Test Bank For Health Assessment in Nursing 6th Edition by Weber All Chapters

TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER CHAPTER 1: NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA 1. A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? A) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments 2. A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician 3. The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. N D) It involves independent nursing actions. 4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client. 5. Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER 6. In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment 7. After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other pha ses? A) Assessment B) Planning C) Implementation D) Evaluation 8. The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously deteNcted problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention 9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg 10. A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER 11. The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern 12. An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. N C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily. 13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception 14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways 15. When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology 16. A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER 17. A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? A) Guaranteeing a continual assessment process B) Identifying abnormal data N C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems 18. A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data. 19. A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior 20. A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data. 21. The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) ìI feel so tired sometimes.î B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) ìMy father died of a heart attack.î F) Pupils equal, round, and reactive to light 22. The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes C,B,A,E,D B) Determining client's nursing problem N C) Collecting information about the client D) Determining outcome achievement E) Carrying out interventions TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER 23. A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening 24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources. 25. A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? A) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment 26. A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level. 27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change N B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery 28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes. 30. A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client. N 29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER Answer Key 1. D 2. B 3. B 4. A 5. C 6. B 7. A 8. A 9. B 10. C 11. C 12. D 13. B 14. A 15. D 16. A 17. C 18. C 19. A 20. C 21. A, D, E 22. C, B, A, E, D N 23. A 24. B 25. C 26. A 27. A 28. D 29. C 30. B TEST BANK FOR HEALTH ASSESSMENT IN NURSING 6TH EDITION BY WEBER Powered byTC PDF ( ) DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal CHAPTER 2: COLSLtuEviaC.cTomIN-GTheSMUaBrkeJtEplCacTe I toVBEuyDanAdTS HISTORY eAll : yoTurHSEtudI yNMTatEerRialVIEW AND HEALTH CHAPTER 2: COLLECTING SUBJECTIVE DATA: THE INTERVIEW AND HEALTH HISTORY 1. A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? A) Establishing a trusting relationship B) Determining the client's strengths C) Identifying potential health problems D) Making clinical inferences 2. A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? A) Introductory B) Working C) Summary D) Closing 3. A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? A) ―How often do your adult children typically visit you?‖ B) ―Your husband's death must have been very difficult for you.‖ C) ―You must quit smoking because it affects others, not only you.‖ D) ―How would you describe your feelings about getting older?‖ N 4. A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? A) Standing while the client is seated B) Using a moderate amount of eye contact C) Sitting across the room from the client D) Minimizing facial expressions 5. A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? Page 1 This study source was downloaded by from CourseH on :34:19 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal A) ―Tell me about your relationship with your children?‖ B) ―Tell me what you eat in a normal day?‖ C) ―Are you allergic to any medications?‖ D) ―What is your typical day like?‖ 6. A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint? A) Ignore the complaint for now and return to it later in the assessment. B) Provide a laundry list of descriptive words. C) Restate the question using simpler terms. D) Wait in silence until the client can determine the correct words. 7. A nurse is eliciting a client's health history and the client asks, ―Can I take the herb ginkgo biloba with my other medications?‖ What action would be best if the nurse is unsure of the answer? A) Promise to find out the information for the client. B) Change the subject and return to this topic later. C) Teach the client to only take prescribed medications. D) Encourage the client to ask the pharmacist or primary care provider. 8. The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? A) The client's sensory abilities B) The client's general intelligence C) The presence of any phobias N D) The client's judgment and insight 9. A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a ―culture broker.‖ How can this individual best facilitate the client's care? A) By interpreting the client's language and culture B) By evaluating the client's culturally based health practices C) By teaching the client about health care D) By making the client feel comfortable and safe 10. Upon entering an exam room, the client states, ―Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!‖ Which response by the nurse would be most appropriate? A) ―Our schedule is very busy also. We got to you as soon as we could.‖ B) ―No one is forcing you to be here, and you are free to leave at any time.‖ C) ―Would you like to report your complaints to someone with power?‖ D) ―You're certainly justified in being upset, but I am ready to begin your exam now.‖ S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 11. A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe? A) ―This helps us to complete your health record accurately.‖ B) ―This helps us to establish a trusting interpersonal relationship.‖ C) ―This helps us to evaluate the seriousness of your risk factors for disease.‖ D) ―This helps us have an appropriate focus for the physical examination.‖ 12. A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? A) ―Do you have adequate health insurance coverage?‖ B) ―Are you generally fairly healthy?‖ C) ―What is your major health concern at this time?‖ D) ―Did you bring all your medications with you?‖ 13. A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the ―P‖? A) ―What makes it worse?‖ B) ―When did it start?‖ C) ―How does it feel?‖ N D) ―How would you rate your pain?‖ 14. A medical nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A) ―High school diploma plus 2 years of college‖ B) ―Caregiver reliable source of information‖ C) ―Menarche at age 13‖ D) ―Lungs clear to auscultation bilaterally‖ 15. A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? A) Ask the client to explain MyPlate. B) Obtain a 24-hour diet recall. C) Ask about the contents of one typical meal. D) Elicit the client's favorite foods. 16. A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise? A) ―I walk briskly on the treadmill once or twice a week.‖ B) ―I play basketball with a team every Friday night without fail.‖ C) ―I go to a step class for an hour three times a week.‖ S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal D) ―I swim for at least half an hour each Saturday morning.‖ 17. During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A) Ask the client to identify which medications taken every day. B) Ask the client to bring all the medications and supplements to an interview. C) Ask the caregiver whether the client is taking prescribed medications. D) Ask the client about the use of any over-the-counter medications. 18. The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? A) ―Do you always wear your seatbelt when driving?‖ B) ―How much beer, wine, or alcohol do you drink?‖ C) ―Do you use condoms with each sexual encounter?‖ N D) ―Could you describe how you perform self-breast exams?‖ 19. A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives? A) Circle B) Square C) Triangle D) Rectangle 20. A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? A) Collaborate with the client to identify problems. B) Explain the purpose of the interview. C) Determine the client's vital signs. D) Obtain family health history data. 21. During the interview, the client states, ―Is today the 12th? My wife died 2 months ago today.‖ Which of the following responses would be most appropriate? A) ―What was the cause of your wife's death?‖ B) ―How does that make you feel right now?‖ C) ―You probably must be sad.‖ D) ―Are you feeling sad, depressed, angry, or upset?‖ 22. The nurse is using the mnemonic ―COLDSPA‖ to assess a client's complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint? A) Character B) Onset S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal C) Severity D) Pattern 23. The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? A) ―My mom's still alive, but my dad died 10 years ago of heart failure.‖ B) ―I have a brother with leukemia and a sister with hypertension.‖ C) ―I had surgery 5 years ago to repair an inguinal hernia.‖ D) ―I have been having some pain when I urinate for the last several days.‖ N 24. A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? A) Maintaining an open attitude B) Using silence appropriately C) Providing a laundry list of descriptors when needed D) Maintaining an open and encouraging facial expression 25. The admission of a new resident to a long-term care facility has necessitated a thorough health history. Place the following focuses in the correct sequence in which the nurse should perform them, beginning with the section obtained first. A) Family health history B) Reason for seeking care C) Biographic data D) Review of body systems E) History of present concern F) Past health history 26. The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply. A) Joint stiffness B) Rhinorrhea C) Shortness of breath D) Chest pain E) Muscle strength F) Knee swelling 27. The nurse is completing an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? A) ―Client's gastrointestinal health is within reference ranges for age.‖ B) ―Client denies GI signs and symptoms.‖ C) ―Gastrointestinal problems are absent.‖ S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal D) ―Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain.‖ 28. A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, ―I'm sure I've been asked these N questions before. Can't we just focus on my foot and not all these other topics?‖ How should the nurse best explain the rationale for obtaining a health history? A) ―In general, it's necessary for us to gather as much information about each client as possible.‖ B) ―We want to make sure your nursing care matches your needs as closely as possible.‖ C) ―The care team needs to cross-reference your diagnostic testing with the information that I'm asking you about.‖ D) ―We don't want to make the mistake of focusing solely on the medical problem that brought you here.‖ 29. During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, ―Unless you're including channel surfing, I don't really do much of anything.‖ How should the nurse best follow up this client's statement? A) Briefly describe some of the potential benefits of regular exercise. B) Ask the client if he understands the risk factors for heart disease and diabetes. C) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week. D) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle. S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal Answer Key 30. A nurse is obtaining subjective data from an adult client who is new to the clinic. The 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. nAurse has asked the client, ―Where do you usually turn for help in a time of crisis?‖ WB hat domain is this nurse assessing? AC) The client's family relationships B) The client's current level of social and relational stability C) The client's critical thinking and problem-solving abilities DB) The client's stress management and coping strategies A A A D D C A 14. C 15. B 16. C 17. B 18. D 19. A 20. B 21. B 22. C N 23. C 24. C 25. C, B, E, F, A, D 26. A, E, F 27. D 28. B 29. A 30. D ! Powered byTC PDF ( ) S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal CHAPTER 3: COLLECTING OBJECTIVE DATA: THE PHYSICAL EXAMINATION 1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman's physical exam? A) Explain the purpose of the interview to the client. B) Construct the client's family genogram. C) Establish the client's reliability as historian. D) Collect necessary equipment essential to the exam. 2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate? A) Ensuring client's privacy by providing an examination gown B) Providing a comfortable, warm room temperature C) Arranging exam equipment on a bedside tray table D) Explaining why standard precautions are being used 3. A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions? A) Performing hand hygiene between examinations of each body part B) Discarding in the trash can the safety pin that was used to assess sensory perception C) Wearing gloves to palpate the tongue and buccal membranes N D) Wearing a gown, gloves, and mask during the physical exam 4. The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? A) Parasitic infection B) Fungal infection C) Bacterial infection D) Allergic reaction 5. A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement? A) Mid-arm circumference B) Client's height C) Skin lesion size D) Pupillary size Page 1 This study source was downloaded by from CourseH on :35:03 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 6. The nurse is preparing to assess an older adult client's near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use? A) Newspaper B) Snellen chart C) Ophthalmoscope D) Penlight 7. A nurse practitioner is performing a comprehensive physical examination of a 51- yearold man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following? A) Parasites B) Blood C) Bacteria D) Fungus 8. The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing? A) Extremity edema B) Joint flexion/extension C) Two-point discrimination D) Vibratory sensation N 9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There's no way I'll let you do that to me!î Which response by the nurse would be most appropriate? A) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. B) Tell the client that this is the only way she can be checked for cancer. C) Ask the client if she would prefer another practitioner to perform the exam. D) Proceed with the pelvic exam and document the client's protests in the health record. 10. The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations? A) Head and neck examination B) Palpation of lymph nodes C) Breast examination D) Vital signs 16. The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize? A) Deep palpation S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal B) Indirect percussion C) Moderate palpation D) Blunt percussion 17. In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A) Heart sounds B) Bowel sounds C) Breath sounds D) Femoral pulses 18. An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? A) ìPlastic tubing should be longer than 3 feet.î B) ìThe bell is used after using the diaphragm.î C) ìWhen using the bell, push on it lightly.î N D) ìA diaphragm picks up low-pitched sounds.î 19. A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse's use of a stethoscope during this phase of assessment? A) Auscultation can be performed through clothing. B) The diaphragm should be held firmly against the body part. C) The bell of the stethoscope can best detect bowel sounds. D) Use of the bell is reserved for advanced practice nurses. 20. A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions? A) Depressing the skin 1 to 2 centimeters with the dominant hand B) Feeling the surface structures using a circular motion C) Placing the nondominant hand on top of the dominant hand D) Using one hand to apply pressure and the other hand to feel the structure 26. A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first? A) Inspection B) Palpation C) Percussion D) Auscultation S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 27. The nurse is percussing the area over the client's lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following? A) Flatness B) Resonance C) Tympany D) Dullness 28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, ìI'd really like to have my mom in the room. That's okay, isn't it?î How should the nurse best respond to the client's request? A) ìOf course. There's a chair in the exam room where she can sit.î B) ìThat's no problem. I'll just have to get you to sign a privacy waiver first.î C) ìThat's fine, but be aware that some of the examinations might be embarrassing for N you or her.î D) ìIt's best to undergo the examination alone in order to make sure I get accurate data, but if you really want her present, we can do that.î 29. The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client's hand. What action should the nurse perform next? A) Obtain a tissue sample for pathology B) Compare the appearance of the client's other hand C) Palpate the lesions for tenderness and warmth D) Perform health promotion teaching about sun protection 30. A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness? A) Light palpation B) Deep palpation C) Direct percussion D) Blunt percussion S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal Answer Key 1. D 2. A 3. C 4. B 5. C 6. A 7. B 8. B 9. A 10. D 11. D 12. B 13. B 14. C 15. D 16. D 17. A 18. C 19. B 20. B 21. B 22. D N 23. C 24. A, C, E, F 25. C 26. A 27. B 28. A 29. B 30. C Powered byTC PDF ( ) S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal CHAPTER 4: VALIDATING AND DOCUMENTING DATA 1. Which of the following would be most important to ensure accurate data when gathering client information? A) Documenting the data B) Validating the data C) Identifying client support systems D) Determining client needs 2. A nurse obtains the following information from a client. Which statement would the nurse need to validate? A) "I've recently lost 20 pounds." B) "I feel very weak and tired." C) "I've had two cesarean deliveries." D) "I am generally healthy and happy." 3. A client who had a mastectomy is being discharged home. The client lives alone. Which data would be most important to validate for this client? A) If the client has transportation for follow-up appointments B) If the client usually functions independently C) What support systems are in place to assist the client D) If the client has a religious belief regarding illness 4. When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason? A) Health care institutions have established policies regarding documentation. B) Incorrect conclusions may be made without documentation of initial data. C) It satisfies legal standards established by health care organizations and institutions. D) It becomes the foundation for the entire nursing process. 5. After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following? A) Subjective data and objective data B) Interpretation and inference C) Observation and inspection D) Data and results 16. The nurse obtains the following information. The nurse would need to validate the data for which client? S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal A) A new mother who says she is tired B) A client who is laughing and talking with a temperature of 104°F C) A young girl with a small right lower quadrant scar who reports she had an appendectomy D) A man who has been a diabetic for 25 years 17. Which method of validation would be most appropriate when the nurse is unsure if a murmur is heard when assessing heart sounds? A) Verify with another health care professional. B) Recheck through reassessment. C) Compare objective data with subjective data. D) Clarify data with the client. 18. A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse include as the purpose of this type of documentation? A) It helps cluster data B) It provides lines for comments. C) It includes specialized data D) It standardizes data collection. 19. A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? A) It provides a chronologic source of client assessment data. B) It creates a data base for care that was not rendered to the client. C) It replaces the client acuity classification system. D) It directly formulates the nursing diagnoses. 20. The nurse compares subjective data and objective data to achieve which of the following? A) Formulation of nursing diagnoses B) Identification of missing data C) Determination of documentation form to use D) Validation of data 21. A nurse is preparing an in-service education program for a group of staff nurses about documentation, including documentation of assessment data. The nurse demonstrates understanding of the significance of documentation by including a discussion of which of the following as playing a role in this area? Select all that apply. A) Joint Commission B) State nurse practice act C) Medicare D) Local city government E) Institutional agency S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 22. A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation? A) Client appears upset about upcoming surgery. B) Client was interviewed about previous history of hypertension C) Skin pale, warm, and dry without evidence of lesions D) Client's oral intake is satisfactory 23. A nurse is using a nursing minimum data set to document assessment information. The nurse most likely would be working in which setting? A) Acute care facility B) Long-term care facility C) Urgent care center D) Health clinic 24. While gathering a nursing history about a client's previous hospitalizations and surgeries, the nurse finds out that this is the client's first hospitalization and that he hasn't had any surgeries. The nurse would document which of the following? A) Client denies prior hospitalizations and surgeries B) Client has not been hospitalized before nor has he had any surgery C) Client answered no to previous hospitalizations or surgery D) Negative for past hospitalizations 25. An instructor is describing various ways that a nurse can validate data to a group of nursing students. The instructor determines that additional teaching is necessary when the students identify which of the following as a reliable method? A) Repeating the assessment B) Asking additional questions C) Having the client repeat what was said D) Checking findings with another health care professional S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 26. A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? A) Open-ended form B) Focused assessment form C) Frequent assessment form D) Ongoing assessment form 27. A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following? A) “Documentation helps support reimbursement but gives little epidemiologic data.” B) “Documentation provides a permanent legal record of care given and not given.” C) “Documentation is a viable means of communication but is repetitious.” D) “Documentation helps determine client education needs but not staff mix.” Answer Key 1. B 2. A 3. C 4. D 5. A 6. C 7. D 8. C 9. D 10. C 11. D 12. A 13. C 14. A 15. A 16. B 17. A 18. A 19. A 20. D 21. A, B, C, E 22. C 23. B 24. A 25. C 26. B 27. B S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal CHAPTER 5: THINKING CRITICALLY TO ANALYZE DATA AND MAKE INFORMED NURSING JUDGMENTS 1. A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which of the following direct results? A) Outcomes evaluation B) Nursing diagnoses C) Holistic interventions D) An interdisciplinary plan of care 2. A new nursing graduate recently made an oversight during the analysis of a client's assessment data that resulted in a postoperative complication. What characteristic of data analysis makes it a challenging aspect of nursing practice? A) Abnormal data must be identified. B) It requires the prior identification of nursing diagnoses. C) It requires sophisticated diagnostic reasoning skills. D) Conclusions must be clearly and accurately documented. 3. A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve client care. The nurse should identify which of the following characteristics of critical thinking? A) It is an innate skill that some individuals possess and which others do not. B) It does not include past experiences. C) It is based primarily on getting correct and timely information. N D) It involves reflections on thoughts before reaching conclusions. 4. The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis? A) Validate the collected data. B) Formulate a nursing diagnosis. C) Make inferences about the data. D) Identify the client's strengths. 5. A nurse has completed a client's initial assessment and is preparing to identify abnormal data and the client's strengths. Successful completion of this phase of the nursing process most requires which of the following? A) Knowledge of anatomy and physiology B) Awareness of the client's medical prognosis C) Inferences about the client D) Knowledge about the referral process S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 6. A nurse is planning a client's care following the completion of an initial assessment. When formulating a risk nursing diagnosis, which piece of data would be most useful? A) The client has an elevated white blood cell count. B) The client is 66 years of age. C) The client has pain in her joints, especially in the morning. D) The client is separated from her usual social supports. 7. During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. This fact would most likely prompt the nurse to identify which of the following? A) Actual nursing diagnosis B) Risk nursing diagnosis C) Collaborative problem D) Health promotion diagnosis 8. A nurse is caring for a client who has been admitted with an infected venous ulcer. The nurse determines that the client will need medical interventions as well as nursing interventions. The nurse would identify which of the following? A) Actual nursing diagnosis B) Referral C) Risk nursing diagnosis D) Collaborative problem N 9. A nurse has assessed a client and identified data that are associated with the diagnoses of Impaired Physical Mobility and Activity Intolerance. How can the nurse best determine which nursing diagnosis is most applicable to the client? A) Document preliminary conclusions. B) Identify abnormal data. C) Check the defining characteristics of the diagnoses. D) Test the nursing diagnoses clinically. 10. A nurse is analyzing the assessment data of a client who has been admitted with exacerbation of heart failure. The nurse has determined that the cue clusters meet the defining characteristics of specific nursing diagnoses. Which of the following would the nurse do next? A) Explain the client's problems to the client and his or her family. B) Verify it with the client and with other health care professionals. C) Validate the diagnosis with the physician. D) Work with the client to begin planning interventions. 11. A nurse's data analysis has led to the formulation of a risk nursing diagnosis. Which of the following best demonstrates accurate documentation of a risk nursing diagnosis? A) Risk for fatigue related to increased job demands, as manifested by feelings of exhaustion and frequent naps B) Risk for infection, as manifested by lack of client knowledge of wound care S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal C) Risk for violence related to history of overt, aggressive acts D) Risk for altered respiratory function related to environmental allergens, as manifested by asthma 12. A nurse is preparing to document conclusions after analyzing data, and he or she includes information about related factors and manifestations. The nurse is formulating which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Collaborative problem D) Problem for referral 13. A nurse is applying the diagnostic reasoning process in the care of a client. What is the correct sequence of the steps that the nurse should perform? A) Check for defining characteristics. B) Draw inferences. D,E,B,C,A C) Propose possible nursing diagnoN ses. D) Identify abnormal data and strengths. E) Cluster data. 14. The nurse has collected objective and subjective data during the assessment of a client who has been admitted for the treatment of an exacerbation of chronic obstructive pulmonary disease (COPD). During the current phase of the diagnostic reasoning process, the nurse is writing down thoughts about each cue cluster of data that was collected. The nurse is involved in which step of the diagnostic reasoning process? A) Step One: Identify Abnormal Data and Strengths B) Step Two: Cluster Data C) Step Three: Draw Inferences D) Step Four: Propose Possible Nursing Diagnoses 15. A nurse is determining whether the data for a client support a potential nursing diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning process? A) Step Three: Draw Inferences B) Step Four: Propose Possible Nursing Diagnoses C) Step Five: Check for Defining Characteristics D) Step Six: Confirm or Rule Out Diagnoses 16. A nurse is applying the diagnostic reasoning process in the care of a client with a number of comorbidities. Which of the following descriptions best characterizes Step Two, Clustering Data? A) Hypothesizing of any potentially applicable health promotion diagnoses, risk diagnoses, and actual diagnoses B) Documentation of all professional judgments along with any data that support those judgments Page 3 S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal C) Examining identified abnormal findings and strengths for cues that are related D) Evaluation of both subjective and objective data to identify strengths and abnormal findings 17. An experienced nurse is teaching a recently graduated colleague about common pitfalls encountered in the diagnostic reasoning process. The experienced nurse should identify a need for further teaching if the new graduate identifies which of the following as a N pitfall? A) View of things as either right or wrong B) Overemphasis on details C) Inclusion of valid data D) Clustering of unrelated cues 18. A nurse on a busy acute medical unit asks a clinical educator for suggestions on how to best develop expertise in using diagnostic reasoning skills to arrive at correct conclusions. Which of the following statements would be most appropriate? A) ―You need to cluster the data more rapidly.‖ B) ―This skill comes with accumulating experience.‖ C) ―Try to be more efficient in documenting the data.‖ D) ―This is a skill that only comes with an advanced practice designation.‖ 19. A nurse has identified a goal of developing his critical thinking skills. In order to facilitate this goal, what action should the nurse prioritize? A) Applying quick decision-making B) Seeking new experiences C) Maintaining an open mind D) Maintaining a stable and static knowledge base 20. After teaching a group of students about the second phase of the nursing process, the instructor determines that additional teaching is needed when the students identify which of the following as a component? A) Organizing data B) Clustering data C) Formulating a medical diagnosis D) Generating hypotheses 21. An experienced medical-surgical nurse has identified critical thinking as an integral component of diagnostic reasoning. How can the relationship between these two concepts be best described? A) Critical thinking is the practical application of diagnostic reasoning skills. B) Critical thinking and diagnostic reasoning are synonymous. C) Critical thinking is the foundation of the process of diagnostic reasoning. D) Critical thinking is the domain of the novice nurse, whereas diagnostic reasoning is N present in experts. S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 22. During an educational inservice, nursing have been encouraged to conduct a selfappraisal of their critical thinking skills. Which of the following questions can best guide this appraisal? A) ―Do I tend to make errors in my nursing practice?‖ B) ―Do I get good feedback from clients and their families?‖ C) ―Am I open to the fact that I may not be right?‖ D) ―Am I a resource to my colleagues during a crisis?‖ 23. A nurse has admitted a client to the medical unit who has just been diagnosed with endocarditis secondary to IV drug use. The nurse has completed the collection of objective and subjective data. What question should guide the next step in the nurse's data analysis? A) ―What are this client's strengths?‖ B) ―What is this client's prognosis?‖ C) ―Why does this client use opioids?‖ D) ―What are this client's hopes for the future?‖ 24. The nurse is attempting to cluster the data that she collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of ―a bit of soreness‖ in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next? A) Document a suspected nursing diagnosis of Impaired Physical Mobility. B) Assess the client further for evidence of reduced mobility and decreased range of motion. C) Make a referral to the physical therapist. D) Plan interventions that will conservatively manage the client's joint dysfunction. 25. A nurse has been clustering the data that he collected during the initial assessment of a frail elderly client. When making inferences about the data clusters, the nurse is unsure whether to associate a cluster of data with a nursing diagnosis or with a collaborative problem. What question may best guide the nurse's decision? A) ―Can an unlicensed care provider meet this person's needs?‖ B) ―Is this problem acute or is it chronic?‖ C) ―Can this issue be addressed on an outpatient basis?‖ D) ―Does this issue require medical intervention?‖ 26. A nurse is providing care for a client who has longstanding type 2 diabetes. In recent days, the client's blood glucose levels have been higher and more volatile than usual. N After drawing this inference, the nurse should take what action? A) Make appropriate referrals B) Assess the client more frequently C) Document the medical diagnosis of hyperglycemia D) Beginning collecting subjective data Page 5 S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 27. The nurse's assessment of a client with a decreased level of consciousness reveals that the client is incontinent of urine. During the process of data analysis, the nurse would be justified in identifying what risk nursing diagnosis? A) Risk for Injury related to urinary incontinence B) Risk for Infection related to urinary incontinence C) Risk for Bowel Incontinence related to urinary incontinence D) Risk for Impaired Skin Integrity related to urinary incontinence 28. A nurse has selected several nursing diagnoses in the process of data analysis of a client with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health Maintenance related to infrequent blood glucose monitoring as manifested by elevated HgA1C. The nurse recognizes the need to corroborate this diagnosis with the client. How should the nurse best do this? A) ―I think you have a nursing diagnosis of Ineffective Health Maintenance.‖ B) ―Would you agree that there's room for improvement in your routines around blood sugar monitoring?‖ C) ―After assessing you, I believe that you're not maintaining your health effectively, specifically around your diabetes.‖ D) ―How do you think that you could better maintain your health?‖ 29. Data analysis of assessment data from a client who presented to the emergency department has resulted in the nurse making a syndrome nursing diagnosis. What is a primary characteristic of this type of diagnosis? A) The client's health problem cannot be conveyed using standard nursing language. B) The client's current signs and symptoms are the result of a longstanding health problem. C) The client has health problems that will require multidisciplinary care. D) The client has a number of nursing diagnoses that typically occur together. 30. A nurse has collecting extensive data during a client assessment and is performing the N first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following? A) Differentiate between expected findings and abnormal findings. B) Validate nursing diagnoses with the client and the client's family. C) Integrate the client's medical diagnosis with nursing diagnoses. D) Perform health promotion education. S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal Answer Key 1. B 2. C 3. D 4. A 5. A 6. D 7. D 8. D 9. C 10. B 11. C 12. B 13. D, E, B, C, A 14. C 15. D 16. C 17. C 18. B 19. C 20. C 21. C 22. C 23. A 24. B 25. D 26. A 27. D 28. B 29. D 30. A ! N Page 7 Powered byTC PDF ( ) S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal CHAPTER 6: ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE 1. The nurse is preparing to assess the remote memory of a client who has a diagnosis of early stage Alzheimer's disease. Which question would be most appropriate for the nurse to use? A) ìCan you tell me what you have eaten in the last 24 hours?î B) ìWhen did you get your first job?î C) ìWhat did you do last evening?î D) ìHow are an apple and orange the same?î 2. When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and the woman's ability to follow directions. Which of the following would the nurse do first? A) Use a Geriatric Depression Scale. B) Refer for further medical evaluation. C) Assess the client's vision and hearing. D) Refer the client to social services for home assistance. 3. The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. Which of the following would be most appropriate for the nurse to do next? A) Refer for further evaluation. B) Evaluate benefits versus risks of a mental health label. C) Assess further for dementia. N D) Document this as a normal score. 4. The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. Which of the following would be the nurse's priority assessment at this time? A) Asking whether the client often feels cold B) Assessing the client's developmental level C) Reviewing the client's culture for possible influence D) Observing the client's overall hygiene 5. A nurse is working in a clinic in a low-income neighborhood and assesses a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong body odor. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this client? A) Caregiver role strain related to fatigue B) Impaired skin integrity related to neurologic deficits C) Deficient fluid volume related to possible urinary tract infection D) Self-care deficit related to possible homelessness Page 1 This study source was downloaded by from CourseH on :01:04 GMT -05:00 S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 6. When preparing to obtain information about a client's mental and psychosocial status, which of the following would the nurse need to do first? A) Question the patient about his or her usual lifestyle and behaviors. B) Perform a neurologic examination to determine any deficits. C) Check the client's level of consciousness for changes. D) Explain the purpose of the exam and types of questions. 7. A nursing student has been assigned to the care of a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system? A) Respiratory B) Neurologic C) Cardiovascular D) Renal 8. The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? A) The client will be less anxious early, providing the nurse with more accurate and reliable data. B) The exam can provide clues about the validity of the client's responses now and N throughout. C) The exam provides data about mental health problems that the client may be afraid to report. D) The client's fears about having a serious illness may be alleviated by the results of the exam. 9. A client's recent episode of becoming lost near his home has prompted the nurse to use the Saint Louis University Mental Status (SLUMS) Assessment Tool. The nurse should begin this assessment by asking what question? A) ìHow would you respond if someone said that you might have dementia?î B) ìCan I ask you some questions about your memory?î C) ìDo you generally consider yourself to be an intelligent person?î D) ìI want to ask you some questions to see if you have Alzheimer's.î 10. Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? A) Obtunded B) Stupor C) Coma D) Lethargy 11. An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem? A) Delirium B) Vascular dementia C) Schizophrenia D) Psychosis 12. The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following? A) Deep coma B) Coma C) Obtunded N D) Alert and oriented 13. A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the client has Alzheimer's disease? Select all that apply. A) ìHe repeats the same story, word for word, over and over again.î B) ìHe took a fall when he was replacing a light bulb last month.î C) ìI have to balance the checkbook now because he just won't do it.î D) ìIf I don't tell him when to shower, he won't and will fight me on it.î E) ìHe got lost walking to the pharmacy around the corner the other day.î 14. As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? A) Concentration and orientation B) Perceptions and thought processes C) Visual perceptual and constructional ability D) Expressions and feelings S - The Marketplace to Buy and Sell your Study Material DDoownnloloaaddeeddbbyy::dSrfoapithii|ed| Distribution of this document is illegal 20. A nurse asks a client the following question: ìWhat do you do if you have pain?î The nurse is assessing which of the following aspects of cognitive function? 15. A nurse who provides care on a medical unit utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted client, the nurse should recognize the possibility of which of the following? A) Hazardous and harmful alcohol use B) Imminent liver disease C) Acute pancreatitis D) Alcoholism 16. A nurse is asses