1
TEST BANK FOR Health Assessment in Nursing 5th Edition Janet R.
Weber, Jane H. Kelley-latest-2023/2024
1. A nurse on a postsurgical unit is admitting a client following the client's
tk tk tk tk tk tk tk tk tk tk tk tk
cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
tk tk tk tk tk tk tk tk tk tk tk tk
this client?
tk tk
A) Collecting accurate data tk tk
B) Assisting the primary care provider tk tk tk tk
C) Validating previous data tk tk
D) Making clinical judgments tk tk
D) Making clinical judgments
tk tk tk
2. A client has presented to the emergency department (ED) with complaints of
tk tk tk tk tk tk tk tk tk tk tk
abdominal pain. Which member of the care team would most likely be responsible for
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
collecting the subjective data on the client during the initial comprehensive assessment?
tk tk tk tk tk tk tk tk tk tk tk tk
A) Gastroenterologist
B) ED nurse tk
C) Admissions clerk tk
D) Diagnostic technician tk
B) ED nurse
tk tk
3. The nurse has completed an initial assessment of a newly admitted client and is
tk tk tk tk tk tk tk tk tk tk tk tk tk
applying the nursing process to plan the client's care. What principle should the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
apply when using the nursing process?
tk tk tk tk tk tk
A) Each step is independent of the others.
tk tk tk tk tk tk
B) It is ongoing and continuous.
tk tk tk tk
C) It is used primarily in acute care settings.
tk tk tk tk tk tk tk
D) It involves independent nursing actions.
tk tk tk tk
B) It is ongoing and continuous.
tk tk tk tk
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
perform a comprehensive health assessment. Which of the following actions should the
tk tk tk tk tk tk tk tk tk tk tk tk
nurse perform first?
tk tk tk
A) Review the client's medical record. tk tk tk tk
B) Obtain basic biographic data. tk tk tk
C) Consult clinical resources explaining the client's diagnosis.
tk tk tk tk tk tk
D) Validate information with the client. tk tk tk tk
A) Review the client's medical record. tk tk tk tk
5. Which of the following client situations would the nurse interpret as requiring an
tk tk tk tk tk tk tk tk tk tk tk tk
emergency assessment?
tk tk
A) A pediatric client with severe sunburn
tk tk tk tk tk
B) A client needing an employment physical
tk tk tk tk tk
C) A client who overdosed on acetaminophen
tk tk tk tk tk
D) A distraught client who wants a pregnancy test
tk tk tk tk tk tk tk
C) A client who overdosed on acetaminophen
tk tk tk tk tk
6. In response to a client's query, the nurse is explaining the differences between the
tk tk tk tk tk tk tk tk tk tk tk tk tk
physician's medical exam and the comprehensive health assessment performed by the
tk tk tk tk tk tk tk tk tk tk tk
nurse. The nurse should describe the fact that the nursing assessment focuses on
tk tk tk tk tk tk tk tk tk tk tk tk tk
which aspect of the client's situation?
tk tk tk tk tk tk
A) Current physiologic status tk tk
B) Effect of health on functional statustk tk tk tk tk
, 2
C) Past medical history tk tk
D) Motivation for adherence to treatment tk tk tk tk
B) Effect of health on functional status
tk tk tk tk tk
7. After teaching a group of students about the phases of the nursing process, the
tk tk tk tk tk tk tk tk tk tk tk tk tk
instructor determines that the teaching was successful when the students identify which
tk tk tk tk tk tk tk tk tk tk tk tk
phase as being foundational to all other phases?
tk tk tk tk tk tk tk tk
A) Assessment
B) Planning
C) Implementation
D) Evaluation
A) Assessment
8. The nurse has completed the comprehensive health assessment of a client who has
tk tk tk tk tk tk tk tk tk tk tk tk
been admitted for the treatment of community-acquired pneumonia. Following the
tk tk tk tk tk tk tk tk tk tk
completion of this assessment, the nurse periodically performs a partial assessment
tk tk tk tk tk tk tk tk tk tk tk
primarily for which reason?
tk tk tk tk
A) Reassess previously detected problems tk tk tk
B) Provide information for the client's record tk tk tk tk tk
C) Address areas previously omitted tk tk tk
D) Determine the need for crisis intervention tk tk tk tk tk
A) Reassess previously detected problems tk tk tk
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
neighborhood. Which client would the nurse determine to be in most need of an
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
emergency assessment?
tk tk
A) A 14-year-old girl who is crying because she thinks she is pregnant
tk tk tk tk tk tk tk tk tk tk tk
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
tk tk tk tk tk tk tk tk tk tk
C) A 3-year-old child with fever, rash, and sore throat
tk tk tk tk tk tk tk tk
D) A 20-year-old man with a 3-inch shallow laceration on his leg
tk tk tk tk tk tk tk tk tk tk
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
tk tk tk tk tk tk tk tk tk tk
10. A nurse has completed gathering some basic data about a client who has multiple
tk tk tk tk tk tk tk tk tk tk tk tk tk
health problems that stem from heavy alcohol use. The nurse has then reflected on her
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
personal feelings about the client and his circumstances. The nurse does this primarily
tk tk tk tk tk tk tk tk tk tk tk tk tk
to accomplish which of the following?
tk tk tk tk tk tk
A) Determine if pertinent data has been omitted tk tk tk tk tk tk
B) Identify the need for referral tk tk tk tk
C) Avoid biases and judgments tk tk tk
D) Construct a plan of care tk tk tk tk
C) Avoid biases and judgments tk tk tk
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
diabetes and who will begin an educational program. The nurse is collecting subjective
tk tk tk tk tk tk tk tk tk tk tk tk tk
and objective data. Which of the following would the nurse categorize as objective
tk tk tk tk tk tk tk tk tk tk tk tk tk
data?
tk
A) Family history tk
B) Occupation
C) Appearance
D) History of present health concern tk tk tk tk
C) Appearance
tk
12. An older adult client has been admitted to the hospital with failure to thrive resulting
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
from complications of diabetes. Which of the following would the nurse implement in
tk tk tk tk tk tk tk tk tk tk tk tk tk
response to a collaborative problem?
tk tk tk tk tk
A) Encourage the client to increase oral fluid intake. tk tk tk tk tk tk tk
B) Provide the client with a bedtime protein snack. tk tk tk tk tk tk tk
C) Assist the client with personal hygiene.tk tk tk tk tk
D) Measure the client's blood glucose four times daily. tk tk tk tk tk tk tk
D) Measure the client's blood glucose four times daily.
tk tk tk tk tk tk tk tk
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
following clients. For which clients would the nurse most likely expect to facilitate a
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
, 3
A) An 80-year-old client who lives with her daughter
tk tk tk tk tk tk tk
B) A 50-year-old client newly diagnosed with diabetes
tk tk tk tk tk tk
C) An adult presenting for an influenza vaccination
tk tk tk tk tk tk
D) A teenager seeking information about contraception
tk tk tk tk tk
B) A 50-year-old client newly diagnosed with diabetes
tk tk tk tk tk tk
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
tk tk tk tk tk tk tk tk tk tk tk tk tk
instructor determines that the teaching was successful when the students identify which
tk tk tk tk tk tk tk tk tk tk tk tk
of the following as the major method used by nurses early in the history of the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
profession?
tk
A) Natural senses tk
B) Biomedical knowledge tk
C) Simple technology tk
D) Critical pathways tk
A) Natural senses tk
15. When describing the expansion of the depth and scope of nursing assessment over
tk tk tk tk tk tk tk tk tk tk tk tk
the past several decades, which of the following would the nurse identify as being the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
primary force?
tk tk
A) Documentation
B) Informatics
C) Diversification
D) Technology
D) Public mistrust of physicians tk tk tk
16. A group of nurses are reviewing information about the potential opportunities for
tk tk tk tk tk tk tk tk tk tk tk
nurses who have advanced assessment skills. When discussing phenomena that have
tk tk tk tk tk tk tk tk tk tk tk
contributed to these increased opportunities, what should the nurses identify?
tk tk tk tk tk tk tk tk tk tk
A) Expansion of health care networks tk tk tk tk
B) Decrease in client participation in care tk tk tk tk tk
C) The shrinking cost of medical caretk tk tk tk tk
D) Public mistrust of physicians tk tk tk
A) Expansion of health care networks tk tk tk tk
17. A nurse has documented the findings of a comprehensive assessment of a new
tk tk tk tk tk tk tk tk tk tk tk tk
client. What is the primary rationale that the nurse should identify for accurate and
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
thorough documentation?
tk tk
A) Guaranteeing a continual assessment process tk tk tk tk
B) Identifying abnormal data tk tk
C) Assuring valid conclusions from analyzed data tk tk tk tk tk
D) Allowing for drawing inferences and identifying problems tk tk tk tk tk tk
C) Assuring valid conclusions from analyzed data tk tk tk tk tk
18. A nurse has received a report on a client who will soon be admitted to the medical
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
unit from the emergency department. When preparing for the assessment phase of the
tk tk tk tk tk tk tk tk tk tk tk tk tk
nursing process, which of the following should the nurse do first?
tk tk tk tk tk tk tk tk tk tk tk
A) Collect objective data. tk tk
B) Validate important data. tk tk
C) Collect subjective data. tk tk
D) Document the data. tk tk
C) Collect subjective data.
tk tk tk
19. A community health nurse is assessing an older adult client in the client's home.
tk tk tk tk tk tk tk tk tk tk tk tk tk
When the nurse is gathering subjective data, which of the following would the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
identify?
tk
A) The client's feelings of happiness
tk tk tk tk
B) The client's posture tk tk
C) The client's affect tk tk
D) The client's behavior tk tk
A) The client's feelings of happiness
tk tk tk tk
20. A nurse on the hospital's subacute medical unit is planning to perform a client's
tk tk tk tk tk tk tk tk tk tk tk tk tk
focused assessment. Which of the following statements should inform the nurse's
tk tk tk tk tk tk tk tk tk tk tk
, 4
A) The focused assessment should be done before the physical exam.
tk tk tk tk tk tk tk tk tk
B) The focused assessment replaces the comprehensive database.
tk tk tk tk tk tk
C) The focused assessment addresses a particular client problem.
tk tk tk tk tk tk tk
D) The focused assessment is done after gathering subjective data.
tk tk tk tk tk tk tk tk
C) The focused assessment addresses a particular client problem.
tk tk tk tk tk tk tk tk
21. The nurse is reviewing a client's health history and the results of the most recent
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
physical examination. Which of the following data would the nurse identify as being
tk tk tk tk tk tk tk tk tk tk tk tk tk
subjective? Select all that apply.
tk tk tk tk tk
A) I feel so tired sometimes.
tk tk tk tk
B) Weight: 145 lbs tk tk
C) Lungs clear to auscultation tk tk tk
D) Client complains of a headache tk tk tk tk
E) My father died of a heart attack.
tk tk tk tk tk tk
F) Pupils equal, round, and reactive to light tk tk tk tk tk tk
A, D, E
tk tk tk
22. The nurse has been applying the nursing process in the care of an adult client who
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
is being treated for acute pancreatitis. Place the nurse's actions in their proper
tk tk tk tk tk tk tk tk tk tk tk tk tk
sequence from first to last.
tk tk tk tk tk
A) Identifying outcomes tk
B) Determining client's nursing problem tk tk tk
C) Collecting information about the client tk tk tk tk
D) Determining outcome achievement tk tk
E) Carrying out interventions tk tk
C, B, A, E, D
tk tk tk tk tk
C) Collecting information about the client tk tk tk tk
B) Determining client's nursing problem tk tk tk
A) Identifying outcomes
tk tk
E) Carrying out interventions tk tk
D) Determining outcome achievement tk tk
23. A nurse is completing an assessment that will involve gathering subjective and
tk tk tk tk tk tk tk tk tk tk tk
objective data. Which of the following assessment techniques will best allow the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk
to collect objective data?
tk tk tk tk
A) Inspection
B) Therapeutic communication tk
C) Interviewing
D) Active listening tk
A) Inspection
24. The nurse is performing a health assessment on a community-dwelling client who is
tk tk tk tk tk tk tk tk tk tk tk tk
recovering from hip replacement surgery. Which of the following actions should the
tk tk tk tk tk tk tk tk tk tk tk tk
nurse prioritize during assessment?
tk tk tk tk
A) Focus the assessment on the client as a member of her age group.
tk tk tk tk tk tk tk tk tk tk tk tk
B) Interpret the information about the client in context. tk tk tk tk tk tk tk
C) Corroborate the client's statements with trusted sources. tk tk tk tk tk tk
D) Gather information from a variety of sources. tk tk tk tk tk tk
B) Interpret the information about the client in context. tk tk tk tk tk tk tk
25. A client comes to the health care provider's office for a visit. The client has been
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
seen in this office on occasion for the past 5 years and arrives today complaining of a
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
fever and sore throat. Which type of assessment would the nurse most likely perform?
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
A) Comprehensive assessment tk
B) Ongoing assessment tk
C) Focused assessment tk
D) Emergency assessment tk
C) Focused assessment tk
26. A nurse has assessed a client who was admitted to the medical unit to treat acute
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
complications of type 1 diabetes. During the assessment, the client admitted that his
tk tk tk tk tk tk tk tk tk tk tk tk tk
blood sugar monitoring when he is at home is a bit sporadic. How should the nurse best
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
TEST BANK FOR Health Assessment in Nursing 5th Edition Janet R.
Weber, Jane H. Kelley-latest-2023/2024
1. A nurse on a postsurgical unit is admitting a client following the client's
tk tk tk tk tk tk tk tk tk tk tk tk
cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
tk tk tk tk tk tk tk tk tk tk tk tk
this client?
tk tk
A) Collecting accurate data tk tk
B) Assisting the primary care provider tk tk tk tk
C) Validating previous data tk tk
D) Making clinical judgments tk tk
D) Making clinical judgments
tk tk tk
2. A client has presented to the emergency department (ED) with complaints of
tk tk tk tk tk tk tk tk tk tk tk
abdominal pain. Which member of the care team would most likely be responsible for
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
collecting the subjective data on the client during the initial comprehensive assessment?
tk tk tk tk tk tk tk tk tk tk tk tk
A) Gastroenterologist
B) ED nurse tk
C) Admissions clerk tk
D) Diagnostic technician tk
B) ED nurse
tk tk
3. The nurse has completed an initial assessment of a newly admitted client and is
tk tk tk tk tk tk tk tk tk tk tk tk tk
applying the nursing process to plan the client's care. What principle should the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
apply when using the nursing process?
tk tk tk tk tk tk
A) Each step is independent of the others.
tk tk tk tk tk tk
B) It is ongoing and continuous.
tk tk tk tk
C) It is used primarily in acute care settings.
tk tk tk tk tk tk tk
D) It involves independent nursing actions.
tk tk tk tk
B) It is ongoing and continuous.
tk tk tk tk
4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
perform a comprehensive health assessment. Which of the following actions should the
tk tk tk tk tk tk tk tk tk tk tk tk
nurse perform first?
tk tk tk
A) Review the client's medical record. tk tk tk tk
B) Obtain basic biographic data. tk tk tk
C) Consult clinical resources explaining the client's diagnosis.
tk tk tk tk tk tk
D) Validate information with the client. tk tk tk tk
A) Review the client's medical record. tk tk tk tk
5. Which of the following client situations would the nurse interpret as requiring an
tk tk tk tk tk tk tk tk tk tk tk tk
emergency assessment?
tk tk
A) A pediatric client with severe sunburn
tk tk tk tk tk
B) A client needing an employment physical
tk tk tk tk tk
C) A client who overdosed on acetaminophen
tk tk tk tk tk
D) A distraught client who wants a pregnancy test
tk tk tk tk tk tk tk
C) A client who overdosed on acetaminophen
tk tk tk tk tk
6. In response to a client's query, the nurse is explaining the differences between the
tk tk tk tk tk tk tk tk tk tk tk tk tk
physician's medical exam and the comprehensive health assessment performed by the
tk tk tk tk tk tk tk tk tk tk tk
nurse. The nurse should describe the fact that the nursing assessment focuses on
tk tk tk tk tk tk tk tk tk tk tk tk tk
which aspect of the client's situation?
tk tk tk tk tk tk
A) Current physiologic status tk tk
B) Effect of health on functional statustk tk tk tk tk
, 2
C) Past medical history tk tk
D) Motivation for adherence to treatment tk tk tk tk
B) Effect of health on functional status
tk tk tk tk tk
7. After teaching a group of students about the phases of the nursing process, the
tk tk tk tk tk tk tk tk tk tk tk tk tk
instructor determines that the teaching was successful when the students identify which
tk tk tk tk tk tk tk tk tk tk tk tk
phase as being foundational to all other phases?
tk tk tk tk tk tk tk tk
A) Assessment
B) Planning
C) Implementation
D) Evaluation
A) Assessment
8. The nurse has completed the comprehensive health assessment of a client who has
tk tk tk tk tk tk tk tk tk tk tk tk
been admitted for the treatment of community-acquired pneumonia. Following the
tk tk tk tk tk tk tk tk tk tk
completion of this assessment, the nurse periodically performs a partial assessment
tk tk tk tk tk tk tk tk tk tk tk
primarily for which reason?
tk tk tk tk
A) Reassess previously detected problems tk tk tk
B) Provide information for the client's record tk tk tk tk tk
C) Address areas previously omitted tk tk tk
D) Determine the need for crisis intervention tk tk tk tk tk
A) Reassess previously detected problems tk tk tk
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
neighborhood. Which client would the nurse determine to be in most need of an
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
emergency assessment?
tk tk
A) A 14-year-old girl who is crying because she thinks she is pregnant
tk tk tk tk tk tk tk tk tk tk tk
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
tk tk tk tk tk tk tk tk tk tk
C) A 3-year-old child with fever, rash, and sore throat
tk tk tk tk tk tk tk tk
D) A 20-year-old man with a 3-inch shallow laceration on his leg
tk tk tk tk tk tk tk tk tk tk
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
tk tk tk tk tk tk tk tk tk tk
10. A nurse has completed gathering some basic data about a client who has multiple
tk tk tk tk tk tk tk tk tk tk tk tk tk
health problems that stem from heavy alcohol use. The nurse has then reflected on her
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
personal feelings about the client and his circumstances. The nurse does this primarily
tk tk tk tk tk tk tk tk tk tk tk tk tk
to accomplish which of the following?
tk tk tk tk tk tk
A) Determine if pertinent data has been omitted tk tk tk tk tk tk
B) Identify the need for referral tk tk tk tk
C) Avoid biases and judgments tk tk tk
D) Construct a plan of care tk tk tk tk
C) Avoid biases and judgments tk tk tk
11. The nurse is collecting data from a client who has recently been diagnosed with type 1
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
diabetes and who will begin an educational program. The nurse is collecting subjective
tk tk tk tk tk tk tk tk tk tk tk tk tk
and objective data. Which of the following would the nurse categorize as objective
tk tk tk tk tk tk tk tk tk tk tk tk tk
data?
tk
A) Family history tk
B) Occupation
C) Appearance
D) History of present health concern tk tk tk tk
C) Appearance
tk
12. An older adult client has been admitted to the hospital with failure to thrive resulting
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
from complications of diabetes. Which of the following would the nurse implement in
tk tk tk tk tk tk tk tk tk tk tk tk tk
response to a collaborative problem?
tk tk tk tk tk
A) Encourage the client to increase oral fluid intake. tk tk tk tk tk tk tk
B) Provide the client with a bedtime protein snack. tk tk tk tk tk tk tk
C) Assist the client with personal hygiene.tk tk tk tk tk
D) Measure the client's blood glucose four times daily. tk tk tk tk tk tk tk
D) Measure the client's blood glucose four times daily.
tk tk tk tk tk tk tk tk
13. The nurse at a busy primary care clinic is analyzing the data obtained from the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
following clients. For which clients would the nurse most likely expect to facilitate a
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
, 3
A) An 80-year-old client who lives with her daughter
tk tk tk tk tk tk tk
B) A 50-year-old client newly diagnosed with diabetes
tk tk tk tk tk tk
C) An adult presenting for an influenza vaccination
tk tk tk tk tk tk
D) A teenager seeking information about contraception
tk tk tk tk tk
B) A 50-year-old client newly diagnosed with diabetes
tk tk tk tk tk tk
14. An instructor is reviewing the evolution of the nurse's role in health assessment. The
tk tk tk tk tk tk tk tk tk tk tk tk tk
instructor determines that the teaching was successful when the students identify which
tk tk tk tk tk tk tk tk tk tk tk tk
of the following as the major method used by nurses early in the history of the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
profession?
tk
A) Natural senses tk
B) Biomedical knowledge tk
C) Simple technology tk
D) Critical pathways tk
A) Natural senses tk
15. When describing the expansion of the depth and scope of nursing assessment over
tk tk tk tk tk tk tk tk tk tk tk tk
the past several decades, which of the following would the nurse identify as being the
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
primary force?
tk tk
A) Documentation
B) Informatics
C) Diversification
D) Technology
D) Public mistrust of physicians tk tk tk
16. A group of nurses are reviewing information about the potential opportunities for
tk tk tk tk tk tk tk tk tk tk tk
nurses who have advanced assessment skills. When discussing phenomena that have
tk tk tk tk tk tk tk tk tk tk tk
contributed to these increased opportunities, what should the nurses identify?
tk tk tk tk tk tk tk tk tk tk
A) Expansion of health care networks tk tk tk tk
B) Decrease in client participation in care tk tk tk tk tk
C) The shrinking cost of medical caretk tk tk tk tk
D) Public mistrust of physicians tk tk tk
A) Expansion of health care networks tk tk tk tk
17. A nurse has documented the findings of a comprehensive assessment of a new
tk tk tk tk tk tk tk tk tk tk tk tk
client. What is the primary rationale that the nurse should identify for accurate and
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
thorough documentation?
tk tk
A) Guaranteeing a continual assessment process tk tk tk tk
B) Identifying abnormal data tk tk
C) Assuring valid conclusions from analyzed data tk tk tk tk tk
D) Allowing for drawing inferences and identifying problems tk tk tk tk tk tk
C) Assuring valid conclusions from analyzed data tk tk tk tk tk
18. A nurse has received a report on a client who will soon be admitted to the medical
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
unit from the emergency department. When preparing for the assessment phase of the
tk tk tk tk tk tk tk tk tk tk tk tk tk
nursing process, which of the following should the nurse do first?
tk tk tk tk tk tk tk tk tk tk tk
A) Collect objective data. tk tk
B) Validate important data. tk tk
C) Collect subjective data. tk tk
D) Document the data. tk tk
C) Collect subjective data.
tk tk tk
19. A community health nurse is assessing an older adult client in the client's home.
tk tk tk tk tk tk tk tk tk tk tk tk tk
When the nurse is gathering subjective data, which of the following would the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
identify?
tk
A) The client's feelings of happiness
tk tk tk tk
B) The client's posture tk tk
C) The client's affect tk tk
D) The client's behavior tk tk
A) The client's feelings of happiness
tk tk tk tk
20. A nurse on the hospital's subacute medical unit is planning to perform a client's
tk tk tk tk tk tk tk tk tk tk tk tk tk
focused assessment. Which of the following statements should inform the nurse's
tk tk tk tk tk tk tk tk tk tk tk
, 4
A) The focused assessment should be done before the physical exam.
tk tk tk tk tk tk tk tk tk
B) The focused assessment replaces the comprehensive database.
tk tk tk tk tk tk
C) The focused assessment addresses a particular client problem.
tk tk tk tk tk tk tk
D) The focused assessment is done after gathering subjective data.
tk tk tk tk tk tk tk tk
C) The focused assessment addresses a particular client problem.
tk tk tk tk tk tk tk tk
21. The nurse is reviewing a client's health history and the results of the most recent
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
physical examination. Which of the following data would the nurse identify as being
tk tk tk tk tk tk tk tk tk tk tk tk tk
subjective? Select all that apply.
tk tk tk tk tk
A) I feel so tired sometimes.
tk tk tk tk
B) Weight: 145 lbs tk tk
C) Lungs clear to auscultation tk tk tk
D) Client complains of a headache tk tk tk tk
E) My father died of a heart attack.
tk tk tk tk tk tk
F) Pupils equal, round, and reactive to light tk tk tk tk tk tk
A, D, E
tk tk tk
22. The nurse has been applying the nursing process in the care of an adult client who
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
is being treated for acute pancreatitis. Place the nurse's actions in their proper
tk tk tk tk tk tk tk tk tk tk tk tk tk
sequence from first to last.
tk tk tk tk tk
A) Identifying outcomes tk
B) Determining client's nursing problem tk tk tk
C) Collecting information about the client tk tk tk tk
D) Determining outcome achievement tk tk
E) Carrying out interventions tk tk
C, B, A, E, D
tk tk tk tk tk
C) Collecting information about the client tk tk tk tk
B) Determining client's nursing problem tk tk tk
A) Identifying outcomes
tk tk
E) Carrying out interventions tk tk
D) Determining outcome achievement tk tk
23. A nurse is completing an assessment that will involve gathering subjective and
tk tk tk tk tk tk tk tk tk tk tk
objective data. Which of the following assessment techniques will best allow the nurse
tk tk tk tk tk tk tk tk tk tk tk tk tk
to collect objective data?
tk tk tk tk
A) Inspection
B) Therapeutic communication tk
C) Interviewing
D) Active listening tk
A) Inspection
24. The nurse is performing a health assessment on a community-dwelling client who is
tk tk tk tk tk tk tk tk tk tk tk tk
recovering from hip replacement surgery. Which of the following actions should the
tk tk tk tk tk tk tk tk tk tk tk tk
nurse prioritize during assessment?
tk tk tk tk
A) Focus the assessment on the client as a member of her age group.
tk tk tk tk tk tk tk tk tk tk tk tk
B) Interpret the information about the client in context. tk tk tk tk tk tk tk
C) Corroborate the client's statements with trusted sources. tk tk tk tk tk tk
D) Gather information from a variety of sources. tk tk tk tk tk tk
B) Interpret the information about the client in context. tk tk tk tk tk tk tk
25. A client comes to the health care provider's office for a visit. The client has been
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
seen in this office on occasion for the past 5 years and arrives today complaining of a
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
fever and sore throat. Which type of assessment would the nurse most likely perform?
tk tk tk tk tk tk tk tk tk tk tk tk tk tk
A) Comprehensive assessment tk
B) Ongoing assessment tk
C) Focused assessment tk
D) Emergency assessment tk
C) Focused assessment tk
26. A nurse has assessed a client who was admitted to the medical unit to treat acute
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
complications of type 1 diabetes. During the assessment, the client admitted that his
tk tk tk tk tk tk tk tk tk tk tk tk tk
blood sugar monitoring when he is at home is a bit sporadic. How should the nurse best
tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk tk
