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Chapter 1 2i
1. A nurse on a postsurgical unit is admitting a client following the client's cholecystect
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
omy (gall bladder removal). What is the overall purpose of assessment for this client?
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A) Collecting accurate data 2i 2i
B) Assisting the primary care provider 2i 2i 2i 2i
C) Validating previous data 2i 2i
D) Making clinical judgments 2i 2i
2. A client has presented to the emergency department (ED) with complaints of abdominal
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
pain. Which member of the care team would most likely be responsible for collecting t
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
he subjective data on the client during the initial comprehensive assessment?
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
A) Gastroenterologist
B) ED nurse 2i
C) Admissions clerk 2i
D) Diagnostic technician 2i
3. The nurse has completed an initial assessment of a newly admitted client and is applying
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
the nursing process to plan the client's care. What principle should the nurse apply when
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
using the nursing process?
2i 2i 2i 2i
A) Each step is independent of the others. 2i 2i 2i 2i 2i 2i
B) It is ongoing and continuous.
2i 2i 2i 2i
C) It is used primarily in acute care settings.
2i 2i 2i 2i 2i 2i 2i
D) It involves independent nursing actions.
2i 2i 2i 2i
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
perform a comprehensive health assessment. Which of the following actions should the
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
nurse perform first? 2i 2i
A) Review the client's medical record. 2i 2i 2i 2i
B) Obtain basic biographic data. 2i 2i 2i
C) Consult clinical resources explaining the client's diagnosis.
2i 2i 2i 2i 2i 2i
D) Validate information with the client. 2i 2i 2i 2i
5. Which of the following client situations would the nurse interpret as requiring an
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
emergency assessment? 2i
A) A pediatric client with severe sunburn
2i 2i 2i 2i 2i
B) A client needing an employment physical
2i 2i 2i 2i 2i
C) A client who overdosed on acetaminophen
2i 2i 2i 2i 2i
D) A distraught client who wants a pregnancy test
2i 2i 2i 2i 2i 2i 2i
, lOMoARcPSD| 12286418
6. In response to a client's query, the nurse is explaining the differences between the phy
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
sician's medical exam and the comprehensive health assessment performed by the nur
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
se. The nurse should describe the fact that the nursing assessment focuses on which asp
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ect of the client's situation?
2i 2i 2i 2i
A) Current physiologic status 2i 2i
B) Effect of health on functional status 2i 2i 2i 2i 2i
C) Past medical history 2i 2i
D) Motivation for adherence to treatment 2i 2i 2i 2i
7. After teaching a group of students about the phases of the nursing process, the instructor
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
determines that the teaching was successful when the students identify which phase as
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
being foundational to all other phases?
2i 2i 2i 2i 2i
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
admitted for the treatment of community-
2i 2i 2i 2i 2i
acquired pneumonia. Following the completion of this assessment, the nurse periodical
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ly performs a partial assessment primarily for which reason?
2i 2i 2i 2i 2i 2i 2i 2i
A) Reassess previously detected problems 2i 2i 2i
B) Provide information for the client's record 2i 2i 2i 2i 2i
C) Address areas previously omitted 2i 2i 2i
D) Determine the need for crisis intervention 2i 2i 2i 2i 2i
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
city neighborhood. Which client would the nurse determine to be in most need of an
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
emergency assessment?
2i 2i
A) A 14-year-old girl who is crying because she thinks she is pregnant
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
C) A 3-year-old child with fever, rash, and sore throat
2i 2i 2i 2i 2i 2i 2i 2i
D) A 20-year-old man with a 3-inch shallow laceration on his leg
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
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10. A nurse has completed gathering some basic data about a client who has multiple health
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2
feelings about the client and his circumstances. The nurse does this primarily to accom
i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
plish which of the following?
2i 2i 2i 2i
A) Determine if pertinent data has been omitted 2i 2i 2i 2i 2i 2i
B) Identify the need for referral 2i 2i 2i 2i
C) Avoid biases and judgments 2i 2i 2i
D) Construct a plan of care 2i 2i 2i 2i
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
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?
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
A) Family history 2i
B) Occupation
C) Appearance
D) History of present health concern 2i 2i 2i 2i
12. An older adult client has been admitted to the hospital with failure to thrive resulting
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
from complications of diabetes. Which of the following would the nurse implement in
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
response to a collaborative problem? 2i 2i 2i 2i
A) Encourage the client to increase oral fluid intake. 2i 2i 2i 2i 2i 2i 2i
B) Provide the client with a bedtime protein snack. 2i 2i 2i 2i 2i 2i 2i
C) Assist the client with personal hygiene. 2i 2i 2i 2i 2i
D) Measure the client's blood glucose four times daily. 2i 2i 2i 2i 2i 2i 2i
13. The nurse at a busy primary care clinic is analyzing the data obtained from the follo
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
wing clients. For which clients would the nurse most likely expect to facilitate a refer
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ral?
A) An 80-year-old client who lives with her daughter
2i 2i 2i 2i 2i 2i 2i
B) A 50-year-old client newly diagnosed with diabetes
2i 2i 2i 2i 2i 2i
C) An adult presenting for an influenza vaccination
2i 2i 2i 2i 2i 2i
D) A teenager seeking information about contraception
2i 2i 2i 2i 2i
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The i
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
nstructor determines that the teaching was successful when the students identify which
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
of the following as the major method used by nurses early in the history of the professi
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
on?
A) Natural senses 2i
B) Biomedical knowledge 2i
C) Simple technology 2i
D) Critical pathways 2i
Chapter 1 2i
1. A nurse on a postsurgical unit is admitting a client following the client's cholecystect
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
omy (gall bladder removal). What is the overall purpose of assessment for this client?
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
A) Collecting accurate data 2i 2i
B) Assisting the primary care provider 2i 2i 2i 2i
C) Validating previous data 2i 2i
D) Making clinical judgments 2i 2i
2. A client has presented to the emergency department (ED) with complaints of abdominal
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
pain. Which member of the care team would most likely be responsible for collecting t
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
he subjective data on the client during the initial comprehensive assessment?
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
A) Gastroenterologist
B) ED nurse 2i
C) Admissions clerk 2i
D) Diagnostic technician 2i
3. The nurse has completed an initial assessment of a newly admitted client and is applying
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
the nursing process to plan the client's care. What principle should the nurse apply when
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
using the nursing process?
2i 2i 2i 2i
A) Each step is independent of the others. 2i 2i 2i 2i 2i 2i
B) It is ongoing and continuous.
2i 2i 2i 2i
C) It is used primarily in acute care settings.
2i 2i 2i 2i 2i 2i 2i
D) It involves independent nursing actions.
2i 2i 2i 2i
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
perform a comprehensive health assessment. Which of the following actions should the
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
nurse perform first? 2i 2i
A) Review the client's medical record. 2i 2i 2i 2i
B) Obtain basic biographic data. 2i 2i 2i
C) Consult clinical resources explaining the client's diagnosis.
2i 2i 2i 2i 2i 2i
D) Validate information with the client. 2i 2i 2i 2i
5. Which of the following client situations would the nurse interpret as requiring an
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
emergency assessment? 2i
A) A pediatric client with severe sunburn
2i 2i 2i 2i 2i
B) A client needing an employment physical
2i 2i 2i 2i 2i
C) A client who overdosed on acetaminophen
2i 2i 2i 2i 2i
D) A distraught client who wants a pregnancy test
2i 2i 2i 2i 2i 2i 2i
, lOMoARcPSD| 12286418
6. In response to a client's query, the nurse is explaining the differences between the phy
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
sician's medical exam and the comprehensive health assessment performed by the nur
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
se. The nurse should describe the fact that the nursing assessment focuses on which asp
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ect of the client's situation?
2i 2i 2i 2i
A) Current physiologic status 2i 2i
B) Effect of health on functional status 2i 2i 2i 2i 2i
C) Past medical history 2i 2i
D) Motivation for adherence to treatment 2i 2i 2i 2i
7. After teaching a group of students about the phases of the nursing process, the instructor
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
determines that the teaching was successful when the students identify which phase as
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
being foundational to all other phases?
2i 2i 2i 2i 2i
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
admitted for the treatment of community-
2i 2i 2i 2i 2i
acquired pneumonia. Following the completion of this assessment, the nurse periodical
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ly performs a partial assessment primarily for which reason?
2i 2i 2i 2i 2i 2i 2i 2i
A) Reassess previously detected problems 2i 2i 2i
B) Provide information for the client's record 2i 2i 2i 2i 2i
C) Address areas previously omitted 2i 2i 2i
D) Determine the need for crisis intervention 2i 2i 2i 2i 2i
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
city neighborhood. Which client would the nurse determine to be in most need of an
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
emergency assessment?
2i 2i
A) A 14-year-old girl who is crying because she thinks she is pregnant
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
C) A 3-year-old child with fever, rash, and sore throat
2i 2i 2i 2i 2i 2i 2i 2i
D) A 20-year-old man with a 3-inch shallow laceration on his leg
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
, lOMoARcPSD| 12286418
10. A nurse has completed gathering some basic data about a client who has multiple health
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2
feelings about the client and his circumstances. The nurse does this primarily to accom
i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
plish which of the following?
2i 2i 2i 2i
A) Determine if pertinent data has been omitted 2i 2i 2i 2i 2i 2i
B) Identify the need for referral 2i 2i 2i 2i
C) Avoid biases and judgments 2i 2i 2i
D) Construct a plan of care 2i 2i 2i 2i
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
diabetes and who will begin an educational program. The nurse is collecting subjective
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
and objective data. Which of the following would the nurse categorize as objective data?
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
A) Family history 2i
B) Occupation
C) Appearance
D) History of present health concern 2i 2i 2i 2i
12. An older adult client has been admitted to the hospital with failure to thrive resulting
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
from complications of diabetes. Which of the following would the nurse implement in
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
response to a collaborative problem? 2i 2i 2i 2i
A) Encourage the client to increase oral fluid intake. 2i 2i 2i 2i 2i 2i 2i
B) Provide the client with a bedtime protein snack. 2i 2i 2i 2i 2i 2i 2i
C) Assist the client with personal hygiene. 2i 2i 2i 2i 2i
D) Measure the client's blood glucose four times daily. 2i 2i 2i 2i 2i 2i 2i
13. The nurse at a busy primary care clinic is analyzing the data obtained from the follo
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
wing clients. For which clients would the nurse most likely expect to facilitate a refer
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
ral?
A) An 80-year-old client who lives with her daughter
2i 2i 2i 2i 2i 2i 2i
B) A 50-year-old client newly diagnosed with diabetes
2i 2i 2i 2i 2i 2i
C) An adult presenting for an influenza vaccination
2i 2i 2i 2i 2i 2i
D) A teenager seeking information about contraception
2i 2i 2i 2i 2i
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The i
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
nstructor determines that the teaching was successful when the students identify which
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
of the following as the major method used by nurses early in the history of the professi
2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i 2i
on?
A) Natural senses 2i
B) Biomedical knowledge 2i
C) Simple technology 2i
D) Critical pathways 2i