Chapter 15, Assessing
Test Bank, Chapter Assignments, Discussions Plus Case Studies and Answers
Fundamentals of Nursing: The Art and Science of Person-Centered Care (10th Edition Taylor)
1. Which nursing assessment guideline is most accurate?
A. "Collect assessment data about the client continuously."
B. "Assess your client after receiving the nursing report and again before giving a
report to the next shift of nurses."
C. "Assess your client at least hourly if the client's vital signs are unstable, and
every 2 hours if the vital signs are stable."
D. "Collect assessment data prior to the physician rounding on the unit."
Answer: A
Rationale: The nurse should collect data about the client continuously because the
client's health status can change quickly. The nurse should complete an initial
assessment early in the clinical shift and then reassess as frequently as the health
care setting policy states. The nurse should assess vital signs at least every 4 hours
and possibly more frequently, depending on the client's status, which the nurse
should evaluated continuously. The nurse simply collecting assessment data before
the physician rounding is not appropriate, as a nursing professional should be
astute to client changes.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process
Reference: p. 404
2. The nurse is using an assessment guide that includes a hierarchy of five life
requirements universal to all persons. Which model for organizing assessment data
is the nurse using?
A. Human Needs (Maslow) model
B. Functional Health Patterns model
C. Human Response Patterns model
D. Body System model
Answer: A
Rationale: The nurse is following the Human Needs model based on Maslow's
Hierarchy of Human Needs. The Functional Health Patterns model was
,developed by Gordon and is a framework that identifies 11 functional health
patterns and organizes data according to these patterns. The Body System model
is often used by the medical community, and it organizes data according to organ
and tissue function in various body systems. The Human Response Patterns model
focuses on a unitary person.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 414
3. When documenting subjective data, the nurse should:
A. use the client's own words placed in quotation marks.
B. paraphrase the information stated by the client.
C. validate the information with the client's family prior to documentation.
D. record the information using nonspecific words.
Answer: A
Rationale: The nurse should record subjective data using the client's own words,
whenever possible, and place quotation marks around the client's statement. The
nurse should avoid using nonspecific terms, which are subject to individual
definition, paraphrasing, or interpreting, all of which can cause inaccuracy.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Reference: p. 424
4. The nurse enters a client's room to find the client diaphoretic (sweat-covered)
and shivering and infers that the client has a fever. How should the nurse best
follow up this cue and inference?
A. Measure the client's oral temperature.
B. Ask a colleague for assistance.
C. Give the client a clean gown and warm blankets.
D. Obtain an order for blood cultures.
Answer: A
,Rationale: An inference must be followed by a validation process. In this case, the
inference of fever is best validated or rejected by measuring the client's
temperature. This should precede interventions such as blood work or even
providing a warm blanket. The nurse does not need to ask a colleague for
assistance.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 421
5. The nurse completes a health history and physical assessment on a client who
has been admitted to the hospital for surgery. What is the purpose of this initial
assessment?
A. To gather data about a specific and current health problem
B. To identify life-threatening problems that require immediate attention
C. To compare and contrast current health status with baseline data
D. To establish a database to identify problems and strengths
Answer: D
Rationale: An initial assessment is performed shortly after the client is admitted to
a health care agency or service. The purpose of the initial assessment is to establish
a complete database for problem identification and care planning. A focused
assessment gathers data about a specific and current health problem. An
emergency assessment identifies life-threatening problems that require immediate
attention. A time-lapse assessment compares and contrasts current health status
with baseline data.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Understand
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 407
6. A client comes to the health care provider's office reporting abdominal pain, for
which the client has previously sought care. Which type of assessment would the
nurse perform?
A. Initial
B. Focused
, C. Emergency
D. Time-lapse
Answer: B
Rationale: The nurse completes a focused assessment to gather data about a
specific problem that has already been identified and to identify new or
overlooked problems. The nurse completes an initial assessment when a client is
new to the health care provider or facility; this type of assessment is
comprehensive and provides baseline data that contribute to developing the care
plan and allow for comparison against future data. The nurse completes an
emergency assessment for a client who is facing a life-threatening situation. The
nurse completes a time-lapse assessment to compare a patient's current status with
baseline data obtained earlier.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 407
7. A nurse is assisting with feeding residents lunch at a nursing home. Suddenly,
one of the residents begins to choke and is unable to breathe. The nurse assesses
the resident's ability to breathe and then begins cardiopulmonary resuscitation.
Why did the nurse assess respiratory status?
A. To identify a life-threatening problem
B. To establish a database for medical care
C. To practice respiratory assessment skills
D. To facilitate the resident's ability to breathe
Answer: A
Rationale: When a life-threatening physiologic or psychological crisis occurs, the
nurse performs an emergency assessment to identify life-threatening problems.
Emergency assessments are not used to establish a database for medical care,
practice assessment skills, or help a physiologic process (such as breathing).
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process
Test Bank, Chapter Assignments, Discussions Plus Case Studies and Answers
Fundamentals of Nursing: The Art and Science of Person-Centered Care (10th Edition Taylor)
1. Which nursing assessment guideline is most accurate?
A. "Collect assessment data about the client continuously."
B. "Assess your client after receiving the nursing report and again before giving a
report to the next shift of nurses."
C. "Assess your client at least hourly if the client's vital signs are unstable, and
every 2 hours if the vital signs are stable."
D. "Collect assessment data prior to the physician rounding on the unit."
Answer: A
Rationale: The nurse should collect data about the client continuously because the
client's health status can change quickly. The nurse should complete an initial
assessment early in the clinical shift and then reassess as frequently as the health
care setting policy states. The nurse should assess vital signs at least every 4 hours
and possibly more frequently, depending on the client's status, which the nurse
should evaluated continuously. The nurse simply collecting assessment data before
the physician rounding is not appropriate, as a nursing professional should be
astute to client changes.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process
Reference: p. 404
2. The nurse is using an assessment guide that includes a hierarchy of five life
requirements universal to all persons. Which model for organizing assessment data
is the nurse using?
A. Human Needs (Maslow) model
B. Functional Health Patterns model
C. Human Response Patterns model
D. Body System model
Answer: A
Rationale: The nurse is following the Human Needs model based on Maslow's
Hierarchy of Human Needs. The Functional Health Patterns model was
,developed by Gordon and is a framework that identifies 11 functional health
patterns and organizes data according to these patterns. The Body System model
is often used by the medical community, and it organizes data according to organ
and tissue function in various body systems. The Human Response Patterns model
focuses on a unitary person.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 414
3. When documenting subjective data, the nurse should:
A. use the client's own words placed in quotation marks.
B. paraphrase the information stated by the client.
C. validate the information with the client's family prior to documentation.
D. record the information using nonspecific words.
Answer: A
Rationale: The nurse should record subjective data using the client's own words,
whenever possible, and place quotation marks around the client's statement. The
nurse should avoid using nonspecific terms, which are subject to individual
definition, paraphrasing, or interpreting, all of which can cause inaccuracy.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Remember
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Reference: p. 424
4. The nurse enters a client's room to find the client diaphoretic (sweat-covered)
and shivering and infers that the client has a fever. How should the nurse best
follow up this cue and inference?
A. Measure the client's oral temperature.
B. Ask a colleague for assistance.
C. Give the client a clean gown and warm blankets.
D. Obtain an order for blood cultures.
Answer: A
,Rationale: An inference must be followed by a validation process. In this case, the
inference of fever is best validated or rejected by measuring the client's
temperature. This should precede interventions such as blood work or even
providing a warm blanket. The nurse does not need to ask a colleague for
assistance.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 421
5. The nurse completes a health history and physical assessment on a client who
has been admitted to the hospital for surgery. What is the purpose of this initial
assessment?
A. To gather data about a specific and current health problem
B. To identify life-threatening problems that require immediate attention
C. To compare and contrast current health status with baseline data
D. To establish a database to identify problems and strengths
Answer: D
Rationale: An initial assessment is performed shortly after the client is admitted to
a health care agency or service. The purpose of the initial assessment is to establish
a complete database for problem identification and care planning. A focused
assessment gathers data about a specific and current health problem. An
emergency assessment identifies life-threatening problems that require immediate
attention. A time-lapse assessment compares and contrasts current health status
with baseline data.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Understand
Client Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 407
6. A client comes to the health care provider's office reporting abdominal pain, for
which the client has previously sought care. Which type of assessment would the
nurse perform?
A. Initial
B. Focused
, C. Emergency
D. Time-lapse
Answer: B
Rationale: The nurse completes a focused assessment to gather data about a
specific problem that has already been identified and to identify new or
overlooked problems. The nurse completes an initial assessment when a client is
new to the health care provider or facility; this type of assessment is
comprehensive and provides baseline data that contribute to developing the care
plan and allow for comparison against future data. The nurse completes an
emergency assessment for a client who is facing a life-threatening situation. The
nurse completes a time-lapse assessment to compare a patient's current status with
baseline data obtained earlier.
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 407
7. A nurse is assisting with feeding residents lunch at a nursing home. Suddenly,
one of the residents begins to choke and is unable to breathe. The nurse assesses
the resident's ability to breathe and then begins cardiopulmonary resuscitation.
Why did the nurse assess respiratory status?
A. To identify a life-threatening problem
B. To establish a database for medical care
C. To practice respiratory assessment skills
D. To facilitate the resident's ability to breathe
Answer: A
Rationale: When a life-threatening physiologic or psychological crisis occurs, the
nurse performs an emergency assessment to identify life-threatening problems.
Emergency assessments are not used to establish a database for medical care,
practice assessment skills, or help a physiologic process (such as breathing).
Question format: Multiple Choice
Chapter 15: Assessing
Cognitive Level: Apply
Client Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process
