, lOMoARcPSD| 12286418
Chapter 1 ai
1. A nurse on a postsurgical unit is admitting a client following the client's cholecystecto
ai ai ai ai ai ai ai ai ai ai ai ai ai
my (gall bladder removal). What is the overall purpose of assessment for this client?
ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Collecting accurate data ai ai
B) Assisting the primary care provider ai ai ai ai
C) Validating previous data ai ai
D) Making clinical judgments ai ai
2. A client has presented to the emergency department (ED) with complaints of abdominal
ai ai ai ai ai ai ai ai ai ai ai ai ai
pain. Which member of the care team would most likely be responsible for collecting th
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
e subjective data on the client during the initial comprehensive assessment?
ai ai ai ai ai ai ai ai ai ai
A) Gastroenterologist
B) ED nurse ai
C) Admissions clerk ai
D) Diagnostic technician ai
3. The nurse has completed an initial assessment of a newly admitted client and is applying t
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
he nursing process to plan the client's care. What principle should the nurse apply when
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
using the nursing process? ai ai ai
A) Each step is independent of the others. ai ai ai ai ai ai
B) It is ongoing and continuous. ai ai ai ai
C) It is used primarily in acute care settings.
ai ai ai ai ai ai ai
D) It involves independent nursing actions.
ai ai ai ai
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and p
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
erform a comprehensive health assessment. Which of the following actions should the n
ai ai ai ai ai ai ai ai ai ai ai ai
urse perform first? ai ai
A) Review the client's medical record. ai ai ai ai
B) Obtain basic biographic data. ai ai ai
C) Consult clinical resources explaining the client's diagnosis. ai ai ai ai ai ai
D) Validate information with the client. ai ai ai ai
5. Which of the following client situations would the nurse interpret as requiring an
ai ai ai ai ai ai ai ai ai ai ai ai ai
emergency assessment? ai
A) A pediatric client with severe sunburn
ai ai ai ai ai
B) A client needing an employment physical
ai ai ai ai ai
C) A client who overdosed on acetaminophen
ai ai ai ai ai
D) A distraught client who wants a pregnancy test
ai ai ai ai ai ai ai
, lOMoARcPSD| 12286418
6. In response to a client's query, the nurse is explaining the differences between the phy
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
sician's medical exam and the comprehensive health assessment performed by the nurs
ai ai ai ai ai ai ai ai ai ai ai
e. The nurse should describe the fact that the nursing assessment focuses on which aspe
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
ct of the client's situation?
ai ai ai ai
A) Current physiologic status ai ai
B) Effect of health on functional status ai ai ai ai ai
C) Past medical history ai ai
D) Motivation for adherence to treatment ai ai ai ai
7. After teaching a group of students about the phases of the nursing process, the instructor
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
determines that the teaching was successful when the students identify which phase as b
ai ai ai ai ai ai ai ai ai ai ai ai ai
eing foundational to all other phases?
ai ai ai ai ai
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
admitted for the treatment of community-
ai ai ai ai ai
acquired pneumonia. Following the completion of this assessment, the nurse periodical
ai ai ai ai ai ai ai ai ai ai
ly performs a partial assessment primarily for which reason?
ai ai ai ai ai ai ai ai
A) Reassess previously detected problems ai ai ai
B) Provide information for the client's record ai ai ai ai ai
C) Address areas previously omitted ai ai ai
D) Determine the need for crisis intervention ai ai ai ai ai
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
city neighborhood. Which client would the nurse determine to be in most need of an
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
emergency assessment? ai
A) A 14-year-old girl who is crying because she thinks she is pregnant
ai ai ai ai ai ai ai ai ai ai ai
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
ai ai ai ai ai ai ai ai ai ai
C) A 3-year-old child with fever, rash, and sore throat
ai ai ai ai ai ai ai ai
D) A 20-year-old man with a 3-inch shallow laceration on his leg
ai ai ai ai ai ai ai ai ai ai
, lOMoARcPSD| 12286418
10. A nurse has completed gathering some basic data about a client who has multiple health
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
problems that stem from heavy alcohol use. The nurse has then reflected on her personal f
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
eelings about the client and his circumstances. The nurse does this primarily to accompl
ai ai ai ai ai ai ai ai ai ai ai ai ai
ish which of the following?
ai ai ai ai
A) Determine if pertinent data has been omitted ai ai ai ai ai ai
B) Identify the need for referral ai ai ai ai
C) Avoid biases and judgments ai ai ai
D) Construct a plan of care ai ai ai ai
11. The nurse is collecting data from a client who has recently been diagnosed with type 1 d
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
iabetes and who will begin an educational program. The nurse is collecting subjective an
ai ai ai ai ai ai ai ai ai ai ai ai ai
d objective data. Which of the following would the nurse categorize as objective data?
ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Family history ai
B) Occupation
C) Appearance
D) History of present health concern ai ai ai ai
12. An older adult client has been admitted to the hospital with failure to thrive resulting f
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
rom complications of diabetes. Which of the following would the nurse implement in r
ai ai ai ai ai ai ai ai ai ai ai ai ai
esponse to a collaborative problem?
ai ai ai ai
A) Encourage the client to increase oral fluid intake. ai ai ai ai ai ai ai
B) Provide the client with a bedtime protein snack. ai ai ai ai ai ai ai
C) Assist the client with personal hygiene. ai ai ai ai ai
D) Measure the client's blood glucose four times daily. ai ai ai ai ai ai ai
13. The nurse at a busy primary care clinic is analyzing the data obtained from the follo
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
wing clients. For which clients would the nurse most likely expect to facilitate a referr
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
al?
A) An 80-year-old client who lives with her daughter
ai ai ai ai ai ai ai
B) A 50-year-old client newly diagnosed with diabetes
ai ai ai ai ai ai
C) An adult presenting for an influenza vaccination
ai ai ai ai ai ai
D) A teenager seeking information about contraception
ai ai ai ai ai
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The in
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
structor determines that the teaching was successful when the students identify which of
ai ai ai ai ai ai ai ai ai ai ai ai ai
the following as the major method used by nurses early in the history of the profession?
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Natural senses ai
B) Biomedical knowledge ai
C) Simple technology ai
D) Critical pathways ai
Chapter 1 ai
1. A nurse on a postsurgical unit is admitting a client following the client's cholecystecto
ai ai ai ai ai ai ai ai ai ai ai ai ai
my (gall bladder removal). What is the overall purpose of assessment for this client?
ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Collecting accurate data ai ai
B) Assisting the primary care provider ai ai ai ai
C) Validating previous data ai ai
D) Making clinical judgments ai ai
2. A client has presented to the emergency department (ED) with complaints of abdominal
ai ai ai ai ai ai ai ai ai ai ai ai ai
pain. Which member of the care team would most likely be responsible for collecting th
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
e subjective data on the client during the initial comprehensive assessment?
ai ai ai ai ai ai ai ai ai ai
A) Gastroenterologist
B) ED nurse ai
C) Admissions clerk ai
D) Diagnostic technician ai
3. The nurse has completed an initial assessment of a newly admitted client and is applying t
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
he nursing process to plan the client's care. What principle should the nurse apply when
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
using the nursing process? ai ai ai
A) Each step is independent of the others. ai ai ai ai ai ai
B) It is ongoing and continuous. ai ai ai ai
C) It is used primarily in acute care settings.
ai ai ai ai ai ai ai
D) It involves independent nursing actions.
ai ai ai ai
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and p
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
erform a comprehensive health assessment. Which of the following actions should the n
ai ai ai ai ai ai ai ai ai ai ai ai
urse perform first? ai ai
A) Review the client's medical record. ai ai ai ai
B) Obtain basic biographic data. ai ai ai
C) Consult clinical resources explaining the client's diagnosis. ai ai ai ai ai ai
D) Validate information with the client. ai ai ai ai
5. Which of the following client situations would the nurse interpret as requiring an
ai ai ai ai ai ai ai ai ai ai ai ai ai
emergency assessment? ai
A) A pediatric client with severe sunburn
ai ai ai ai ai
B) A client needing an employment physical
ai ai ai ai ai
C) A client who overdosed on acetaminophen
ai ai ai ai ai
D) A distraught client who wants a pregnancy test
ai ai ai ai ai ai ai
, lOMoARcPSD| 12286418
6. In response to a client's query, the nurse is explaining the differences between the phy
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
sician's medical exam and the comprehensive health assessment performed by the nurs
ai ai ai ai ai ai ai ai ai ai ai
e. The nurse should describe the fact that the nursing assessment focuses on which aspe
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
ct of the client's situation?
ai ai ai ai
A) Current physiologic status ai ai
B) Effect of health on functional status ai ai ai ai ai
C) Past medical history ai ai
D) Motivation for adherence to treatment ai ai ai ai
7. After teaching a group of students about the phases of the nursing process, the instructor
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
determines that the teaching was successful when the students identify which phase as b
ai ai ai ai ai ai ai ai ai ai ai ai ai
eing foundational to all other phases?
ai ai ai ai ai
A) Assessment
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
admitted for the treatment of community-
ai ai ai ai ai
acquired pneumonia. Following the completion of this assessment, the nurse periodical
ai ai ai ai ai ai ai ai ai ai
ly performs a partial assessment primarily for which reason?
ai ai ai ai ai ai ai ai
A) Reassess previously detected problems ai ai ai
B) Provide information for the client's record ai ai ai ai ai
C) Address areas previously omitted ai ai ai
D) Determine the need for crisis intervention ai ai ai ai ai
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
city neighborhood. Which client would the nurse determine to be in most need of an
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
emergency assessment? ai
A) A 14-year-old girl who is crying because she thinks she is pregnant
ai ai ai ai ai ai ai ai ai ai ai
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
ai ai ai ai ai ai ai ai ai ai
C) A 3-year-old child with fever, rash, and sore throat
ai ai ai ai ai ai ai ai
D) A 20-year-old man with a 3-inch shallow laceration on his leg
ai ai ai ai ai ai ai ai ai ai
, lOMoARcPSD| 12286418
10. A nurse has completed gathering some basic data about a client who has multiple health
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
problems that stem from heavy alcohol use. The nurse has then reflected on her personal f
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
eelings about the client and his circumstances. The nurse does this primarily to accompl
ai ai ai ai ai ai ai ai ai ai ai ai ai
ish which of the following?
ai ai ai ai
A) Determine if pertinent data has been omitted ai ai ai ai ai ai
B) Identify the need for referral ai ai ai ai
C) Avoid biases and judgments ai ai ai
D) Construct a plan of care ai ai ai ai
11. The nurse is collecting data from a client who has recently been diagnosed with type 1 d
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
iabetes and who will begin an educational program. The nurse is collecting subjective an
ai ai ai ai ai ai ai ai ai ai ai ai ai
d objective data. Which of the following would the nurse categorize as objective data?
ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Family history ai
B) Occupation
C) Appearance
D) History of present health concern ai ai ai ai
12. An older adult client has been admitted to the hospital with failure to thrive resulting f
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
rom complications of diabetes. Which of the following would the nurse implement in r
ai ai ai ai ai ai ai ai ai ai ai ai ai
esponse to a collaborative problem?
ai ai ai ai
A) Encourage the client to increase oral fluid intake. ai ai ai ai ai ai ai
B) Provide the client with a bedtime protein snack. ai ai ai ai ai ai ai
C) Assist the client with personal hygiene. ai ai ai ai ai
D) Measure the client's blood glucose four times daily. ai ai ai ai ai ai ai
13. The nurse at a busy primary care clinic is analyzing the data obtained from the follo
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
wing clients. For which clients would the nurse most likely expect to facilitate a referr
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
al?
A) An 80-year-old client who lives with her daughter
ai ai ai ai ai ai ai
B) A 50-year-old client newly diagnosed with diabetes
ai ai ai ai ai ai
C) An adult presenting for an influenza vaccination
ai ai ai ai ai ai
D) A teenager seeking information about contraception
ai ai ai ai ai
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The in
ai ai ai ai ai ai ai ai ai ai ai ai ai ai
structor determines that the teaching was successful when the students identify which of
ai ai ai ai ai ai ai ai ai ai ai ai ai
the following as the major method used by nurses early in the history of the profession?
ai ai ai ai ai ai ai ai ai ai ai ai ai ai ai
A) Natural senses ai
B) Biomedical knowledge ai
C) Simple technology ai
D) Critical pathways ai
