Deck 47: Data Collection in Client Care

Question 1

What are the primary purposes of nursing data gathering and assessments? Select all that apply.

A) Identify and report normal findings
B) Identify and report unusual findings
C) Identify potential problems
D) Provide needed nursing care measures
E) Formulate the client's specialized plan of care

Answer 1

Identify and report unusual findings
Identify potential problems
Provide needed nursing care measures
Formulate the client's specialized plan of care

Question 2

The nurse uses the COLDSPA mnemonic when engaging in data gathering and assessment. What information is the nurse seeking when asking the client: "How bad is it?" and "Can you rate it on a scale of 1 to 10?"?

A) Onset
B) Location
C) Duration
D) Severity

Answer 2

Severity

Question 3

The nurse is completing the data collection for a newly admitted client to the healthcare facility. The nurse is reviewing the information and notices several lifestyle risk factors for the client present. Which are lifestyle risk factors? Select all that apply.

A) Obesity
B) Smoking
C) Lack of exercise
D) Hypertension
E) High fat diet

Answer 3

Obesity
Smoking
Lack of exercise
High fat diet

Question 4

What term is used to identify the relationship between a recent history of influenza and the current diagnosis of pneumonia?

A) Acute
B) Chronic
C) Primary
D) Secondary

Question 5

What term can be used to identify a secondary infection?

A) Acute infection
B) Chronic infection
C) Independent infection
D) Dependent infection

Question 6

What situation is considered a risk factor for sickle cell disease?

A) Lack of iron in the diet
B) Genetic predisposition
C) Lack of cardio exercise
D) Systemic effects of nicotine

Question 7

What causes purulent exudate?

A) Presence of blood
B) Presence of mucus
C) Presence of fluid and cells
D) Presence of bacteria

Question 8

What term is used to refer to the unhealed area of an epithelial tissue wound?

A) Ulcer
B) Abscess
C) Wound sinus
D) Fistula

Question 9

Which response best describes the purpose of the metabolic panel? Select all that apply.

A) Provides baseline set of values for the client after surgery
B) Differentiates somatic disorders from physiological disorders
C) Evaluates clients with total body situations
D) Assesses a number of body organs at one time
E) Effective in for conditions that include alcoholism and drug toxicity

Question 10

What is the purpose of obtaining a UTox blood test?

A) Type and crossmatch the client's blood for later blood transfusions
B) Evaluate situations, such as driving under the influence of alcohol
C) Determine the blood level of a therapeutic medication
D) Perform a urine pregnancy test before prescribing certain medications

Question 11

What is the purpose of the spirometry test?

A) Cardiovascular status
B) Status of the nervous system
C) Respiratory status
D) Status of the endocrine system

Question 12

A nurse is to prepare a client for a lumbar puncture. The client asks the purpose of the test to be performed. What is the purpose of the lumber puncture?

A) To determine intracranial pressure
B) To record the electric potentials of the brain
C) To determine muscle response to stimulation
D) To determine the status of the respiratory system

Question 13

What are the primary medical goals for performing the physical examination? Select all that apply.

A) Examine the client's functional abilities and ability to move
B) Determine the client's level of functioning in self-care
C) Assess for abnormalities to establish a medical diagnosis
D) Monitor a disease's progression
E) Track changes in a client's condition

Question 14

What is the primary nursing goal for performing the physical examination?

A) Identify potential or actual problems that can be prevented or treated
B) Examine the client's functional abilities and ability to move
C) Determine the client's level of functioning in self-care
D) Assess changes and unusual or abnormal findings that have to be reported

Question 15

What assessment technique requires the tapping of one's fingers against a client's abdomen?

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

Question 16

In which order will the following assessment techniques be implemented when assessing a client's abdomen?

A) Inspection, auscultation, palpation
B) Auscultation, palpation, inspection
C) Palpation, inspection, auscultation

Question 17

A client is admitted to the healthcare facility for shortness of breath. Which type of physical examination will the nurse perform initially?

A) Head to toe examination
B) Body system review
C) Focused physical examination
D) Observation and inspection

Question 18

What is the most common format for a general physical examination of a client?

A) Head to toe examination
B) Body system review
C) Focused physical examination
D) Observation and inspection

Question 19

During a physical examination of a client, the nurse observes lesions on the client's hands, which are less than 0.5 cm in diameter with a well-defined border and elevated cavity filled with serous fluid. How should the nurse record this observation in the electronic medical record?

A) Pustule
B) Vesicle
C) Papule
D) Macule

Question 20

During a physical examination of a client, the nurse observes massive generalized edema. What term should the nurse use when recording this observation in the electronic medical record?

A) Pitting edema
B) Nonpitting edema
C) Anasarca
D) Ecchymosis

Question 21

Which finding is normal for a client's oxygen saturation when breathing room air?

A) 91%
B) 92%
C) 93%
D) 94%

Question 22

The nurse assesses the client's eyes and notices extreme redness of the eyes. Which term would the nurse use to document this assessment data?

A) Conjunctivitis
B) Strabismus
C) Diplopia
D) Ptosis

Question 23

Which are examples of an abnormal breath sound? Select all that apply.

A) Eupnea
B) Rales
C) Rhonchi
D) Stridor
E) Wheezes

Question 24

A nurse is required to prepare a client for a radiology test involving the use of dye. What preparatory steps should the nurse take?

A) Wear lead shields to protect vital organs.
B) Observe the client for signs of anaphylaxis.
C) Use masks to protect self.
D) Ask if the client is allergic to iodine.