, CHAPTER h11: h 1 NURSE’S h 1 ROLE h 1 IN h1HEALTH h 1 ASSESSMENT: h1 COLLECTING h1 AND h1 ANALYZING h 1 DATA
1. A nurse on a postsurgical unit is admitting a client following the client's
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
cholecystectomy (gall bladder removal). What is the overall purpose of
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
assessment for this client?
h1 h1 h1 h1
A) Collecting accurate data h1 h1
B) Assisting the primary care provider h1 h1 h1 h1
C) Validating previous data h1 h1
D) Making clinical judgments h1 h1
2. A client has presented to the emergency department (ED) with complaints of
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
abdominal pain. Which member of the care team would most likely be
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
responsible for collecting the subjective data on the client during the initial
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
comprehensive assessment?
h1 h1
A) Gastroenterologist
B) ED nurse h1
C) Admissions clerk h1
D) Diagnostic technician h1
3. The nurse has completed an initial assessment of a newly admitted client and is
h1 h1 h1 h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1
applying the nursing process to plan the client's care. What principle should the
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurse apply when using the nursing process?
h1 h1 h1 h1 h1 h1 h1
A) Each step is independent of the others.
h1 h1 h1 h1 h1 h1
B) It is ongoing and continuous.
h1 h1 h1 h1
C) It is used primarily in acute care settings. N
h1 h1 h1 h1 h1 h1 h1 h1
D) It involves independent nursing actions.
h1 h1 h1 h1
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
and perform a comprehensive health assessment. Which of the following actions
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
should the nurse perform first?
h1 h1 h1 h1 h1
A) Review the client's medical record. h1 h1 h1 h1
B) Obtain basic biographic data. h1 h1 h1
C) Consult clinical resources explaining the client's diagnosis.
h1 h1 h1 h1 h1 h1
D) Validate information with the client. h1 h1 h1 h1
5. Which of the following client situations would the nurse interpret as
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
requiring an emergency assessment?
h1 h1 h1 h1
A) A pediatric client with severe sunburn
h1 h1 h1 h1 h1
B) A client needing an employment physical
h1 h1 h1 h1 h1
C) A client who overdosed on acetaminophen
h1 h1 h1 h1 h1
D) A distraught client who wants a pregnancy test
h1 h1 h1 h1 h1 h1 h1
,6. In response to a client's query, the nurse is explaining the differences between
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
the physician's medical exam and the comprehensive health assessment
h1 h1 h1 h1 h1 h1 h1 h1 h1
performed by the nurse. The nurse should describe the fact that the nursing
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
assessment focuses on which aspect of the client's situation?
h1 h1 h1 h1 h1 h1 h1 h1 h1
A) Current physiologic status h1 h1
B) Effect of health on functional status h1 h1 h1 h1 h1
C) Past medical history h1 h1
D) Motivation for adherence to treatment h1 h1 h1 h1
7. After teaching a group of students about the phases of the nursing process,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
the instructor determines that the teaching was successful when the students
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify which phase as being foundational to all other pha ses?
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
has been admitted for the treatment of community-acquired pneumonia.
h1 h1 h1 h1 h1 h1 h1 h1 h1
Following the completion of this assessment, the nurse periodically performs a
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
partial assessment primarily for which reason?
h1 h1 h1 h1 h1 h1
A) Reassess previously deteNcted problems h1 h1 h1
B) Provide information for the client's record h1 h1 h1 h1 h1
C) Address areas previously omitted h1 h1 h1
D) Determine the need for crisis intervention h1 h1 h1 h1 h1
9. The nurse is working in an ambulatory care clinic that is located in a busy,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
inner- city neighborhood. Which client would the nurse determine to be in
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
most need of an emergency assessment?
h1 h1 h1 h1 h1 h1
A) A 14-year-old girl who is crying because she thinks she is pregnant
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
C) A 3-year-old child with fever, rash, and sore throat
h1 h1 h1 h1 h1 h1 h1 h1
D) A 20-year-old man with a 3-inch shallow laceration on his leg
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
10. A nurse has completed gathering some basic data about a client who has multiple
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
health problems that stem from heavy alcohol use. The nurse has then reflected
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
on her personal
h1 h1 h1
feelings about the client and his circumstances. The nurse does this primarily to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
accomplish which of the following?
h1 h1 h1 h1 h1
A) Determine if pertinent data has been omitted h1 h1 h1 h1 h1 h1
B) Identify the need for referral h1 h1 h1 h1
C) Avoid biases and judgments h1 h1 h1
D) Construct a plan of care h1 h1 h1 h1
, 11. The nurse is collecting data from a client who has recently been diagnosed with
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
type 1 diabetes and who will begin an educational program. The nurse is
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
h1collecting subjective and objective data. Which of the following would the nurse
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
categorize as objective data?
h1 h1 h1 h1
A) Family history h1
B) Occupation
C) Appearance
D) History of present health concern h1 h1 h1 h1
12. An older adult client has been admitted to the hospital with failure to thrive
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
resulting from complications of diabetes. Which of the following would the
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurse implement in response to a collaborative problem?
h1 h1 h1 h1 h1 h1 h1 h1
A) Encourage the client to increase oral fluid intake. h1 h1 h1 h1 h1 h1 h1
B) Provide the client with a bedtime protein snack. N h1 h1 h1 h1 h1 h1 h1 h1
C) Assist the client with personal hygiene. h1 h1 h1 h1 h1
D) Measure the client's blood glucose four times daily. h1 h1 h1 h1 h1 h1 h1
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
following clients. For which clients would the nurse most likely expect to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
facilitate a referral?
h1 h1 h1
A) An 80-year-old client who lives with her daughter
h1 h1 h1 h1 h1 h1 h1
B) A 50-year-old client newly diagnosed with diabetes
h1 h1 h1 h1 h1 h1
C) An adult presenting for an influenza vaccination
h1 h1 h1 h1 h1 h1
D) A teenager seeking information about contraception
h1 h1 h1 h1 h1
14. An instructor is reviewing the evolution of the nurse's role in health assessment.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
The instructor determines that the teaching was successful when the students
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify which of the following as the major method used by nurses
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
h1early in the history of the profession? A) Natural senses
h1 h1 h1 h1 h1 h1 h1 h1 h1
B) Biomedical knowledge h1
C) Simple technology h1
D) Critical pathways h1
15. When describing the expansion of the depth and scope of nursing assessment
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
over the past several decades, which of the following would the nurse
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify as being the primary force? A) Documentation
h1 h1 h1 h1 h1 h1 h1 h1
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurses who have advanced assessment skills. When discussing phenomena that
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
have contributed to these increased opportunities, what should the nurses
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify?
h1
A) Expansion of health care networks h1 h1 h1 h1
B) Decrease in client participation in care h1 h1 h1 h1 h1
C) The shrinking cost of medical careh1 h1 h1 h1 h1
D) Public mistrust of physicians h1 h1 h1
1. A nurse on a postsurgical unit is admitting a client following the client's
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
cholecystectomy (gall bladder removal). What is the overall purpose of
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
assessment for this client?
h1 h1 h1 h1
A) Collecting accurate data h1 h1
B) Assisting the primary care provider h1 h1 h1 h1
C) Validating previous data h1 h1
D) Making clinical judgments h1 h1
2. A client has presented to the emergency department (ED) with complaints of
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
abdominal pain. Which member of the care team would most likely be
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
responsible for collecting the subjective data on the client during the initial
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
comprehensive assessment?
h1 h1
A) Gastroenterologist
B) ED nurse h1
C) Admissions clerk h1
D) Diagnostic technician h1
3. The nurse has completed an initial assessment of a newly admitted client and is
h1 h1 h1 h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1
applying the nursing process to plan the client's care. What principle should the
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurse apply when using the nursing process?
h1 h1 h1 h1 h1 h1 h1
A) Each step is independent of the others.
h1 h1 h1 h1 h1 h1
B) It is ongoing and continuous.
h1 h1 h1 h1
C) It is used primarily in acute care settings. N
h1 h1 h1 h1 h1 h1 h1 h1
D) It involves independent nursing actions.
h1 h1 h1 h1
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
and perform a comprehensive health assessment. Which of the following actions
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
should the nurse perform first?
h1 h1 h1 h1 h1
A) Review the client's medical record. h1 h1 h1 h1
B) Obtain basic biographic data. h1 h1 h1
C) Consult clinical resources explaining the client's diagnosis.
h1 h1 h1 h1 h1 h1
D) Validate information with the client. h1 h1 h1 h1
5. Which of the following client situations would the nurse interpret as
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
requiring an emergency assessment?
h1 h1 h1 h1
A) A pediatric client with severe sunburn
h1 h1 h1 h1 h1
B) A client needing an employment physical
h1 h1 h1 h1 h1
C) A client who overdosed on acetaminophen
h1 h1 h1 h1 h1
D) A distraught client who wants a pregnancy test
h1 h1 h1 h1 h1 h1 h1
,6. In response to a client's query, the nurse is explaining the differences between
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
the physician's medical exam and the comprehensive health assessment
h1 h1 h1 h1 h1 h1 h1 h1 h1
performed by the nurse. The nurse should describe the fact that the nursing
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
assessment focuses on which aspect of the client's situation?
h1 h1 h1 h1 h1 h1 h1 h1 h1
A) Current physiologic status h1 h1
B) Effect of health on functional status h1 h1 h1 h1 h1
C) Past medical history h1 h1
D) Motivation for adherence to treatment h1 h1 h1 h1
7. After teaching a group of students about the phases of the nursing process,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
the instructor determines that the teaching was successful when the students
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify which phase as being foundational to all other pha ses?
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
has been admitted for the treatment of community-acquired pneumonia.
h1 h1 h1 h1 h1 h1 h1 h1 h1
Following the completion of this assessment, the nurse periodically performs a
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
partial assessment primarily for which reason?
h1 h1 h1 h1 h1 h1
A) Reassess previously deteNcted problems h1 h1 h1
B) Provide information for the client's record h1 h1 h1 h1 h1
C) Address areas previously omitted h1 h1 h1
D) Determine the need for crisis intervention h1 h1 h1 h1 h1
9. The nurse is working in an ambulatory care clinic that is located in a busy,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
inner- city neighborhood. Which client would the nurse determine to be in
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
most need of an emergency assessment?
h1 h1 h1 h1 h1 h1
A) A 14-year-old girl who is crying because she thinks she is pregnant
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
C) A 3-year-old child with fever, rash, and sore throat
h1 h1 h1 h1 h1 h1 h1 h1
D) A 20-year-old man with a 3-inch shallow laceration on his leg
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
10. A nurse has completed gathering some basic data about a client who has multiple
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
health problems that stem from heavy alcohol use. The nurse has then reflected
h 1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
on her personal
h1 h1 h1
feelings about the client and his circumstances. The nurse does this primarily to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
accomplish which of the following?
h1 h1 h1 h1 h1
A) Determine if pertinent data has been omitted h1 h1 h1 h1 h1 h1
B) Identify the need for referral h1 h1 h1 h1
C) Avoid biases and judgments h1 h1 h1
D) Construct a plan of care h1 h1 h1 h1
, 11. The nurse is collecting data from a client who has recently been diagnosed with
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
type 1 diabetes and who will begin an educational program. The nurse is
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
h1collecting subjective and objective data. Which of the following would the nurse
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
categorize as objective data?
h1 h1 h1 h1
A) Family history h1
B) Occupation
C) Appearance
D) History of present health concern h1 h1 h1 h1
12. An older adult client has been admitted to the hospital with failure to thrive
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
resulting from complications of diabetes. Which of the following would the
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurse implement in response to a collaborative problem?
h1 h1 h1 h1 h1 h1 h1 h1
A) Encourage the client to increase oral fluid intake. h1 h1 h1 h1 h1 h1 h1
B) Provide the client with a bedtime protein snack. N h1 h1 h1 h1 h1 h1 h1 h1
C) Assist the client with personal hygiene. h1 h1 h1 h1 h1
D) Measure the client's blood glucose four times daily. h1 h1 h1 h1 h1 h1 h1
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
following clients. For which clients would the nurse most likely expect to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
facilitate a referral?
h1 h1 h1
A) An 80-year-old client who lives with her daughter
h1 h1 h1 h1 h1 h1 h1
B) A 50-year-old client newly diagnosed with diabetes
h1 h1 h1 h1 h1 h1
C) An adult presenting for an influenza vaccination
h1 h1 h1 h1 h1 h1
D) A teenager seeking information about contraception
h1 h1 h1 h1 h1
14. An instructor is reviewing the evolution of the nurse's role in health assessment.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
The instructor determines that the teaching was successful when the students
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify which of the following as the major method used by nurses
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
h1early in the history of the profession? A) Natural senses
h1 h1 h1 h1 h1 h1 h1 h1 h1
B) Biomedical knowledge h1
C) Simple technology h1
D) Critical pathways h1
15. When describing the expansion of the depth and scope of nursing assessment
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
over the past several decades, which of the following would the nurse
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify as being the primary force? A) Documentation
h1 h1 h1 h1 h1 h1 h1 h1
B) Informatics
C) Diversification
D) Technology
16. A group of nurses are reviewing information about the potential opportunities for
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
nurses who have advanced assessment skills. When discussing phenomena that
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
have contributed to these increased opportunities, what should the nurses
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
identify?
h1
A) Expansion of health care networks h1 h1 h1 h1
B) Decrease in client participation in care h1 h1 h1 h1 h1
C) The shrinking cost of medical careh1 h1 h1 h1 h1
D) Public mistrust of physicians h1 h1 h1
