Test Generator Questions, Chapter 6, Nursing Assessment

Format: Multiple Choice

Chapter: 6

Client Needs: Safe and Effective Care Environment: Management of Care

Cognitive Level: Understand

Integrated Process: Nursing Process

Learning Objective: 1

Page and Header: Introduction, p. 84.

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.

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.

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.

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

5. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

A) Complete

B) Focused

C) General

D) Time-lapse

6. 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

7. An unconscious client is brought to the emergency department. Which assessment should be implemented first?

A) The client’s airway should be assessed.

B) The nurse should determine the reason for admission.

C) The nurse should review the client’s medications.

D) The client’s past medical history is assessed.

8. 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.

9. 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.

10. 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

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

A) parents.

B) siblings.

C) physician.

D) infant.

12. 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.

13. The nurse observes the client while walking into the room. What information will this provide the nurse?

A) Information regarding the client’s gait

B) Information regarding the client’s personality

C) Information regarding the client’s psychosocial status

D) Information on the rate of recovery from surgery

14. 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

15. 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

16. 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.

17. 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.

18. 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.

19. When assessing the client’s pulse, the nurse should use which assessment technique?

A) Inspection

B) Palpation

C) Percussion

D) Auscultation

20. After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which client information as objective data?

A) Auscultation of the lungs

B) Complaint of nausea

C) Sensation of burning in his or her epigastric area

D) Belief that demons are in his or her stomach

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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

27. 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

28. 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

29. 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."

30. 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

31. 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.

32. 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