,
,
,
,20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused
assessment. Which of the following statements should inform the nurse's practice?
A) The focused assessment should be done before the physical exam.
B) The focused assessment replaces the comprehensive database.
C) The focused assessment addresses a particular client problem.
D) The focused assessment is done after gathering subjective data.
21. The nurse is reviewing a client's health history and the results of the most recent
physical examination. Which of the following data would the nurse identify as being
subjective? Select all that apply.
A) ìI feel so tired sometimes.î
B) Weight: 145 lbs
C) Lungs clear to auscultation
D) Client complains of a headache
E) ìMy father died of a heart attack.î
F) Pupils equal, round, and reactive to light
22. The nurse has been applying the nursing process in the care of an adult client who is
being treated for acute pancreatitis. Place the nurse's actions in their proper sequence
from first to last.
A) Identifying outcomes C,B,A,E,D
B) Determining client's nursing problem
C) Collecting information about the client
D) Determining outcome achievement
E) Carrying out interventions
23. A nurse is completing an assessment that will involve gathering subjective and objective
data. Which of the following assessment techniques will best allow the nurse to collect
objective data?
A) Inspection
B) Therapeutic communication
C) Interviewing
D) Active listening
24. The nurse is performing a health assessment on a community-dwelling client who is
recovering from hip replacement surgery. Which of the following actions should the
nurse prioritize during assessment?
A) Focus the assessment on the client as a member of her age group.
B) Interpret the information about the client in context.
C) Corroborate the client's statements with trusted sources.
D) Gather information from a variety of sources.
Page 5
,25. A client comes to the health care provider's office for a visit. The client has been seen in
this office on occasion for the past 5 years and arrives today complaining of a fever and
sore throat. Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment
26. A nurse has assessed a client who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the client admitted that his
blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse
best respond to this assessment finding?
A) Identify a nursing diagnosis of Ineffective Health Maintenance.
B) Identify a collaborative problem that should involve the occupational therapist.
C) Make a referral to the unit's social work department.
D) Reassess the client's blood glucose level.
27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse should
begin by assessing which of the following?
A) The client's motivation for change
B) The client's medical comorbidities
C) The client's learning style
D) The client's prognosis for recovery
28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who
is new to the clinic. What goal should the nurse identify for this type of assessment?
A) Identify the most appropriate forms of medical intervention for the client.
B) Determine the most likely prognosis for the client's health problem.
C) Identify the status of the client's airway, breathing, and circulation.
D) Establish a baseline for the comparison of future health changes.
29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a
client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent
ongoing assessments. The frequency of these nursing assessments should be primarily
determined by what variable?
A) The client's age
B) The unit's protocols
C) The client's acuity
D) The nurse's potential for liability
Page 6
,30. A client who is new to the facility has a recent history of chronic pain that is attributed
to fibromyalgia. The nurse has reviewed the available health records and suspects that
pain management will be a major focus of nursing care. How can the nurse best validate
this assumption?
A) Review the client's medication administration record for analgesic use.
B) Ask the client about the most recent experiences of pain.
C) Meet with the client's spouse and daughter to discuss the client's pain.
D) Collaborate with the physician who is treating the client.
Page 7
,Answer Key
1. D
2. B
3. B
4. A
5. C
6. B
7. A
8. A
9. B
10. C
11. C
12. D
13. B
14. A
15. D
16. A
17. C
18. C
19. A
20. C
21. A, D, E
22. C, B, A, E, D
23. A
24. B
25. C
26. A
27. A
28. D
29. C
30. B
Page 8
,Chapter 2 Collecting Subjective Data-The Interview and Health History
1. A nurse is preparing to assess a client who is new to the clinic. When beginning the
collection of the client database, which of the following actions should the nurse
prioritize?
A) Establishing a trusting relationship
B) Determining the client's strengths
C) Identifying potential health problems
D) Making clinical inferences
2. A nurse is interpreting and validating information from an older adult client who has
been experiencing a functional decline. The nurse is in which phase of the interview?
A) Introductory
B) Working
C) Summary
D) Closing
3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and
the nurse is collecting subjective data prior to surgery. Which statement by the nurse
could be construed as judgmental?
A) “How often do your adult children typically visit you?”
B) “Your husband's death must have been very difficult for you.”
C) “You must quit smoking because it affects others, not only you.”
D) “How would you describe your feelings about getting older?”
4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during this
phase of assessment?
A) Standing while the client is seated
B) Using a moderate amount of eye contact
C) Sitting across the room from the client
D) Minimizing facial expressions
5. A nurse is providing feedback to a colleague after observing the colleague's interview of
a newly admitted client. Which of the following would the nurse identify as an example
of a closed-ended question or statement?
A) “Tell me about your relationship with your children?”
B) “Tell me what you eat in a normal day?”
C) “Are you allergic to any medications?”
D) “What is your typical day like?”
Page 1
, 6. A client has presented to the emergency department and is having difficulty describing
her vague sensation of physical discomfort and unease. How can the nurse best elicit
meaningful assessment data about the nature of the client's complaint?
A) Ignore the complaint for now and return to it later in the assessment.
B) Provide a laundry list of descriptive words.
C) Restate the question using simpler terms.
D) Wait in silence until the client can determine the correct words.
7. A nurse is eliciting a client's health history and the client asks, “Can I take the herb
ginkgo biloba with my other medications?” What action would be best if the nurse is
unsure of the answer?
A) Promise to find out the information for the client.
B) Change the subject and return to this topic later.
C) Teach the client to only take prescribed medications.
D) Encourage the client to ask the pharmacist or primary care provider.
8. The nurse is preparing to assess the mental status of a 90-year-old client who is being
admitted to the hospital from a long-term care facility. Which of the following should
the nurse assess first?
A) The client's sensory abilities
B) The client's general intelligence
C) The presence of any phobias
D) The client's judgment and insight
9. A nurse provides care in a rural hospital that serves a community that has few minority
residents. When interviewing a client from a minority culture, the nurse has enlisted the
assistance of a “culture broker.” How can this individual best facilitate the client's care?
A) By interpreting the client's language and culture
B) By evaluating the client's culturally based health practices
C) By teaching the client about health care
D) By making the client feel comfortable and safe
10. Upon entering an exam room, the client states, “Well! I was getting ready to leave. My
schedule is very busy and I don't have time to waste waiting until you have the time to
see me!” Which response by the nurse would be most appropriate?
A) “Our schedule is very busy also. We got to you as soon as we could.”
B) “No one is forcing you to be here, and you are free to leave at any time.”
C) “Would you like to report your complaints to someone with power?”
D) “You're certainly justified in being upset, but I am ready to begin your exam now.”
Page 2
,
,
,20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused
assessment. Which of the following statements should inform the nurse's practice?
A) The focused assessment should be done before the physical exam.
B) The focused assessment replaces the comprehensive database.
C) The focused assessment addresses a particular client problem.
D) The focused assessment is done after gathering subjective data.
21. The nurse is reviewing a client's health history and the results of the most recent
physical examination. Which of the following data would the nurse identify as being
subjective? Select all that apply.
A) ìI feel so tired sometimes.î
B) Weight: 145 lbs
C) Lungs clear to auscultation
D) Client complains of a headache
E) ìMy father died of a heart attack.î
F) Pupils equal, round, and reactive to light
22. The nurse has been applying the nursing process in the care of an adult client who is
being treated for acute pancreatitis. Place the nurse's actions in their proper sequence
from first to last.
A) Identifying outcomes C,B,A,E,D
B) Determining client's nursing problem
C) Collecting information about the client
D) Determining outcome achievement
E) Carrying out interventions
23. A nurse is completing an assessment that will involve gathering subjective and objective
data. Which of the following assessment techniques will best allow the nurse to collect
objective data?
A) Inspection
B) Therapeutic communication
C) Interviewing
D) Active listening
24. The nurse is performing a health assessment on a community-dwelling client who is
recovering from hip replacement surgery. Which of the following actions should the
nurse prioritize during assessment?
A) Focus the assessment on the client as a member of her age group.
B) Interpret the information about the client in context.
C) Corroborate the client's statements with trusted sources.
D) Gather information from a variety of sources.
Page 5
,25. A client comes to the health care provider's office for a visit. The client has been seen in
this office on occasion for the past 5 years and arrives today complaining of a fever and
sore throat. Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment
26. A nurse has assessed a client who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the client admitted that his
blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse
best respond to this assessment finding?
A) Identify a nursing diagnosis of Ineffective Health Maintenance.
B) Identify a collaborative problem that should involve the occupational therapist.
C) Make a referral to the unit's social work department.
D) Reassess the client's blood glucose level.
27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse should
begin by assessing which of the following?
A) The client's motivation for change
B) The client's medical comorbidities
C) The client's learning style
D) The client's prognosis for recovery
28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who
is new to the clinic. What goal should the nurse identify for this type of assessment?
A) Identify the most appropriate forms of medical intervention for the client.
B) Determine the most likely prognosis for the client's health problem.
C) Identify the status of the client's airway, breathing, and circulation.
D) Establish a baseline for the comparison of future health changes.
29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a
client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent
ongoing assessments. The frequency of these nursing assessments should be primarily
determined by what variable?
A) The client's age
B) The unit's protocols
C) The client's acuity
D) The nurse's potential for liability
Page 6
,30. A client who is new to the facility has a recent history of chronic pain that is attributed
to fibromyalgia. The nurse has reviewed the available health records and suspects that
pain management will be a major focus of nursing care. How can the nurse best validate
this assumption?
A) Review the client's medication administration record for analgesic use.
B) Ask the client about the most recent experiences of pain.
C) Meet with the client's spouse and daughter to discuss the client's pain.
D) Collaborate with the physician who is treating the client.
Page 7
,Answer Key
1. D
2. B
3. B
4. A
5. C
6. B
7. A
8. A
9. B
10. C
11. C
12. D
13. B
14. A
15. D
16. A
17. C
18. C
19. A
20. C
21. A, D, E
22. C, B, A, E, D
23. A
24. B
25. C
26. A
27. A
28. D
29. C
30. B
Page 8
,Chapter 2 Collecting Subjective Data-The Interview and Health History
1. A nurse is preparing to assess a client who is new to the clinic. When beginning the
collection of the client database, which of the following actions should the nurse
prioritize?
A) Establishing a trusting relationship
B) Determining the client's strengths
C) Identifying potential health problems
D) Making clinical inferences
2. A nurse is interpreting and validating information from an older adult client who has
been experiencing a functional decline. The nurse is in which phase of the interview?
A) Introductory
B) Working
C) Summary
D) Closing
3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and
the nurse is collecting subjective data prior to surgery. Which statement by the nurse
could be construed as judgmental?
A) “How often do your adult children typically visit you?”
B) “Your husband's death must have been very difficult for you.”
C) “You must quit smoking because it affects others, not only you.”
D) “How would you describe your feelings about getting older?”
4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during this
phase of assessment?
A) Standing while the client is seated
B) Using a moderate amount of eye contact
C) Sitting across the room from the client
D) Minimizing facial expressions
5. A nurse is providing feedback to a colleague after observing the colleague's interview of
a newly admitted client. Which of the following would the nurse identify as an example
of a closed-ended question or statement?
A) “Tell me about your relationship with your children?”
B) “Tell me what you eat in a normal day?”
C) “Are you allergic to any medications?”
D) “What is your typical day like?”
Page 1
, 6. A client has presented to the emergency department and is having difficulty describing
her vague sensation of physical discomfort and unease. How can the nurse best elicit
meaningful assessment data about the nature of the client's complaint?
A) Ignore the complaint for now and return to it later in the assessment.
B) Provide a laundry list of descriptive words.
C) Restate the question using simpler terms.
D) Wait in silence until the client can determine the correct words.
7. A nurse is eliciting a client's health history and the client asks, “Can I take the herb
ginkgo biloba with my other medications?” What action would be best if the nurse is
unsure of the answer?
A) Promise to find out the information for the client.
B) Change the subject and return to this topic later.
C) Teach the client to only take prescribed medications.
D) Encourage the client to ask the pharmacist or primary care provider.
8. The nurse is preparing to assess the mental status of a 90-year-old client who is being
admitted to the hospital from a long-term care facility. Which of the following should
the nurse assess first?
A) The client's sensory abilities
B) The client's general intelligence
C) The presence of any phobias
D) The client's judgment and insight
9. A nurse provides care in a rural hospital that serves a community that has few minority
residents. When interviewing a client from a minority culture, the nurse has enlisted the
assistance of a “culture broker.” How can this individual best facilitate the client's care?
A) By interpreting the client's language and culture
B) By evaluating the client's culturally based health practices
C) By teaching the client about health care
D) By making the client feel comfortable and safe
10. Upon entering an exam room, the client states, “Well! I was getting ready to leave. My
schedule is very busy and I don't have time to waste waiting until you have the time to
see me!” Which response by the nurse would be most appropriate?
A) “Our schedule is very busy also. We got to you as soon as we could.”
B) “No one is forcing you to be here, and you are free to leave at any time.”
C) “Would you like to report your complaints to someone with power?”
D) “You're certainly justified in being upset, but I am ready to begin your exam now.”
Page 2
