational basis for health achievement.

Question 22

The nurse is reviewing the following flow chart entries for a client experiencing pain.Which of the following chart entries represents a subjective entry?
1)The client's leg is red and swollen.
2)The client complains of leg tenderness.
3)The client's white blood cell count is 5.6.
4)The client demonstrates guarding behaviors during the assessment of the affected extremity.

Question 23

The nurse is preparing the care plan for a client who has undergone an abdominal hysterectomy to manage endometriosis.When reviewing goal statements,which of the following reflect the need for further development?
1)The nurse will assess the vital signs every 2 hours.
2)The client will walk Q2h on the first postoperative day.
3)The client will report feeling better.
4)The client will begin a clear liquid diet on the first postoperative day.
5)The healthcare provider will prescribe oral analgesics on the first postoperative day.

Question 24

A female client has been admitted to the acute care unit with complaints of abdominal pain,nausea,and vomiting.During the interview the nurse determines the client's history includes pelvic inflammatory disease,mitral valve prolapse,and childbirth.The assessment finds the client's vital signs to be within normal limits.When analyzing the available data,what items should be clustered together?
1)Vital signs,complaints of pain history of childbirth
2)Abdominal pain,nausea,vomiting,and history of pelvic inflammatory disease
3)Gender,history of mitral valve prolapse,and vital signs
4)History of pelvic inflammatory disease,mitral valve prolapse,and pain scale reports

Question 25

The nurse manager is reviewing the following SOAP chart entries for a recently licensed nurse.Which of the following entries indicate that the nurse needs further instruction concerning documentation?
1)S: The client states," I am so nauseated."
2)O: The client reports feeling fatigued.
3)A: Bowel sounds are high-pitched in all abdominal quadrants.
4)P: The client will remain NPO.

Question 26

The nurse educator is discussing the charting used in the facility with a group of recently hired nurses.The facility uses the APIE method of charting.Which of the following responses by one of the newly hired nurses indicates understanding of the charting method?
1)"I will only need to chart by exception with this method."
2)"Only subjective data are included in the assessment portion."
3)"The 'P' refers to the planning phase of the process."
4)"The activities implemented to manage the client's needs will be documented in the 'I' section."

Question 27

During step 3 of the nursing process,which of the following activities is performed?
1)Statement of client goals
2)Collection of subjective data
3)Performance of care activities
4)Review of client goal achievement

Question 28

The nurse is developing a plan of care for a recently admitted client.The nurse recognizes that the basis for the plan and implementation of care is (are):
1)The nursing diagnosis
2)The objective data
3)The subjective data
4)Client goals

Question 29

The student nurse is preparing a care plan for an assigned client.The student correctly recognizes that the nursing diagnosis is composed of which of the following elements?
1)Medical diagnosis
2)Risk or related factors
3)Defining characteristics
4)A diagnostic label
5)A definition

Question 30

The nurse manager is considering changing the type of charting/documentation done on the client care unit.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?
1)Focus documentation
2)Flow sheets
3)SOAP charting
4)APIE charting