NURS 100 Fundamentals of Nursing Assessment 1
UPDATED ACTUAL Questions and CORRECT Answers
• A nurse is caring for a client who has a terminal illness and is at the end of life.
The nurse should recognize that which of the following statements by the client's
partner indicates effective coping? -✓✓ "I am relying on support from our family
during this time."
(This statement indicates effective coping because the partner is relying on others
in the family for support during a time of crisis.)
• A nurse is assessing an older adult client's risk for falls. Which of the following
assessments should the nurse use to identify the client's safety needs? (Select all
that apply.) -✓✓ Pupil clarity
Visual fields
Visual acuity
-Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This
makes vision cloudy and creates halos around lights, which can increase the risk
for falls because clients cannot see items in their path clearly.
-Visual fields is correct. The nurse should use a finger to test the client's peripheral
vision by moving the finger out of range and then back into the visual field to
determine when the client sees the finger. Clients who have a visual field
impairment are at an increased risk for falls because they might not see objects
outside of their central vision and trip over them or bump into them and fall.
-Visual acuity is correct. The nurse should use a Snellen chart to assess distance
vision and a handheld card to assess near vision. Clients who wear eyeglasses
should wear them during the assessments. Clients who have impaired visual acuity
are at an increased risk for falls because they might not see objects in their path
and trip over them or bump into them and fall.
• A nurse is evaluating a client's use of a cane. Which of the following actions
should the nurse identify as an indication of correct use? -✓✓ The client holds the
cane on the stronger side of her body.
,(The client should hold the cane on the stronger side of her body to increase
support and maintain alignment.)
• A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
nurse plan for this client? -✓✓ Make sure the client wears a mask when outside her
room if there is construction in the area.
(An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from
breathing in any pathogens in the environment.)
• A nurse is providing discharge instructions to a client who will be using a walker.
Which of the following client statements indicates an understanding of the
teaching? -✓✓ "I will hire someone to trim the tree that hangs low over the stairs
of my front porch."
(Clearing stairs of any object that could cause the client to trip or require them to
bend over while walking will decrease the risk for falls.)
• A nurse is preparing to administer enoxaparin subcutaneously to a client. Which
of the following actions should the nurse take? -✓✓ Administer the medication
with the needle at a 45° angle.
(The nurse should insert the needle at a 45° to 90° angle for a subcutaneous
injection.)
• A nurse manager is preparing to review medication documentation with a group
of newly licensed nurses. Which of the following statements should the nurse
manager plan to include in the teaching? -✓✓ "Use the complete name of the
medication magnesium sulfate."
(The Institute for Safe Medication Practices designates that nurses and providers
write the complete medication name for magnesium sulfate when documenting
, medications to avoid any misinterpretation of MgSO4 as MSO4, which means
morphine sulfate.)
• A nurse is talking with the partner of a client who has dementia. The client's
partner expresses frustration about finding time to manage household
responsibilities while caring for their partner. The nurse should identify that the
partner is experiencing which of the following types of role-performance stress? -
✓✓ Role overload
(The partner's expression of frustration is an example of role overload, which refers
to having more responsibilities within a role than one person can manage.)
• A nurse is preparing an education program for staff about advocacy. Which of the
following information should the nurse include? -✓✓ Advocacy ensures clients'
safety, health, and rights.
(Advocacy is a key component of professional nurses' code of ethics. As a client
advocate, the nurse ensures clients' safety, health, and rights, including the right to
privacy, confidentiality, and refusal of care.)
• A nurse is caring for a client who has a new diagnosis of seizure disorder.
-Exhibit 1
Nurses' Notes
0800:Client awake, alert, oriented to person, place, and time. Preparing for
discharge today. No seizure activity recorded during the night. Discharge teaching
provided to client and partner regarding a new prescription for carbamazepine.
Taught importance of taking medication twice daily as prescribed, not to miss a
dose, and not to double a dose if one is missed. Advised client to avoid grapefruit
and grapefruit juice while taking carbamazepine. Reminded client that follow-up
laboratory tests and eye examinations will be necessary while on this medication.
Client and partner verbalized understanding of all medication teaching.
0900:On entry into client's room with discharge papers, client was found on the
floor seizing. Call button pressed to ask for additional help.
UPDATED ACTUAL Questions and CORRECT Answers
• A nurse is caring for a client who has a terminal illness and is at the end of life.
The nurse should recognize that which of the following statements by the client's
partner indicates effective coping? -✓✓ "I am relying on support from our family
during this time."
(This statement indicates effective coping because the partner is relying on others
in the family for support during a time of crisis.)
• A nurse is assessing an older adult client's risk for falls. Which of the following
assessments should the nurse use to identify the client's safety needs? (Select all
that apply.) -✓✓ Pupil clarity
Visual fields
Visual acuity
-Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This
makes vision cloudy and creates halos around lights, which can increase the risk
for falls because clients cannot see items in their path clearly.
-Visual fields is correct. The nurse should use a finger to test the client's peripheral
vision by moving the finger out of range and then back into the visual field to
determine when the client sees the finger. Clients who have a visual field
impairment are at an increased risk for falls because they might not see objects
outside of their central vision and trip over them or bump into them and fall.
-Visual acuity is correct. The nurse should use a Snellen chart to assess distance
vision and a handheld card to assess near vision. Clients who wear eyeglasses
should wear them during the assessments. Clients who have impaired visual acuity
are at an increased risk for falls because they might not see objects in their path
and trip over them or bump into them and fall.
• A nurse is evaluating a client's use of a cane. Which of the following actions
should the nurse identify as an indication of correct use? -✓✓ The client holds the
cane on the stronger side of her body.
,(The client should hold the cane on the stronger side of her body to increase
support and maintain alignment.)
• A nurse is initiating a protective environment for a client who has had an
allogeneic stem cell transplant. Which of the following precautions should the
nurse plan for this client? -✓✓ Make sure the client wears a mask when outside her
room if there is construction in the area.
(An allogeneic stem cell transplant compromises the client's immune system,
greatly increasing the risk for infection. The client will need protection from
breathing in any pathogens in the environment.)
• A nurse is providing discharge instructions to a client who will be using a walker.
Which of the following client statements indicates an understanding of the
teaching? -✓✓ "I will hire someone to trim the tree that hangs low over the stairs
of my front porch."
(Clearing stairs of any object that could cause the client to trip or require them to
bend over while walking will decrease the risk for falls.)
• A nurse is preparing to administer enoxaparin subcutaneously to a client. Which
of the following actions should the nurse take? -✓✓ Administer the medication
with the needle at a 45° angle.
(The nurse should insert the needle at a 45° to 90° angle for a subcutaneous
injection.)
• A nurse manager is preparing to review medication documentation with a group
of newly licensed nurses. Which of the following statements should the nurse
manager plan to include in the teaching? -✓✓ "Use the complete name of the
medication magnesium sulfate."
(The Institute for Safe Medication Practices designates that nurses and providers
write the complete medication name for magnesium sulfate when documenting
, medications to avoid any misinterpretation of MgSO4 as MSO4, which means
morphine sulfate.)
• A nurse is talking with the partner of a client who has dementia. The client's
partner expresses frustration about finding time to manage household
responsibilities while caring for their partner. The nurse should identify that the
partner is experiencing which of the following types of role-performance stress? -
✓✓ Role overload
(The partner's expression of frustration is an example of role overload, which refers
to having more responsibilities within a role than one person can manage.)
• A nurse is preparing an education program for staff about advocacy. Which of the
following information should the nurse include? -✓✓ Advocacy ensures clients'
safety, health, and rights.
(Advocacy is a key component of professional nurses' code of ethics. As a client
advocate, the nurse ensures clients' safety, health, and rights, including the right to
privacy, confidentiality, and refusal of care.)
• A nurse is caring for a client who has a new diagnosis of seizure disorder.
-Exhibit 1
Nurses' Notes
0800:Client awake, alert, oriented to person, place, and time. Preparing for
discharge today. No seizure activity recorded during the night. Discharge teaching
provided to client and partner regarding a new prescription for carbamazepine.
Taught importance of taking medication twice daily as prescribed, not to miss a
dose, and not to double a dose if one is missed. Advised client to avoid grapefruit
and grapefruit juice while taking carbamazepine. Reminded client that follow-up
laboratory tests and eye examinations will be necessary while on this medication.
Client and partner verbalized understanding of all medication teaching.
0900:On entry into client's room with discharge papers, client was found on the
floor seizing. Call button pressed to ask for additional help.
