Assessment | ASU | Graded A+
1. Which statement best describes the purpose of a comprehensive health
assessment in nursing practice?
A) To diagnose medical conditions and prescribe treatments
B) To collect, validate, and organize data about a client's health status
C) To perform surgical procedures and invasive interventions
D) To evaluate the effectiveness of prescribed medications
Correct Answer: To collect, validate, and organize data about a client's health
status
Rationale: Health assessment involves the collection, clinical judgment, and
evaluation of data to plan and deliver client-centered care. It identifies client
needs and involves the collection of subjective and objective information.
2. A client reports feeling short of breath and lightheaded. The nurse
documents these findings. Which type of data is the nurse documenting?
A) Objective data
B) Subjective data
C) Measurable data
D) Physical assessment data
Correct Answer: Subjective data
Rationale: Subjective data is derived from the client's self-report, including
feelings, perceptions, and assumptions. Shortness of breath and
lightheadedness are symptoms reported by the client and cannot be directly
measured, making them subjective data.
,3. A nurse is preparing to perform a physical assessment. Which technique
involves using the hands to feel for temperature, texture, and tenderness?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
Correct Answer: Palpation
Rationale: Palpation involves using the hands to feel for temperature,
texture, moisture, tenderness, and the presence of masses or other
abnormalities. Inspection is visual examination, percussion involves tapping,
and auscultation involves listening.
4. A nurse is assessing a client's pain. Which question is most appropriate for
assessing the quality of the client's pain?
A) "Where is your pain located?"
B) "On a scale of 0 to 10, how severe is your pain?"
C) "Can you describe what the pain feels like?"
D) "When did the pain start?"
Correct Answer: "Can you describe what the pain feels like?"
Rationale: Quality of pain refers to the nature of the pain (e.g., sharp,
burning, aching). Asking the client to describe the pain assesses quality.
Location, intensity, and timing assess other dimensions of pain.
5. A nursing student is reviewing the steps of the nursing process. Which
sequence correctly represents the order of the five steps?
,A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Planning, Assessment, Diagnosis, Implementation, Evaluation
Correct Answer: Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: The nursing process is a five-step sequential process: Assessment,
Diagnosis, Planning, Implementation, and Evaluation. This systematic
approach provides a framework for delivering holistic, client-centered care.
6. A nurse is performing a comprehensive head-to-toe examination. This type
of assessment is best described as:
A) A focused exam
B) A review of systems
C) A comprehensive exam
D) A screening exam
Correct Answer: A comprehensive exam
Rationale: A comprehensive exam is a full examination of all body systems
conducted in a systematic head-to-toe manner. It includes review of previous
health conditions, concerns, and social determinants of health.
7. A client presents with chest pain. The nurse performs an assessment
focused primarily on the cardiovascular system. This type of assessment is
best described as:
A) A comprehensive exam
, B) A focused exam
C) A screening exam
D) A systems review
Correct Answer: A focused exam
Rationale: A focused exam is the assessment of either a body system or a
body part that is guided by the client's presenting concern. When a client
presents with chest pain, the nurse prioritizes assessment of the
cardiovascular system.
8. A nurse is documenting subjective data in the medical record. Which
approach is most appropriate?
A) Documenting the nurse's interpretation of the client's symptoms
B) Using quotation marks to indicate the client's verbatim remarks
C) Documenting only objective measurements
D) Using medical abbreviations to save time
Correct Answer: Using quotation marks to indicate the client's verbatim
remarks
Rationale: Subjective data should be documented using quotation marks to
indicate the client's verbatim remarks. This preserves the accuracy of the
client's self-report and distinguishes it from the nurse's objective
observations.
9. Which skills are essential for a nurse to perform during a physical health
assessment?
A) Inspection, palpation, percussion, and auscultation
B) Medication administration and IV insertion