, CHAPTER p1: p NURSE’S p ROLE p IN pHEALTH p ASSESSMENT: pCOLLECTING p AND p ANALYZING p DATA
1. A nurse on a postsurgical unit is admitting a client following the client's
p p p p p p p p p p p p
pcholecystectomy (gall bladder removal). What is the overall purpose of assessment p p p p p p p p p p
pfor this client?
p p
A) Collecting accurate data p p
B) Assisting the primary care provider p p p p
C) Validating previous data p p
D) Making clinical judgments p p
2. A client has presented to the emergency department (ED) with complaints of
p p p p p p p p p p p
pabdominal pain. Which member of the care team would most likely be responsible for
p p p p p p p p p p p p p
pcollecting the subjective data on the client during the initial comprehensive
p p p p p p p p p p
passessment?
A) Gastroenterologist
B) ED nurse p
C) Admissions clerk p
D) Diagnostic technician p
3. The nurse has completed an initial assessment of a newly admitted client and is
p p p p p p p p p p p p p
papplying the nursing process to plan the client's care. What principle should the nurse
p p p p p p p p p p p p p
papply when using the nursing process?
p p p p p
A) Each step is independent of the others.
p p p p p p
B) It is ongoing and continuous.
p p p p
C) It is used primarily in acute care settings. N
p p p p p p p p
D) It involves independent nursing actions.
p p p p
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
p p p p p p p p p p p p p p p
pperform a comprehensive health assessment. Which of the following actions should
p p p p p p p p p p
pthe nurse perform first?
p p p
A) Review the client's medical record. p p p p
B) Obtain basic biographic data. p p p
C) Consult clinical resources explaining the client's diagnosis.
p p p p p p
D) Validate information with the client. p p p p
5. Which of the following client situations would the nurse interpret as requiring
p p p p p p p p p p p
pan emergency assessment?
p p
A) A pediatric client with severe sunburn
p p p p p
B) A client needing an employment physical
p p p p p
C) A client who overdosed on acetaminophen
p p p p p
D) A distraught client who wants a pregnancy test
p p p p p p p
,6. In response to a client's query, the nurse is explaining the differences between the
p p p p p p p p p p p p p
physician's medical exam and the comprehensive health assessment performed by
p p p p p p p p p p
the nurse. The nurse should describe the fact that the nursing assessment focuses on
p p p p p p p p p p p p p p
which aspect of the client's situation?
p p p p p p
A) Current physiologic status p p
B) Effect of health on functional status p p p p p
C) Past medical history p p
D) Motivation for adherence to treatment p p p p
7. After teaching a group of students about the phases of the nursing process, the
p p p p p p p p p p p p p
instructor determines that the teaching was successful when the students identify
p p p p p p p p p p p
which phase as being foundational to all other pha ses?
p p p p p p p p p p
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has
p p p p p p p p p p p p
been admitted for the treatment of community-acquired pneumonia. Following the
p p p p p p p p p p
completion of this assessment, the nurse periodically performs a partial assessment
p p p p p p p p p p p
primarily for which reason?
p p p p
A) Reassess previouslydeteNcted problems p p p
B) Provide information for the client's record p p p p p
C) Address areas previously omitted p p p
D) Determine the need for crisis intervention p p p p p
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
p p p p p p p p p p p p p p p
city neighborhood. Which client would the nurse determine to be in most need of
p p p p p p p p p p p p p p
an emergency assessment?
p p p
A) A 14-year-old girl who is crying because she thinks she is pregnant
p p p p p p p p p p p
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
p p p p p p p p p p
C) A 3-year-old child with fever, rash, and sore throat
p p p p p p p p
D) A 20-year-old man with a 3-inch shallow laceration on his leg
p p p p p p p p p p
10. A nurse has completed gathering some basic data about a client who has multiple
p p p p p p p p p p p p p
health problems that stem from heavy alcohol use. The nurse has then reflected on her
p p p p p p p p p p p p p p p
personal
p
feelings about the client and his circumstances. The nurse does this primarily to
p p p p p p p p p p p p
paccomplish which of the following? p p p p
A) Determine if pertinent data has been omitted p p p p p p
B) Identify the need for referral p p p p
C) Avoid biases and judgments p p p
D) Construct a plan of care p p p p
, 11. The nurse is collecting data from a client who has recently been diagnosed with type 1
p p p p p p p p p p p p p p p
pdiabetes and who will begin an educational program. The nurse is collecting
p p p p p p p p p p p
psubjective and objective data. Which of the following would the nurse categorize as
p p p p p p p p p p p p
pobjective data? p
A) Family history p
B) Occupation
C) Appearance
D) History of present health concern p p p p
12. An older adult client has been admitted to the hospital with failure to thrive
p p p p p p p p p p p p p
presulting from complications of diabetes. Which of the following would the nurse
p p p p p p p p p p p
pimplement in response to a collaborative problem?
p p p p p p
A) Encourage the client to increase oral fluid intake. p p p p p p p
B) Provide the client with a bedtime protein snack. N p p p p p p p p
C) Assist the client with personal hygiene. p p p p p
D) Measure the client's blood glucose four times daily. p p p p p p p
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
p p p p p p p p p p p p p p
pfollowing clients. For which clients would the nurse most likely expect to facilitate a
p p p p p p p p p p p p p
preferral?
A) An 80-year-old client who lives with her daughter
p p p p p p p
B) A 50-year-old client newly diagnosed with diabetes
p p p p p p
C) An adult presenting for an influenza vaccination
p p p p p p
D) A teenager seeking information about contraception
p p p p p
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
p p p p p p p p p p p p p
pinstructor determines that the teaching was successful when the students identify
p p p p p p p p p p
pwhich of the following as the major method used by nurses early in the history
p p p p p p p p p p p p p p
pof the profession? A) Natural senses
p p p p p
B) Biomedical knowledge p
C) Simple technology p
D) Critical pathways p
15. When describing the expansion of the depth and scope of nursing assessment over
p p p p p p p p p p p p
pthe past several decades, which of the following would the nurse identify as being
p p p p p p p p p p p p p
pthe primary force? A) Documentation
p p p p
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
p p p p p p p p p p p
pnurses who have advanced assessment skills. When discussing phenomena that have
p p p p p p p p p p
pcontributed to these increased opportunities, what should the nurses identify?
p p p p p p p p p
A) Expansion of health care networks p p p p
B) Decrease in client participation in care p p p p p
C) The shrinking cost of medical care
p p p p p
D) Public mistrust of physicians p p p
1. A nurse on a postsurgical unit is admitting a client following the client's
p p p p p p p p p p p p
pcholecystectomy (gall bladder removal). What is the overall purpose of assessment p p p p p p p p p p
pfor this client?
p p
A) Collecting accurate data p p
B) Assisting the primary care provider p p p p
C) Validating previous data p p
D) Making clinical judgments p p
2. A client has presented to the emergency department (ED) with complaints of
p p p p p p p p p p p
pabdominal pain. Which member of the care team would most likely be responsible for
p p p p p p p p p p p p p
pcollecting the subjective data on the client during the initial comprehensive
p p p p p p p p p p
passessment?
A) Gastroenterologist
B) ED nurse p
C) Admissions clerk p
D) Diagnostic technician p
3. The nurse has completed an initial assessment of a newly admitted client and is
p p p p p p p p p p p p p
papplying the nursing process to plan the client's care. What principle should the nurse
p p p p p p p p p p p p p
papply when using the nursing process?
p p p p p
A) Each step is independent of the others.
p p p p p p
B) It is ongoing and continuous.
p p p p
C) It is used primarily in acute care settings. N
p p p p p p p p
D) It involves independent nursing actions.
p p p p
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
p p p p p p p p p p p p p p p
pperform a comprehensive health assessment. Which of the following actions should
p p p p p p p p p p
pthe nurse perform first?
p p p
A) Review the client's medical record. p p p p
B) Obtain basic biographic data. p p p
C) Consult clinical resources explaining the client's diagnosis.
p p p p p p
D) Validate information with the client. p p p p
5. Which of the following client situations would the nurse interpret as requiring
p p p p p p p p p p p
pan emergency assessment?
p p
A) A pediatric client with severe sunburn
p p p p p
B) A client needing an employment physical
p p p p p
C) A client who overdosed on acetaminophen
p p p p p
D) A distraught client who wants a pregnancy test
p p p p p p p
,6. In response to a client's query, the nurse is explaining the differences between the
p p p p p p p p p p p p p
physician's medical exam and the comprehensive health assessment performed by
p p p p p p p p p p
the nurse. The nurse should describe the fact that the nursing assessment focuses on
p p p p p p p p p p p p p p
which aspect of the client's situation?
p p p p p p
A) Current physiologic status p p
B) Effect of health on functional status p p p p p
C) Past medical history p p
D) Motivation for adherence to treatment p p p p
7. After teaching a group of students about the phases of the nursing process, the
p p p p p p p p p p p p p
instructor determines that the teaching was successful when the students identify
p p p p p p p p p p p
which phase as being foundational to all other pha ses?
p p p p p p p p p p
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has
p p p p p p p p p p p p
been admitted for the treatment of community-acquired pneumonia. Following the
p p p p p p p p p p
completion of this assessment, the nurse periodically performs a partial assessment
p p p p p p p p p p p
primarily for which reason?
p p p p
A) Reassess previouslydeteNcted problems p p p
B) Provide information for the client's record p p p p p
C) Address areas previously omitted p p p
D) Determine the need for crisis intervention p p p p p
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
p p p p p p p p p p p p p p p
city neighborhood. Which client would the nurse determine to be in most need of
p p p p p p p p p p p p p p
an emergency assessment?
p p p
A) A 14-year-old girl who is crying because she thinks she is pregnant
p p p p p p p p p p p
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
p p p p p p p p p p
C) A 3-year-old child with fever, rash, and sore throat
p p p p p p p p
D) A 20-year-old man with a 3-inch shallow laceration on his leg
p p p p p p p p p p
10. A nurse has completed gathering some basic data about a client who has multiple
p p p p p p p p p p p p p
health problems that stem from heavy alcohol use. The nurse has then reflected on her
p p p p p p p p p p p p p p p
personal
p
feelings about the client and his circumstances. The nurse does this primarily to
p p p p p p p p p p p p
paccomplish which of the following? p p p p
A) Determine if pertinent data has been omitted p p p p p p
B) Identify the need for referral p p p p
C) Avoid biases and judgments p p p
D) Construct a plan of care p p p p
, 11. The nurse is collecting data from a client who has recently been diagnosed with type 1
p p p p p p p p p p p p p p p
pdiabetes and who will begin an educational program. The nurse is collecting
p p p p p p p p p p p
psubjective and objective data. Which of the following would the nurse categorize as
p p p p p p p p p p p p
pobjective data? p
A) Family history p
B) Occupation
C) Appearance
D) History of present health concern p p p p
12. An older adult client has been admitted to the hospital with failure to thrive
p p p p p p p p p p p p p
presulting from complications of diabetes. Which of the following would the nurse
p p p p p p p p p p p
pimplement in response to a collaborative problem?
p p p p p p
A) Encourage the client to increase oral fluid intake. p p p p p p p
B) Provide the client with a bedtime protein snack. N p p p p p p p p
C) Assist the client with personal hygiene. p p p p p
D) Measure the client's blood glucose four times daily. p p p p p p p
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
p p p p p p p p p p p p p p
pfollowing clients. For which clients would the nurse most likely expect to facilitate a
p p p p p p p p p p p p p
preferral?
A) An 80-year-old client who lives with her daughter
p p p p p p p
B) A 50-year-old client newly diagnosed with diabetes
p p p p p p
C) An adult presenting for an influenza vaccination
p p p p p p
D) A teenager seeking information about contraception
p p p p p
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
p p p p p p p p p p p p p
pinstructor determines that the teaching was successful when the students identify
p p p p p p p p p p
pwhich of the following as the major method used by nurses early in the history
p p p p p p p p p p p p p p
pof the profession? A) Natural senses
p p p p p
B) Biomedical knowledge p
C) Simple technology p
D) Critical pathways p
15. When describing the expansion of the depth and scope of nursing assessment over
p p p p p p p p p p p p
pthe past several decades, which of the following would the nurse identify as being
p p p p p p p p p p p p p
pthe primary force? A) Documentation
p p p p
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
p p p p p p p p p p p
pnurses who have advanced assessment skills. When discussing phenomena that have
p p p p p p p p p p
pcontributed to these increased opportunities, what should the nurses identify?
p p p p p p p p p
A) Expansion of health care networks p p p p
B) Decrease in client participation in care p p p p p
C) The shrinking cost of medical care
p p p p p
D) Public mistrust of physicians p p p
