, CHAPTER jh1: j h NURSE’S j h ROLE j h IN jhHEALTH j h ASSESSMENT: jhCOLLECTING j h AND j h ANALYZING j h DATA
1. A nurse on a postsurgical unit is admitting a client following the client's
jh jh jh jh jh jh jh jh jh jh jh jh
cholecystectomy (gall bladder removal). What is the overall purpose of
jh jh jh jh jh jh jh jh jh jh
assessment for this client?
jh jh jh jh
A) Collecting accurate data jh jh
B) Assisting the primary care provider jh jh jh jh
C) Validating previous data jh jh
D) Making clinical judgments jh jh
2. A client has presented to the emergency department (ED) with complaints of
jh jh jh jh jh jh jh jh jh jh jh
abdominal pain. Which member of the care team would most likely be responsible
j h jh jh jh jh jh jh jh jh jh jh jh jh
for collecting the subjective data on the client during the initial comprehensive
jh jh jh jh jh jh jh jh jh jh jh jh
assessment?
jh
A) Gastroenterologist
B) ED nurse jh
C) Admissions clerk jh
D) Diagnostic technician jh
3. The nurse has completed an initial assessment of a newly admitted client and is
jh jh jh j h jh jh jh jh jh jh jh jh jh
applying the nursing process to plan the client's care. What principle should the
j h jh jh jh jh jh jh jh jh jh jh jh jh
nurse apply when using the nursing process?
jh jh jh jh jh jh jh
A) Each step is independent of the others.
jh jh jh jh jh jh
B) It is ongoing and continuous.
jh jh jh jh
C) It is used primarily in acute care settings. N
jh jh jh jh jh jh jh jh
D) It involves independent nursing actions.
jh jh jh jh
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
and perform a comprehensive health assessment. Which of the following actions
jh jh jh jh jh jh jh jh jh jh jh
should the nurse perform first?
jh jh jh jh jh
A) Review the client's medical record. jh jh jh jh
B) Obtain basic biographic data. jh jh jh
C) Consult clinical resources explaining the client's diagnosis.
jh jh jh jh jh jh
D) Validate information with the client. jh jh jh jh
5. Which of the following client situations would the nurse interpret as
jh jh jh jh jh jh jh jh jh jh
requiring an emergency assessment?
jh jh jh jh
A) A pediatric client with severe sunburn
jh jh jh jh jh
B) A client needing an employment physical
jh jh jh jh jh
C) A client who overdosed on acetaminophen
jh jh jh jh jh
D) A distraught client who wants a pregnancy test
jh jh jh jh jh jh jh
,6. In response to a client's query, the nurse is explaining the differences between the
jh jh jh jh jh jh jh jh jh jh jh jh jh
physician's medical exam and the comprehensive health assessment performed
jh jh jh jh jh jh jh jh jh
by the nurse. The nurse should describe the fact that the nursing assessment
jh jh jh jh jh jh jh jh jh jh jh jh jh
focuses on which aspect of the client's situation?
jh jh jh jh jh jh jh jh
A) Current physiologic status jh jh
B) Effect of health on functional status jh jh jh jh jh
C) Past medical history jh jh
D) Motivation for adherence to treatment jh jh jh jh
7. After teaching a group of students about the phases of the nursing process, the
jh jh jh jh jh jh jh jh jh jh jh jh jh
instructor determines that the teaching was successful when the students
jh jh jh jh jh jh jh jh jh jh
identify which phase as being foundational to all other pha ses?
jh jh jh jh jh jh jh jh jh jh jh
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who
jh jh jh jh jh jh jh jh jh jh jh
has been admitted for the treatment of community-acquired pneumonia.
jh jh jh jh jh jh jh jh jh
Following the completion of this assessment, the nurse periodically performs a
jh jh jh jh jh jh jh jh jh jh jh
partial assessment primarily for which reason?
jh jh jh jh jh jh
A) Reassess previouslydeteNcted problems jh jh jh
B) Provide information for the client's record jh jh jh jh jh
C) Address areas previously omitted jh jh jh
D) Determine the need for crisis intervention jh jh jh jh jh
9. The nurse is working in an ambulatory care clinic that is located in a busy,
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
inner- city neighborhood. Which client would the nurse determine to be in most
jh jh jh jh jh jh jh jh jh jh jh jh jh
need of an emergency assessment?
jh jh jh jh jh
A) A 14-year-old girl who is crying because she thinks she is pregnant
jh jh jh jh jh jh jh jh jh jh jh
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
jh jh jh jh jh jh jh jh jh jh
C) A 3-year-old child with fever, rash, and sore throat
jh jh jh jh jh jh jh jh
D) A 20-year-old man with a 3-inch shallow laceration on his leg
jh jh jh jh jh jh jh jh jh jh
10. A nurse has completed gathering some basic data about a client who has multiple
jh jh jh jh jh jh jh jh jh jh jh jh jh
health problems that stem from heavy alcohol use. The nurse has then reflected on
j h jh jh jh jh jh jh jh jh jh jh jh jh jh
her personal
jh jh
feelings about the client and his circumstances. The nurse does this primarily to
jh jh jh jh jh jh jh jh jh jh jh jh
accomplish which of the following?
jh jh jh jh jh
A) Determine if pertinent data has been omitted jh jh jh jh jh jh
B) Identify the need for referral jh jh jh jh
C) Avoid biases and judgments jh jh jh
D) Construct a plan of care jh jh jh jh
, 11. The nurse is collecting data from a client who has recently been diagnosed with type
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
1 diabetes and who will begin an educational program. The nurse is
jh jh jh jh jh jh jh jh jh jh jh jh
jhcollecting subjective and objective data. Which of the following would the nurse
jh jh jh jh jh jh jh jh jh jh jh
categorize as objective data?
jh jh jh jh
A) Family history jh
B) Occupation
C) Appearance
D) History of present health concern jh jh jh jh
12. An older adult client has been admitted to the hospital with failure to thrive
jh jh jh jh jh jh jh jh jh jh jh jh jh
resulting from complications of diabetes. Which of the following would the
jh jh jh jh jh jh jh jh jh jh jh
nurse implement in response to a collaborative problem?
jh jh jh jh jh jh jh jh
A) Encourage the client to increase oral fluid intake. jh jh jh jh jh jh jh
B) Provide the client with a bedtime protein snack. N jh jh jh jh jh jh jh jh
C) Assist the client with personal hygiene. jh jh jh jh jh
D) Measure the client's blood glucose four times daily. jh jh jh jh jh jh jh
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
following clients. For which clients would the nurse most likely expect to facilitate
jh jh jh jh jh jh jh jh jh jh jh jh jh
a referral?
jh jh
A) An 80-year-old client who lives with her daughter
jh jh jh jh jh jh jh
B) A 50-year-old client newly diagnosed with diabetes
jh jh jh jh jh jh
C) An adult presenting for an influenza vaccination
jh jh jh jh jh jh
D) A teenager seeking information about contraception
jh jh jh jh jh
14. An instructor is reviewing the evolution of the nurse's role in health assessment.
jh jh jh jh jh jh jh jh jh jh jh jh
The instructor determines that the teaching was successful when the students
jh jh jh jh jh jh jh jh jh jh jh
identify which of the following as the major method used by nurses early
jh jh jh jh jh jh jh jh jh jh jh jh jh
in the history of the profession? A) Natural senses
jh jh jh jh jh jh jh jh jh
B) Biomedical knowledge jh
C) Simple technology jh
D) Critical pathways jh
15. When describing the expansion of the depth and scope of nursing assessment
jh jh jh jh jh jh jh jh jh jh jh
over the past several decades, which of the following would the nurse identify
jh jh jh jh jh jh jh jh jh jh jh jh jh
as being the primary force? A) Documentation
jh jh jh jh jh jh jh
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
jh jh jh jh jh jh jh jh jh jh jh
nurses who have advanced assessment skills. When discussing phenomena that
jh jh jh jh jh jh jh jh jh jh
have contributed to these increased opportunities, what should the nurses identify?
jh jh jh jh jh jh jh jh jh jh jh
A) Expansion of health care networks jh jh jh jh
B) Decrease in client participation in care jh jh jh jh jh
C) The shrinking cost of medical care jh jh jh jh jh
D) Public mistrust of physicians jh jh jh
1. A nurse on a postsurgical unit is admitting a client following the client's
jh jh jh jh jh jh jh jh jh jh jh jh
cholecystectomy (gall bladder removal). What is the overall purpose of
jh jh jh jh jh jh jh jh jh jh
assessment for this client?
jh jh jh jh
A) Collecting accurate data jh jh
B) Assisting the primary care provider jh jh jh jh
C) Validating previous data jh jh
D) Making clinical judgments jh jh
2. A client has presented to the emergency department (ED) with complaints of
jh jh jh jh jh jh jh jh jh jh jh
abdominal pain. Which member of the care team would most likely be responsible
j h jh jh jh jh jh jh jh jh jh jh jh jh
for collecting the subjective data on the client during the initial comprehensive
jh jh jh jh jh jh jh jh jh jh jh jh
assessment?
jh
A) Gastroenterologist
B) ED nurse jh
C) Admissions clerk jh
D) Diagnostic technician jh
3. The nurse has completed an initial assessment of a newly admitted client and is
jh jh jh j h jh jh jh jh jh jh jh jh jh
applying the nursing process to plan the client's care. What principle should the
j h jh jh jh jh jh jh jh jh jh jh jh jh
nurse apply when using the nursing process?
jh jh jh jh jh jh jh
A) Each step is independent of the others.
jh jh jh jh jh jh
B) It is ongoing and continuous.
jh jh jh jh
C) It is used primarily in acute care settings. N
jh jh jh jh jh jh jh jh
D) It involves independent nursing actions.
jh jh jh jh
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
and perform a comprehensive health assessment. Which of the following actions
jh jh jh jh jh jh jh jh jh jh jh
should the nurse perform first?
jh jh jh jh jh
A) Review the client's medical record. jh jh jh jh
B) Obtain basic biographic data. jh jh jh
C) Consult clinical resources explaining the client's diagnosis.
jh jh jh jh jh jh
D) Validate information with the client. jh jh jh jh
5. Which of the following client situations would the nurse interpret as
jh jh jh jh jh jh jh jh jh jh
requiring an emergency assessment?
jh jh jh jh
A) A pediatric client with severe sunburn
jh jh jh jh jh
B) A client needing an employment physical
jh jh jh jh jh
C) A client who overdosed on acetaminophen
jh jh jh jh jh
D) A distraught client who wants a pregnancy test
jh jh jh jh jh jh jh
,6. In response to a client's query, the nurse is explaining the differences between the
jh jh jh jh jh jh jh jh jh jh jh jh jh
physician's medical exam and the comprehensive health assessment performed
jh jh jh jh jh jh jh jh jh
by the nurse. The nurse should describe the fact that the nursing assessment
jh jh jh jh jh jh jh jh jh jh jh jh jh
focuses on which aspect of the client's situation?
jh jh jh jh jh jh jh jh
A) Current physiologic status jh jh
B) Effect of health on functional status jh jh jh jh jh
C) Past medical history jh jh
D) Motivation for adherence to treatment jh jh jh jh
7. After teaching a group of students about the phases of the nursing process, the
jh jh jh jh jh jh jh jh jh jh jh jh jh
instructor determines that the teaching was successful when the students
jh jh jh jh jh jh jh jh jh jh
identify which phase as being foundational to all other pha ses?
jh jh jh jh jh jh jh jh jh jh jh
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who
jh jh jh jh jh jh jh jh jh jh jh
has been admitted for the treatment of community-acquired pneumonia.
jh jh jh jh jh jh jh jh jh
Following the completion of this assessment, the nurse periodically performs a
jh jh jh jh jh jh jh jh jh jh jh
partial assessment primarily for which reason?
jh jh jh jh jh jh
A) Reassess previouslydeteNcted problems jh jh jh
B) Provide information for the client's record jh jh jh jh jh
C) Address areas previously omitted jh jh jh
D) Determine the need for crisis intervention jh jh jh jh jh
9. The nurse is working in an ambulatory care clinic that is located in a busy,
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
inner- city neighborhood. Which client would the nurse determine to be in most
jh jh jh jh jh jh jh jh jh jh jh jh jh
need of an emergency assessment?
jh jh jh jh jh
A) A 14-year-old girl who is crying because she thinks she is pregnant
jh jh jh jh jh jh jh jh jh jh jh
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
jh jh jh jh jh jh jh jh jh jh
C) A 3-year-old child with fever, rash, and sore throat
jh jh jh jh jh jh jh jh
D) A 20-year-old man with a 3-inch shallow laceration on his leg
jh jh jh jh jh jh jh jh jh jh
10. A nurse has completed gathering some basic data about a client who has multiple
jh jh jh jh jh jh jh jh jh jh jh jh jh
health problems that stem from heavy alcohol use. The nurse has then reflected on
j h jh jh jh jh jh jh jh jh jh jh jh jh jh
her personal
jh jh
feelings about the client and his circumstances. The nurse does this primarily to
jh jh jh jh jh jh jh jh jh jh jh jh
accomplish which of the following?
jh jh jh jh jh
A) Determine if pertinent data has been omitted jh jh jh jh jh jh
B) Identify the need for referral jh jh jh jh
C) Avoid biases and judgments jh jh jh
D) Construct a plan of care jh jh jh jh
, 11. The nurse is collecting data from a client who has recently been diagnosed with type
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
1 diabetes and who will begin an educational program. The nurse is
jh jh jh jh jh jh jh jh jh jh jh jh
jhcollecting subjective and objective data. Which of the following would the nurse
jh jh jh jh jh jh jh jh jh jh jh
categorize as objective data?
jh jh jh jh
A) Family history jh
B) Occupation
C) Appearance
D) History of present health concern jh jh jh jh
12. An older adult client has been admitted to the hospital with failure to thrive
jh jh jh jh jh jh jh jh jh jh jh jh jh
resulting from complications of diabetes. Which of the following would the
jh jh jh jh jh jh jh jh jh jh jh
nurse implement in response to a collaborative problem?
jh jh jh jh jh jh jh jh
A) Encourage the client to increase oral fluid intake. jh jh jh jh jh jh jh
B) Provide the client with a bedtime protein snack. N jh jh jh jh jh jh jh jh
C) Assist the client with personal hygiene. jh jh jh jh jh
D) Measure the client's blood glucose four times daily. jh jh jh jh jh jh jh
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
jh jh jh jh jh jh jh jh jh jh jh jh jh jh
following clients. For which clients would the nurse most likely expect to facilitate
jh jh jh jh jh jh jh jh jh jh jh jh jh
a referral?
jh jh
A) An 80-year-old client who lives with her daughter
jh jh jh jh jh jh jh
B) A 50-year-old client newly diagnosed with diabetes
jh jh jh jh jh jh
C) An adult presenting for an influenza vaccination
jh jh jh jh jh jh
D) A teenager seeking information about contraception
jh jh jh jh jh
14. An instructor is reviewing the evolution of the nurse's role in health assessment.
jh jh jh jh jh jh jh jh jh jh jh jh
The instructor determines that the teaching was successful when the students
jh jh jh jh jh jh jh jh jh jh jh
identify which of the following as the major method used by nurses early
jh jh jh jh jh jh jh jh jh jh jh jh jh
in the history of the profession? A) Natural senses
jh jh jh jh jh jh jh jh jh
B) Biomedical knowledge jh
C) Simple technology jh
D) Critical pathways jh
15. When describing the expansion of the depth and scope of nursing assessment
jh jh jh jh jh jh jh jh jh jh jh
over the past several decades, which of the following would the nurse identify
jh jh jh jh jh jh jh jh jh jh jh jh jh
as being the primary force? A) Documentation
jh jh jh jh jh jh jh
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
jh jh jh jh jh jh jh jh jh jh jh
nurses who have advanced assessment skills. When discussing phenomena that
jh jh jh jh jh jh jh jh jh jh
have contributed to these increased opportunities, what should the nurses identify?
jh jh jh jh jh jh jh jh jh jh jh
A) Expansion of health care networks jh jh jh jh
B) Decrease in client participation in care jh jh jh jh jh
C) The shrinking cost of medical care jh jh jh jh jh
D) Public mistrust of physicians jh jh jh
