,Chapter 1 ss
1. A nurse on a postsurgical unit is admitting a client following the client's
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cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
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this client?
ss ss
A) Collecting accurate data ss ss
B) Assisting the primary care provider ss ss ss ss
C) Validating previous data ss ss
D) Making clinical judgments ss ss s s
2. A client has presented to the emergency department (ED) with complaints of abdominal
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pain. Which member of the care team would most likely be responsible for collecting
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the subjective data on the client during the initial comprehensive assessment?
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A) Gastroenterologist
B) ED nurse ss s s
C) Admissions clerk ss
D) Diagnostic technician ss
3. The nurse has completed an initial assessment of a newly admitted client and is applying
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the nursing process to plan the client's care. What principle should the nurse apply
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
when using the nursing process?
ss ss ss ss ss
A) Each step is independent of the others. ss ss ss ss ss ss
B) It is ongoing and continuous.
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C) It is used primarily in acute care settings.
ss ss ss ss ss ss ss
D) It involves independent nursing actions.
ss ss ss ss
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
perform a comprehensive health assessment. Which of the following actions should the
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nurse perform first?
ss ss ss
A) Review the client's medical record. ss ss ss ss s s
B) Obtain basic biographic data. ss ss ss
C) Consult clinical resources explaining the client's diagnosis.ss ss ss ss ss ss
D) Validate information with the client. ss ss ss ss
5. Which of the following client situations would the nurse interpret as requiring an
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emergency assessment?
ss ss
A) A pediatric client with severe sunburn
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B) A client needing an employment physical
ss ss ss ss ss
C) A client who overdosed on acetaminophen
ss ss ss ss ss s s
D) A distraught client who wants a pregnancy test
ss ss ss ss ss ss ss
,6. In response to a client's query, the nurse is explaining the differences between the
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physician's medical exam and the comprehensive health assessment performed by the
ss ss ss ss ss ss ss ss ss ss ss
nurse. The nurse should describe the fact that the nursing assessment focuses on which
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
aspect of the client's situation?
ss ss ss ss ss
A) Current physiologic status ss ss
B) Effect of health on functional statusss ss ss ss ss s s
C) Past medical history ss ss
D) Motivation for adherence to treatment ss ss ss ss
7. After teaching a group of students about the phases of the nursing process, the instructor
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determines that the teaching was successful when the students identify which phase as
ss ss ss ss ss ss ss ss ss ss ss ss ss
being foundational to all other phases?
ss ss ss ss ss ss
A) Assessment s s
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
ss ss ss ss ss ss ss ss ss ss ss ss ss
admitted for the treatment of community-acquired pneumonia. Following the
ss ss ss ss ss ss ss ss ss
completion of this assessment, the nurse periodically performs a partial assessment
ss ss ss ss ss ss ss ss ss ss ss
primarily for which reason?
ss ss ss ss
A) Reassess previously detected problems ss ss ss s s
B) Provide information for the client's record ss ss ss ss ss
C) Address areas previously omitted ss ss ss
D) Determine the need for crisis intervention ss ss ss ss ss
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
neighborhood. Which client would the nurse determine to be in most need of an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
emergency assessment?
ss ss
A) A 14-year-old girl who is crying because she thinks she is pregnant
ss ss ss ss ss ss ss ss ss ss ss
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
ss ss ss ss ss ss ss ss ss ss s s
C) A 3-year-old child with fever, rash, and sore throat
ss ss ss ss ss ss ss ss
D) A 20-year-old man with a 3-inch shallow laceration on his leg
ss ss ss ss ss ss ss ss ss ss
, 10. A nurse has completed gathering some basic data about a client who has multiple health
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
feelings about the client and his circumstances. The nurse does this primarily to
ss ss ss ss ss ss ss ss ss ss ss ss ss
accomplish which of the following?
ss ss ss ss ss
A) Determine if pertinent data has been omitted ss ss ss ss ss ss
B) Identify the need for referral ss ss ss ss
C) Avoid biases and judgments ss ss ss s s
D) Construct a plan of care ss ss ss ss
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
diabetes and who will begin an educational program. The nurse is collecting subjective
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and objective data. Which of the following would the nurse categorize as objective data?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
A) Family history ss
B) Occupation
C) Appearance s s
D) History of present health concern ss ss ss ss
12. An older adult client has been admitted to the hospital with failure to thrive resulting
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
from complications of diabetes. Which of the following would the nurse implement in
ss ss ss ss ss ss ss ss ss ss ss ss ss
response to a collaborative problem?
ss ss ss ss ss
A) Encourage the client to increase oral fluid intake. ss ss ss ss ss ss ss
B) Provide the client with a bedtime protein snack. ss ss ss ss ss ss ss
C) Assist the client with personal hygiene. ss ss ss ss ss
D) Measure the client's blood glucose four times daily. ss ss ss ss ss ss ss s s
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
following clients. For which clients would the nurse most likely expect to facilitate a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
referral?
ss
A) An 80-year-old client who lives with her daughter
ss ss ss ss ss ss ss
B) A 50-year-old client newly diagnosed with diabetes
ss ss ss ss ss ss s s
C) An adult presenting for an influenza vaccination
ss ss ss ss ss ss
D) A teenager seeking information about contraception
ss ss ss ss ss
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
instructor determines that the teaching was successful when the students identify which
ss ss ss ss ss ss ss ss ss ss ss ss
of the following as the major method used by nurses early in the history of the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
profession?
ss
A) Natural senses ss s s
B) Biomedical knowledge ss
C) Simple technology ss
D) Critical pathways ss
1. A nurse on a postsurgical unit is admitting a client following the client's
ss ss ss ss ss ss ss ss ss ss ss ss
cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
ss ss ss ss ss ss ss ss ss ss ss ss
this client?
ss ss
A) Collecting accurate data ss ss
B) Assisting the primary care provider ss ss ss ss
C) Validating previous data ss ss
D) Making clinical judgments ss ss s s
2. A client has presented to the emergency department (ED) with complaints of abdominal
ss ss ss ss ss ss ss ss ss ss ss ss
pain. Which member of the care team would most likely be responsible for collecting
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the subjective data on the client during the initial comprehensive assessment?
ss ss ss ss ss ss ss ss ss ss ss
A) Gastroenterologist
B) ED nurse ss s s
C) Admissions clerk ss
D) Diagnostic technician ss
3. The nurse has completed an initial assessment of a newly admitted client and is applying
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the nursing process to plan the client's care. What principle should the nurse apply
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
when using the nursing process?
ss ss ss ss ss
A) Each step is independent of the others. ss ss ss ss ss ss
B) It is ongoing and continuous.
ss ss ss ss s s
C) It is used primarily in acute care settings.
ss ss ss ss ss ss ss
D) It involves independent nursing actions.
ss ss ss ss
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
perform a comprehensive health assessment. Which of the following actions should the
ss ss ss ss ss ss ss ss ss ss ss ss
nurse perform first?
ss ss ss
A) Review the client's medical record. ss ss ss ss s s
B) Obtain basic biographic data. ss ss ss
C) Consult clinical resources explaining the client's diagnosis.ss ss ss ss ss ss
D) Validate information with the client. ss ss ss ss
5. Which of the following client situations would the nurse interpret as requiring an
ss ss ss ss ss ss ss ss ss ss ss ss
emergency assessment?
ss ss
A) A pediatric client with severe sunburn
ss ss ss ss ss
B) A client needing an employment physical
ss ss ss ss ss
C) A client who overdosed on acetaminophen
ss ss ss ss ss s s
D) A distraught client who wants a pregnancy test
ss ss ss ss ss ss ss
,6. In response to a client's query, the nurse is explaining the differences between the
ss ss ss ss ss ss ss ss ss ss ss ss ss
physician's medical exam and the comprehensive health assessment performed by the
ss ss ss ss ss ss ss ss ss ss ss
nurse. The nurse should describe the fact that the nursing assessment focuses on which
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
aspect of the client's situation?
ss ss ss ss ss
A) Current physiologic status ss ss
B) Effect of health on functional statusss ss ss ss ss s s
C) Past medical history ss ss
D) Motivation for adherence to treatment ss ss ss ss
7. After teaching a group of students about the phases of the nursing process, the instructor
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
determines that the teaching was successful when the students identify which phase as
ss ss ss ss ss ss ss ss ss ss ss ss ss
being foundational to all other phases?
ss ss ss ss ss ss
A) Assessment s s
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
ss ss ss ss ss ss ss ss ss ss ss ss ss
admitted for the treatment of community-acquired pneumonia. Following the
ss ss ss ss ss ss ss ss ss
completion of this assessment, the nurse periodically performs a partial assessment
ss ss ss ss ss ss ss ss ss ss ss
primarily for which reason?
ss ss ss ss
A) Reassess previously detected problems ss ss ss s s
B) Provide information for the client's record ss ss ss ss ss
C) Address areas previously omitted ss ss ss
D) Determine the need for crisis intervention ss ss ss ss ss
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
neighborhood. Which client would the nurse determine to be in most need of an
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
emergency assessment?
ss ss
A) A 14-year-old girl who is crying because she thinks she is pregnant
ss ss ss ss ss ss ss ss ss ss ss
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
ss ss ss ss ss ss ss ss ss ss s s
C) A 3-year-old child with fever, rash, and sore throat
ss ss ss ss ss ss ss ss
D) A 20-year-old man with a 3-inch shallow laceration on his leg
ss ss ss ss ss ss ss ss ss ss
, 10. A nurse has completed gathering some basic data about a client who has multiple health
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
feelings about the client and his circumstances. The nurse does this primarily to
ss ss ss ss ss ss ss ss ss ss ss ss ss
accomplish which of the following?
ss ss ss ss ss
A) Determine if pertinent data has been omitted ss ss ss ss ss ss
B) Identify the need for referral ss ss ss ss
C) Avoid biases and judgments ss ss ss s s
D) Construct a plan of care ss ss ss ss
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
diabetes and who will begin an educational program. The nurse is collecting subjective
ss ss ss ss ss ss ss ss ss ss ss ss ss
and objective data. Which of the following would the nurse categorize as objective data?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
A) Family history ss
B) Occupation
C) Appearance s s
D) History of present health concern ss ss ss ss
12. An older adult client has been admitted to the hospital with failure to thrive resulting
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
from complications of diabetes. Which of the following would the nurse implement in
ss ss ss ss ss ss ss ss ss ss ss ss ss
response to a collaborative problem?
ss ss ss ss ss
A) Encourage the client to increase oral fluid intake. ss ss ss ss ss ss ss
B) Provide the client with a bedtime protein snack. ss ss ss ss ss ss ss
C) Assist the client with personal hygiene. ss ss ss ss ss
D) Measure the client's blood glucose four times daily. ss ss ss ss ss ss ss s s
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
following clients. For which clients would the nurse most likely expect to facilitate a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
referral?
ss
A) An 80-year-old client who lives with her daughter
ss ss ss ss ss ss ss
B) A 50-year-old client newly diagnosed with diabetes
ss ss ss ss ss ss s s
C) An adult presenting for an influenza vaccination
ss ss ss ss ss ss
D) A teenager seeking information about contraception
ss ss ss ss ss
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
ss ss ss ss ss ss ss ss ss ss ss ss ss
instructor determines that the teaching was successful when the students identify which
ss ss ss ss ss ss ss ss ss ss ss ss
of the following as the major method used by nurses early in the history of the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
profession?
ss
A) Natural senses ss s s
B) Biomedical knowledge ss
C) Simple technology ss
D) Critical pathways ss
