, CHAPTER ss1: s s NURSE’S ssROLE ssIN ssHEALTH ssASSESSMENT: ssCOLLECTING ssAND ssANALYZING ssDATA
1. A ssnurse sson ssa sspostsurgical ssunit ssis ssadmitting ssa ssclient ssfollowing ssthe ssclient's
sscholecystectomy ss(gall ssbladder ssremoval). ssWhat ssis ssthe ssoverall sspurpose ssof
ssassessment ssfor ssthis ssclient?
A) Collecting ssaccurate ssdata
B) Assisting ssthe ssprimary sscare ssprovider
C) Validating ssprevious ssdata
D) Making ssclinical ssjudgments
2. A ssclient sshas sspresented ssto ssthe ssemergency ssdepartment ss(ED) sswith sscomplaints ssof
ssabdominal sspain. ssWhich ssmember ssof ssthe sscare ssteam sswould ssmost sslikely ssbe ssresponsible
ssfor sscollecting ssthe sssubjective ssdata sson ssthe ssclient ssduring ssthe ssinitial sscomprehensive
ssassessment?
A) Gastroenterologist
B) ED ssnurse
C) Admissions ssclerk
D) Diagnostic sstechnician
3. The ssnurse sshas sscompleted ssan ssinitial ssassessment ssof ssa ssnewly ssadmitted ssclient ssand ssis
ssapplying ssthe ssnursing ssprocess ssto ssplan ssthe ssclient's sscare. ssWhat ssprinciple ssshould ssthe
ssnurse ssapply sswhen ssusing ssthe ssnursing ssprocess?
A) Each ssstep ssis ssindependent ssof ssthe ssothers.
B) It ssis ssongoing ssand sscontinuous.
C) It ssis ssused ssprimarily ssin ssacute sscare sssettings. ssN
D) It ssinvolves ssindependent ssnursing ssactions.
4. The ssnurse sswho ssprovides sscare ssat ssan ssambulatory ssclinic ssis sspreparing ssto ssmeet ssa ssclient
ssand ssperform ssa sscomprehensive sshealth ssassessment. ssWhich ssof ssthe ssfollowing ssactions
ssshould ssthe ssnurse ssperform ssfirst?
A) Review ssthe ssclient's ssmedical ssrecord.
B) Obtain ssbasic ssbiographic ssdata.
C) Consult ssclinical ssresources ssexplaining ssthe ssclient's ssdiagnosis.
D) Validate ssinformation sswith ssthe ssclient.
5. Which ssof ssthe ssfollowing ssclient sssituations sswould ssthe ssnurse ssinterpret ssas
ssrequiring ssan ssemergency ssassessment?
A) A sspediatric ssclient sswith sssevere sssunburn
B) A ssclient ssneeding ssan ssemployment ssphysical
C) A ssclient sswho ssoverdosed sson ssacetaminophen
D) A ssdistraught ssclient sswho sswants ssa sspregnancy sstest
,6. In ssresponse ssto ssa ssclient's ssquery, ssthe ssnurse ssis ssexplaining ssthe ssdifferences ssbetween
ssthe ssphysician's ssmedical ssexam ssand ssthe sscomprehensive sshealth ssassessment
ssperformed ssby ssthe ssnurse. ssThe ssnurse ssshould ssdescribe ssthe ssfact ssthat ssthe ssnursing
ssassessment ssfocuses sson sswhich ssaspect ssof ssthe ssclient's sssituation?
A) Current ssphysiologic ssstatus
B) Effect ssof sshealth sson ssfunctional ssstatus
C) Past ssmedical sshistory
D) Motivation ssfor ssadherence ssto sstreatment
7. After ssteaching ssa ssgroup ssof ssstudents ssabout ssthe ssphases ssof ssthe ssnursing ssprocess, ssthe
ssinstructor ssdetermines ssthat ssthe ssteaching sswas sssuccessful sswhen ssthe ssstudents ssidentify
sswhich ssphase ssas ssbeing ssfoundational ssto ssall ssother sspha ssses?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The ssnurse sshas sscompleted ssthe sscomprehensive sshealth ssassessment ssof ssa ssclient sswho sshas
ssbeen ssadmitted ssfor ssthe sstreatment ssof sscommunity-acquired sspneumonia. ssFollowing ssthe
sscompletion ssof ssthis ssassessment, ssthe ssnurse ssperiodically ssperforms ssa sspartial
ssassessment ssprimarily ssfor sswhich ssreason?
A) Reassess sspreviouslyssdeteNcted ssproblems
B) Provide ssinformation ssfor ssthe ssclient's ssrecord
C) Address ssareas sspreviously ssomitted
D) Determine ssthe ssneed ssfor sscrisis ssintervention
9. The ssnurse ssis ssworking ssin ssan ssambulatory sscare ssclinic ssthat ssis sslocated ssin ssa ssbusy,
ssinner-city ssneighborhood. ssWhich ssclient sswould ssthe ssnurse ssdetermine ssto ssbe ssin ssmost
ssneed ssof ssan ssemergency ssassessment?
A) A ss14-year-old ssgirl sswho ssis sscrying ssbecause ssshe ssthinks ssshe ssis sspregnant
B) A ss45-year-old ssman sswith sschest sspain ssand ssdiaphoresis ssfor ss1 sshour
C) A ss3-year-old sschild sswith ssfever, ssrash, ssand sssore ssthroat
D) A ss20-year-old ssman sswith ssa ss3-inch ssshallow sslaceration sson sshis ssleg
10. A ssnurse sshas sscompleted ssgathering sssome ssbasic ssdata ssabout ssa ssclient sswho sshas ssmultiple
sshealth ssproblems ssthat ssstem ssfrom ssheavy ssalcohol ssuse. ssThe ssnurse sshas ssthen ssreflected sson
ssher sspersonal
feelings ssabout ssthe ssclient ssand sshis sscircumstances. ssThe ssnurse ssdoes ssthis ssprimarily ssto
ssaccomplish sswhich ssof ssthe ssfollowing?
A) Determine ssif sspertinent ssdata sshas ssbeen ssomitted
B) Identify ssthe ssneed ssfor ssreferral
C) Avoid ssbiases ssand ssjudgments
D) Construct ssa ssplan ssof sscare
, 11. The ssnurse ssis sscollecting ssdata ssfrom ssa ssclient sswho sshas ssrecently ssbeen ssdiagnosed sswith
sstype ss1 ssdiabetes ssand sswho sswill ssbegin ssan sseducational ssprogram. ssThe ssnurse ssis
sscollecting sssubjective ssand ssobjective ssdata. ssWhich ssof ssthe ssfollowing sswould ssthe ssnurse
sscategorize ssas ssobjective ssdata?
A) Family sshistory
B) Occupation
C) Appearance
D) History ssof sspresent sshealth ssconcern
12. An ssolder ssadult ssclient sshas ssbeen ssadmitted ssto ssthe sshospital sswith ssfailure ssto ssthrive
ssresulting ssfrom sscomplications ssof ssdiabetes. ssWhich ssof ssthe ssfollowing sswould ssthe
ssnurse ssimplement ssin ssresponse ssto ssa sscollaborative ssproblem?
A) Encourage ssthe ssclient ssto ssincrease ssoral ssfluid ssintake.
B) Provide ssthe ssclient sswith ssa ssbedtime ssprotein sssnack. ssN
C) Assist ssthe ssclient sswith sspersonal sshygiene.
D) Measure ssthe ssclient's ssblood ssglucose ssfour sstimes ssdaily.
13. The ssnurse ssat ssa ssbusy ssprimary sscare ssclinic ssis ssanalyzing ssthe ssdata ssobtained ssfrom ssthe
ssfollowing ssclients. ssFor sswhich ssclients sswould ssthe ssnurse ssmost sslikely ssexpect ssto
ssfacilitate ssa ssreferral?
A) An ss80-year-old ssclient sswho sslives sswith ssher ssdaughter
B) A ss50-year-old ssclient ssnewly ssdiagnosed sswith ssdiabetes
C) An ssadult sspresenting ssfor ssan ssinfluenza ssvaccination
D) A ssteenager ssseeking ssinformation ssabout sscontraception
14. An ssinstructor ssis ssreviewing ssthe ssevolution ssof ssthe ssnurse's ssrole ssin sshealth ssassessment.
ssThe ssinstructor ssdetermines ssthat ssthe ssteaching sswas sssuccessful sswhen ssthe ssstudents
ssidentify sswhich ssof ssthe ssfollowing ssas ssthe ssmajor ssmethod ssused ssby ssnurses ssearly ssin ssthe
sshistory ssof ssthe ssprofession? ssA) ssNatural sssenses
B) Biomedical ssknowledge
C) Simple sstechnology
D) Critical sspathways
15. When ssdescribing ssthe ssexpansion ssof ssthe ssdepth ssand ssscope ssof ssnursing ssassessment
ssover ssthe sspast ssseveral ssdecades, sswhich ssof ssthe ssfollowing sswould ssthe ssnurse ssidentify
ssas ssbeing ssthe ssprimary ssforce? ssA) ssDocumentation
B) Informatics
C) Diversification
D) Technology
16. A ssgroup ssof ssnurses ssare ssreviewing ssinformation ssabout ssthe sspotential ssopportunities ssfor
ssnurses sswho sshave ssadvanced ssassessment ssskills. ssWhen ssdiscussing ssphenomena ssthat
sshave sscontributed ssto ssthese ssincreased ssopportunities, sswhat ssshould ssthe ssnurses ssidentify?
A) Expansion ssof sshealth sscare ssnetworks
B) Decrease ssin ssclient ssparticipation ssin sscare
C) The ssshrinking sscost ssof ssmedical sscare
D) Public ssmistrust ssof ssphysicians
1. A ssnurse sson ssa sspostsurgical ssunit ssis ssadmitting ssa ssclient ssfollowing ssthe ssclient's
sscholecystectomy ss(gall ssbladder ssremoval). ssWhat ssis ssthe ssoverall sspurpose ssof
ssassessment ssfor ssthis ssclient?
A) Collecting ssaccurate ssdata
B) Assisting ssthe ssprimary sscare ssprovider
C) Validating ssprevious ssdata
D) Making ssclinical ssjudgments
2. A ssclient sshas sspresented ssto ssthe ssemergency ssdepartment ss(ED) sswith sscomplaints ssof
ssabdominal sspain. ssWhich ssmember ssof ssthe sscare ssteam sswould ssmost sslikely ssbe ssresponsible
ssfor sscollecting ssthe sssubjective ssdata sson ssthe ssclient ssduring ssthe ssinitial sscomprehensive
ssassessment?
A) Gastroenterologist
B) ED ssnurse
C) Admissions ssclerk
D) Diagnostic sstechnician
3. The ssnurse sshas sscompleted ssan ssinitial ssassessment ssof ssa ssnewly ssadmitted ssclient ssand ssis
ssapplying ssthe ssnursing ssprocess ssto ssplan ssthe ssclient's sscare. ssWhat ssprinciple ssshould ssthe
ssnurse ssapply sswhen ssusing ssthe ssnursing ssprocess?
A) Each ssstep ssis ssindependent ssof ssthe ssothers.
B) It ssis ssongoing ssand sscontinuous.
C) It ssis ssused ssprimarily ssin ssacute sscare sssettings. ssN
D) It ssinvolves ssindependent ssnursing ssactions.
4. The ssnurse sswho ssprovides sscare ssat ssan ssambulatory ssclinic ssis sspreparing ssto ssmeet ssa ssclient
ssand ssperform ssa sscomprehensive sshealth ssassessment. ssWhich ssof ssthe ssfollowing ssactions
ssshould ssthe ssnurse ssperform ssfirst?
A) Review ssthe ssclient's ssmedical ssrecord.
B) Obtain ssbasic ssbiographic ssdata.
C) Consult ssclinical ssresources ssexplaining ssthe ssclient's ssdiagnosis.
D) Validate ssinformation sswith ssthe ssclient.
5. Which ssof ssthe ssfollowing ssclient sssituations sswould ssthe ssnurse ssinterpret ssas
ssrequiring ssan ssemergency ssassessment?
A) A sspediatric ssclient sswith sssevere sssunburn
B) A ssclient ssneeding ssan ssemployment ssphysical
C) A ssclient sswho ssoverdosed sson ssacetaminophen
D) A ssdistraught ssclient sswho sswants ssa sspregnancy sstest
,6. In ssresponse ssto ssa ssclient's ssquery, ssthe ssnurse ssis ssexplaining ssthe ssdifferences ssbetween
ssthe ssphysician's ssmedical ssexam ssand ssthe sscomprehensive sshealth ssassessment
ssperformed ssby ssthe ssnurse. ssThe ssnurse ssshould ssdescribe ssthe ssfact ssthat ssthe ssnursing
ssassessment ssfocuses sson sswhich ssaspect ssof ssthe ssclient's sssituation?
A) Current ssphysiologic ssstatus
B) Effect ssof sshealth sson ssfunctional ssstatus
C) Past ssmedical sshistory
D) Motivation ssfor ssadherence ssto sstreatment
7. After ssteaching ssa ssgroup ssof ssstudents ssabout ssthe ssphases ssof ssthe ssnursing ssprocess, ssthe
ssinstructor ssdetermines ssthat ssthe ssteaching sswas sssuccessful sswhen ssthe ssstudents ssidentify
sswhich ssphase ssas ssbeing ssfoundational ssto ssall ssother sspha ssses?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The ssnurse sshas sscompleted ssthe sscomprehensive sshealth ssassessment ssof ssa ssclient sswho sshas
ssbeen ssadmitted ssfor ssthe sstreatment ssof sscommunity-acquired sspneumonia. ssFollowing ssthe
sscompletion ssof ssthis ssassessment, ssthe ssnurse ssperiodically ssperforms ssa sspartial
ssassessment ssprimarily ssfor sswhich ssreason?
A) Reassess sspreviouslyssdeteNcted ssproblems
B) Provide ssinformation ssfor ssthe ssclient's ssrecord
C) Address ssareas sspreviously ssomitted
D) Determine ssthe ssneed ssfor sscrisis ssintervention
9. The ssnurse ssis ssworking ssin ssan ssambulatory sscare ssclinic ssthat ssis sslocated ssin ssa ssbusy,
ssinner-city ssneighborhood. ssWhich ssclient sswould ssthe ssnurse ssdetermine ssto ssbe ssin ssmost
ssneed ssof ssan ssemergency ssassessment?
A) A ss14-year-old ssgirl sswho ssis sscrying ssbecause ssshe ssthinks ssshe ssis sspregnant
B) A ss45-year-old ssman sswith sschest sspain ssand ssdiaphoresis ssfor ss1 sshour
C) A ss3-year-old sschild sswith ssfever, ssrash, ssand sssore ssthroat
D) A ss20-year-old ssman sswith ssa ss3-inch ssshallow sslaceration sson sshis ssleg
10. A ssnurse sshas sscompleted ssgathering sssome ssbasic ssdata ssabout ssa ssclient sswho sshas ssmultiple
sshealth ssproblems ssthat ssstem ssfrom ssheavy ssalcohol ssuse. ssThe ssnurse sshas ssthen ssreflected sson
ssher sspersonal
feelings ssabout ssthe ssclient ssand sshis sscircumstances. ssThe ssnurse ssdoes ssthis ssprimarily ssto
ssaccomplish sswhich ssof ssthe ssfollowing?
A) Determine ssif sspertinent ssdata sshas ssbeen ssomitted
B) Identify ssthe ssneed ssfor ssreferral
C) Avoid ssbiases ssand ssjudgments
D) Construct ssa ssplan ssof sscare
, 11. The ssnurse ssis sscollecting ssdata ssfrom ssa ssclient sswho sshas ssrecently ssbeen ssdiagnosed sswith
sstype ss1 ssdiabetes ssand sswho sswill ssbegin ssan sseducational ssprogram. ssThe ssnurse ssis
sscollecting sssubjective ssand ssobjective ssdata. ssWhich ssof ssthe ssfollowing sswould ssthe ssnurse
sscategorize ssas ssobjective ssdata?
A) Family sshistory
B) Occupation
C) Appearance
D) History ssof sspresent sshealth ssconcern
12. An ssolder ssadult ssclient sshas ssbeen ssadmitted ssto ssthe sshospital sswith ssfailure ssto ssthrive
ssresulting ssfrom sscomplications ssof ssdiabetes. ssWhich ssof ssthe ssfollowing sswould ssthe
ssnurse ssimplement ssin ssresponse ssto ssa sscollaborative ssproblem?
A) Encourage ssthe ssclient ssto ssincrease ssoral ssfluid ssintake.
B) Provide ssthe ssclient sswith ssa ssbedtime ssprotein sssnack. ssN
C) Assist ssthe ssclient sswith sspersonal sshygiene.
D) Measure ssthe ssclient's ssblood ssglucose ssfour sstimes ssdaily.
13. The ssnurse ssat ssa ssbusy ssprimary sscare ssclinic ssis ssanalyzing ssthe ssdata ssobtained ssfrom ssthe
ssfollowing ssclients. ssFor sswhich ssclients sswould ssthe ssnurse ssmost sslikely ssexpect ssto
ssfacilitate ssa ssreferral?
A) An ss80-year-old ssclient sswho sslives sswith ssher ssdaughter
B) A ss50-year-old ssclient ssnewly ssdiagnosed sswith ssdiabetes
C) An ssadult sspresenting ssfor ssan ssinfluenza ssvaccination
D) A ssteenager ssseeking ssinformation ssabout sscontraception
14. An ssinstructor ssis ssreviewing ssthe ssevolution ssof ssthe ssnurse's ssrole ssin sshealth ssassessment.
ssThe ssinstructor ssdetermines ssthat ssthe ssteaching sswas sssuccessful sswhen ssthe ssstudents
ssidentify sswhich ssof ssthe ssfollowing ssas ssthe ssmajor ssmethod ssused ssby ssnurses ssearly ssin ssthe
sshistory ssof ssthe ssprofession? ssA) ssNatural sssenses
B) Biomedical ssknowledge
C) Simple sstechnology
D) Critical sspathways
15. When ssdescribing ssthe ssexpansion ssof ssthe ssdepth ssand ssscope ssof ssnursing ssassessment
ssover ssthe sspast ssseveral ssdecades, sswhich ssof ssthe ssfollowing sswould ssthe ssnurse ssidentify
ssas ssbeing ssthe ssprimary ssforce? ssA) ssDocumentation
B) Informatics
C) Diversification
D) Technology
16. A ssgroup ssof ssnurses ssare ssreviewing ssinformation ssabout ssthe sspotential ssopportunities ssfor
ssnurses sswho sshave ssadvanced ssassessment ssskills. ssWhen ssdiscussing ssphenomena ssthat
sshave sscontributed ssto ssthese ssincreased ssopportunities, sswhat ssshould ssthe ssnurses ssidentify?
A) Expansion ssof sshealth sscare ssnetworks
B) Decrease ssin ssclient ssparticipation ssin sscare
C) The ssshrinking sscost ssof ssmedical sscare
D) Public ssmistrust ssof ssphysicians
