C HAPTER 16: N URSING A SSESSMENT
Fundamentals of Nursing 10th Edi tion; Potter Perry
MULTIPLE CHOICE
1. An ER nurse is interviewing a client who complains of abdominal pain.
Which of the following questions asked by the nurse has priorit y at this
time?
A. Can you describe your pain?
B. Have you had this problem b efore?
C. What have you done to ease the pain?
D. When did your abdominal pain begin?
ANS: D
If a client presents to the emergency department with pain, the nurse
should first ask the client about the onset, severit y, and duration of the
pain. In an emergency situation, the clients current health problem
becomes the priorit y assessment. Gathering data about the problem
currentl y affecting the client has greater priorit y, but a description of
the pain does not have priorit y over onset. Asking the client about
medical history is appropriate but not at this time. The priority is to
assess the symptoms the client is experiencing. Gathering data about
the problem currently affecting the client has greater priorit y, but
attempted self -treatment does not have priorit y over onset.
, DIF: C REF: 236-237 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Health
Promotion and Maintenance
2. Which subjective assessment data are most supportive of a clients
diagnosis of anxiet y?
A. Diaphoretic and cool skin
B. An apical pulse rate of 120 beats per minute
C. Reports needing to leave now
D. Claims something is terribl y wrong
ANS: D
Subjective data are clients perceptions about their health problems. The
statement by the client regarding his sense of impending doom is the
best example of subjective data regarding his anxiet y because it is his
own verbalization of the problem. Cool, damp skin is an example of
objective data. Objective data are observations or measurements made
by the data collector. A pulse rate is an example of objective data.
Objective data are observations or measurements made by the data
collector. While a client statement regarding the need to leave the
hospital is subjective in nature, it is not as strong an indicator of
anxiet y as is the verbalization of impending doom.
DIF: C REF: 241 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
,3. Which of the following questions asked by the nurse during the
assessment process is best d irected towards gathering information
regarding the clients depression?
A. Have you ever felt this depressed before?
B. What do you believe is the cause of your depression?
C. What makes you feel that you are experiencing depression?
D. What can we do to make you comf ortable while you are here?
ANS: B
This option is an open -ended question that encourages the client to
express his insight regarding his condition. This option is a closed -
ended question requiring onl y a yes or no response and so provides
minimal information regarding the clients condition. While this is an
open-ended question, it is not the best option because it is not directed
towards assessment of the clients current complaint. While this is an
open-ended question, it is not the best option because it is directed at
the clients comfort, not towards assessing his current complaint.
DIF: C REF: 234 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
4. Which of the following statements best r eflects the nurses correct
understanding of the importance of selecting the optimum time for
interviewing a client newl y admitted to the unit?
A. Im going to do the clients history before his famil y leaves so they
can help with the admission history questions .
B. You are scheduled for some x -rays, so Id like to complete this
admission history interview before you have to leave.
, C. I have some questions to ask you regarding your admission history.
Ill be back once you are settled in and comfortable.
D. Please let me kno w when the blood lab is finished with the new
client so I can complete his admission history interview.
ANS: C
Completion of the admission history is scheduled for a time when
interruptions by other staff or visiting famil y members are minimal.
The nurse should create an environment where the client feels
comfortable and the clients orientation to the room is completed. While
this may be appropriate if the client requires help with answering the
questions, it is not the best option because famil y and visi tors can be
distracting and may represent a confidentialit y problem. While the
history must be taken within a specific time period, rushing to
complete it before the client goes to radiology is not appropriate. The
interview requires the clients attention and cooperation. Attempting to
complete it immediatel y after a treatment or other intervention would
not be the best choice of time.
DIF: C REF: 239 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
5. The nurse is conducting an admissions history interview with a client who
has a history of gastroesophageal reflux disease (GERD). Which of the
following questions shows the best example of relevant questioning by the
nurse?
A. How long have you been dealing with GERD?
B. Are you currentl y taking any medications for your GERD?
C. Do you follow a particular diet to help manage your GERD?
Fundamentals of Nursing 10th Edi tion; Potter Perry
MULTIPLE CHOICE
1. An ER nurse is interviewing a client who complains of abdominal pain.
Which of the following questions asked by the nurse has priorit y at this
time?
A. Can you describe your pain?
B. Have you had this problem b efore?
C. What have you done to ease the pain?
D. When did your abdominal pain begin?
ANS: D
If a client presents to the emergency department with pain, the nurse
should first ask the client about the onset, severit y, and duration of the
pain. In an emergency situation, the clients current health problem
becomes the priorit y assessment. Gathering data about the problem
currentl y affecting the client has greater priorit y, but a description of
the pain does not have priorit y over onset. Asking the client about
medical history is appropriate but not at this time. The priority is to
assess the symptoms the client is experiencing. Gathering data about
the problem currently affecting the client has greater priorit y, but
attempted self -treatment does not have priorit y over onset.
, DIF: C REF: 236-237 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Health
Promotion and Maintenance
2. Which subjective assessment data are most supportive of a clients
diagnosis of anxiet y?
A. Diaphoretic and cool skin
B. An apical pulse rate of 120 beats per minute
C. Reports needing to leave now
D. Claims something is terribl y wrong
ANS: D
Subjective data are clients perceptions about their health problems. The
statement by the client regarding his sense of impending doom is the
best example of subjective data regarding his anxiet y because it is his
own verbalization of the problem. Cool, damp skin is an example of
objective data. Objective data are observations or measurements made
by the data collector. A pulse rate is an example of objective data.
Objective data are observations or measurements made by the data
collector. While a client statement regarding the need to leave the
hospital is subjective in nature, it is not as strong an indicator of
anxiet y as is the verbalization of impending doom.
DIF: C REF: 241 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
,3. Which of the following questions asked by the nurse during the
assessment process is best d irected towards gathering information
regarding the clients depression?
A. Have you ever felt this depressed before?
B. What do you believe is the cause of your depression?
C. What makes you feel that you are experiencing depression?
D. What can we do to make you comf ortable while you are here?
ANS: B
This option is an open -ended question that encourages the client to
express his insight regarding his condition. This option is a closed -
ended question requiring onl y a yes or no response and so provides
minimal information regarding the clients condition. While this is an
open-ended question, it is not the best option because it is not directed
towards assessment of the clients current complaint. While this is an
open-ended question, it is not the best option because it is directed at
the clients comfort, not towards assessing his current complaint.
DIF: C REF: 234 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
4. Which of the following statements best r eflects the nurses correct
understanding of the importance of selecting the optimum time for
interviewing a client newl y admitted to the unit?
A. Im going to do the clients history before his famil y leaves so they
can help with the admission history questions .
B. You are scheduled for some x -rays, so Id like to complete this
admission history interview before you have to leave.
, C. I have some questions to ask you regarding your admission history.
Ill be back once you are settled in and comfortable.
D. Please let me kno w when the blood lab is finished with the new
client so I can complete his admission history interview.
ANS: C
Completion of the admission history is scheduled for a time when
interruptions by other staff or visiting famil y members are minimal.
The nurse should create an environment where the client feels
comfortable and the clients orientation to the room is completed. While
this may be appropriate if the client requires help with answering the
questions, it is not the best option because famil y and visi tors can be
distracting and may represent a confidentialit y problem. While the
history must be taken within a specific time period, rushing to
complete it before the client goes to radiology is not appropriate. The
interview requires the clients attention and cooperation. Attempting to
complete it immediatel y after a treatment or other intervention would
not be the best choice of time.
DIF: C REF: 239 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Safe, Effective
Care Environment
5. The nurse is conducting an admissions history interview with a client who
has a history of gastroesophageal reflux disease (GERD). Which of the
following questions shows the best example of relevant questioning by the
nurse?
A. How long have you been dealing with GERD?
B. Are you currentl y taking any medications for your GERD?
C. Do you follow a particular diet to help manage your GERD?
