NURSING NCLEX - MODULE 2. QUESTIONS AND ANSWERS. RATIONALES PROVIDED.

NURSING NCLEX - MODULE 2. QUESTIONS AND ANSWERS. RATIONALES PROVIDED. Questions 1. 1.ID: 0 A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. Correct D. The client has diminished reflexes in the legs. Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain during the physical examination. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical DecisionMaking/ Clinical Judgment, EvidenceBased Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 6 A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2inch scar is present on the lower right portion of the abdomen. Correct Rationale: Subjective data, collected during the health history, consist of information that the client gives about himself or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the nurse would obtain from the client during the health history. Review: the difference between subjective and objective data . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical DecisionMaking/ Clinical Judgment, EvidenceBased Practice/Evidence Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 8 A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Followup C. Emergency D. Complete Correct Rationale: A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. The complete database is collected in a primary care setting such as a pediatric or family practice clinic, an independent or group private practice, a college health service, a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic database is compiled for a limited or shortterm problem and is focused mainly on one problem or one body system. A followup database is used to evaluate an identified problem at regular and appropriate intervals. An emergency database involves the rapid collection of the data that are often compiled as lifesaving measures are being performed. TestTaking Strategy: Noting the words “initial home visit” in the question will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Technology and Informatics HESI Concepts: EvidenceBased Practice/Evidence, Informatics/Technology Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 8 A nurse is examining a 25yearold client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to followup care B. A complete (total health) database C. Data related to the respiratory system Correct D. Data related to the treatment for the cold Rationale: An episodic database is compiled for a limited or shortterm problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client’s current and past state of health and forms a baseline against which all future changes can be measured. A followup database is used to evaluate an identified problem at regular and appropriate intervals. TestTaking Strategy: Focusing on the data in the question and noting the words “now complaining of chest congestion and cough” will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Gas Exchange HESI Concepts: EvidenceBased Practice/Evidence, Oxygenation/Gas Exchange Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 1 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination B. Ask health history questions while performing the examination and initiating emergency measures Correct C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room Rationale: If the client is alert and cooperative and if the situation is not lifethreatening, the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client. Collecting health history information and then performing the physical examination does not address the priority, which is treating the client. Collecting all data requested on the history does not specifically address the client’s immediate problems. Performing emergency measures and not asking any health history questions does not address data collection before treatment. TestTaking Strategy: Focus on the data in the question and note the words “alert and cooperative.” Noting that the client has not sustained lifethreatening injuries will direct you to the correct option. Review: the different types of databases . Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Health Assessment/Physical Exam Priority Concepts: Evidence, Health Care Quality HESI Concepts: EvidenceBased Practice/Evidence, Health Policy/Systems—Health Care Quality Awarded 1.0 points out of 1.0 possible points.