Physical Assessment
**1. A nurse gathers information from a client through interview, physical
exam, and observation. This describes which step of the nursing process?**
A) Planning
B) Implementation
C) Assessment
D) Evaluation
Correct Answer: C) Assessment
Rationale: The assessment step involves gathering subjective and objective
data from the client through interviewing, physical examination, and
observation. This data forms the foundation for all subsequent nursing
actions and clinical decisions.
**2. Which type of data is defined as what the client tells you during the
health history interview?**
A) Objective data
B) Subjective data
C) Measurable data
D) Observable data
Correct Answer: B) Subjective data
Rationale: Subjective data consists of information provided by the client,
including their symptoms, feelings, perceptions, and health history. This
information cannot be directly measured or observed by the nurse.
,**3. A nurse measures a client's blood pressure and observes a skin rash.
These are examples of which type of data?**
A) Subjective data
B) Reported data
C) Objective data
D) Historical data
Correct Answer: C) Objective data
Rationale: Objective data consists of measurable and observable findings
that the nurse obtains through physical examination, vital signs, and
inspection. These findings can be verified by others.
**4. A nurse asks a client, "Tell me more about the pain you are
experiencing." This is an example of which type of question?**
A) Closed-ended question
B) Open-ended question
C) Leading question
D) Direct question
Correct Answer: B) Open-ended question
Rationale: Open-ended questions allow clients to elaborate on their
symptoms and concerns in their own words, providing richer and more
detailed information. They encourage the client to share their perspective
freely.
**5. Which type of question allows for only a "yes" or "no" answer?**
A) Open-ended question
,B) Probing question
C) Closed-ended question
D) Clarifying question
Correct Answer: C) Closed-ended question
Rationale: Closed-ended questions are used to obtain specific, brief
information and typically result in a "yes" or "no" answer or a short factual
response. They are useful for gathering focused data efficiently.
**6. A nurse is preparing to assess a new client. Which action should the
nurse prioritize when beginning the collection of client data?**
A) Reviewing the client's medical records
B) Establishing a trusting relationship
C) Performing a physical examination
D) Obtaining a medication history
Correct Answer: B) Establishing a trusting relationship
Rationale: Establishing a trusting relationship is the priority when beginning
data collection. Trust is foundational to effective communication and
encourages the client to share accurate and complete information.
**7. A nurse identifies expected outcomes, individualizes them to the client,
and sets a timeline. This occurs during which step of the nursing process?**
A) Assessment
B) Diagnosis
C) Outcome Identification
D) Implementation
, Correct Answer: C) Outcome Identification
Rationale: Outcome identification involves identifying expected outcomes
that are individualized, culturally appropriate, realistic, measurable, and
include a timeline. This step guides the planning and implementation phases.
**8. A nurse administers a prescribed medication to a client. This action
occurs during which step of the nursing process?**
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: C) Implementation
Rationale: Implementation involves carrying out the established
interventions in a safe and timely manner using evidence-based practice.
This step translates the care plan into action.
**9. A nurse compares clinical findings with normal and abnormal variations
and creates a hypothesis. This describes which step of the nursing process?
**
A) Assessment
B) Diagnosis
C) Planning
D) Evaluation
Correct Answer: B) Diagnosis