Chapter 14: Assessing
1. A family presents to the emergency room with a 4 year old child who is crying and
reporting that his legs are itching and hurting. The parent explains that they were out
walking in the woods when the child went running off the path and into some tall weeds.
Which findings should the nurse prioritize in this assessment? Select all that apply.
a. 4 year old at 85 percentile of growth and development
b. Stating “my legs feel like they are burning”
c. Redness and blisters forming on both legs
d. Respirations 18 breath/min and regular
e. Crying and trying to scratch legs due to itching
f. ANSWER: B, C, E
2. When performing an assessment, the nurse should focus most on the developmental
stage of which client?
a. Toddler
3. Which nursing qualities are helpful in winning the confidence of clients when first caring
for them? Select all that apply.
a. Respect for client
b. Competence
c. Professionalism
d. Number of years in profession
e. Caring
f. ANSWER: A, B, C, E
4. When is the best time for a nurse to take a client’s health history?
a. As soon as possible after client presents for care
5. An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates
the nurse is an effective caregiver?
a. The nurse uses open-ended questions when working with a crying client.
6. After performing the admission assessment on an older adult client, the nurse notes the
following, “client observed fidgeting with covers; facial grimacing when turning from
side to side.” This documentation is an example of which type of data?
a. Objective
7. The nursing instructor is teaching students about assessment and the importance of
having baseline data when caring for clients. The instructor should inform the students
that its best to get baseline data is:
a. The initial comprehensive client assessment
8. The nurse is gathering subjective data from a client during an interview after a suicide
attempt. Which assessment data gathered by the nurse would be documented as
subjective data? Select all that apply.
a. Client states “I feel so sad all of the time”
b. Clothes visibly soiled and hair greasy
c. Blood pressure 140/82 mm Hg
d. Client states, “I am in pain.”
e. Ecchymosis on upper left arm
, f. ANSWER: A, D
9. A nurse caring for a client with a respiratory condition notices the client’s breathing
pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths
per minute. The nurse notes that this client’s vital signs are assessed once every shift, but
believes the assessment should be done more frequently. Who is responsible for
increasing the frequency of this client’s assessments?
a. The nurse
10. The nurse is performing an assessment on a newly admitted client and understands the
importance of validating all data. When is the BEST time to validate such data?
a. Both during the collection and at the end of the collection.
11. A nurse is preparing to interview a client who is newly admitted to the unit. Which
strategies will help establish a quiet, relaxed, and comfortable environment during the
interview? Select all that apply.
a. Leaving the door to the room open
b. Leaving the television on
c. Keeping the heat on high
d. Providing a proper seating arrangement
e. Maintaining a proper distance from the client
f. ANSWER: D, E
12. Which nursing skill uses all five senses?
a. Observation
13. The nursing is planning to do a physical assessment on a newly admitted client. The
assessment will review the systems. This means the nurse plans to:
a. Complete an exam of all body systems
14. A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue
is a client’s description of pain in the right leg?
a. Subjective
15. How should a nurse best document the assessment findings that have caused the nurse
to suspect that a client is depressed following a below-the-knee amputation?
a. “Client states, ‘I don’t see the point in trying anymore’.”
16. The nurse is assessing a 3-week-old infant who has not gained weight since birth. The
infant’s bowel sounds are present in all quadrants and breath sounds are clear to
auscultation. The infant’s mother reports that the child cries much of the night but sleeps
better in the daytime. The mother reports that the child only breastfeeds about four
times in a 24-hour time period and that the mother doesn’t seem to have much milk.
Which nursing diagnosis would be of highest priority for this client?
a. Ineffective breastfeeding
17. After conducting the initial assessment of a new resident of a long-term care facility, the
nurse is preparing to terminate the interview. Which question is the MOST appropriate
conclusion to the interview?
a. Is there anything else we should know in order to care for you better?
18. After collecting data from a client with respiratory distress, the nurse prioritizes the
client interventions to provide oxygen to the client first. This is an example of which
model for organizing data?
a. Hierarchy of Human Needs
1. A family presents to the emergency room with a 4 year old child who is crying and
reporting that his legs are itching and hurting. The parent explains that they were out
walking in the woods when the child went running off the path and into some tall weeds.
Which findings should the nurse prioritize in this assessment? Select all that apply.
a. 4 year old at 85 percentile of growth and development
b. Stating “my legs feel like they are burning”
c. Redness and blisters forming on both legs
d. Respirations 18 breath/min and regular
e. Crying and trying to scratch legs due to itching
f. ANSWER: B, C, E
2. When performing an assessment, the nurse should focus most on the developmental
stage of which client?
a. Toddler
3. Which nursing qualities are helpful in winning the confidence of clients when first caring
for them? Select all that apply.
a. Respect for client
b. Competence
c. Professionalism
d. Number of years in profession
e. Caring
f. ANSWER: A, B, C, E
4. When is the best time for a nurse to take a client’s health history?
a. As soon as possible after client presents for care
5. An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates
the nurse is an effective caregiver?
a. The nurse uses open-ended questions when working with a crying client.
6. After performing the admission assessment on an older adult client, the nurse notes the
following, “client observed fidgeting with covers; facial grimacing when turning from
side to side.” This documentation is an example of which type of data?
a. Objective
7. The nursing instructor is teaching students about assessment and the importance of
having baseline data when caring for clients. The instructor should inform the students
that its best to get baseline data is:
a. The initial comprehensive client assessment
8. The nurse is gathering subjective data from a client during an interview after a suicide
attempt. Which assessment data gathered by the nurse would be documented as
subjective data? Select all that apply.
a. Client states “I feel so sad all of the time”
b. Clothes visibly soiled and hair greasy
c. Blood pressure 140/82 mm Hg
d. Client states, “I am in pain.”
e. Ecchymosis on upper left arm
, f. ANSWER: A, D
9. A nurse caring for a client with a respiratory condition notices the client’s breathing
pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths
per minute. The nurse notes that this client’s vital signs are assessed once every shift, but
believes the assessment should be done more frequently. Who is responsible for
increasing the frequency of this client’s assessments?
a. The nurse
10. The nurse is performing an assessment on a newly admitted client and understands the
importance of validating all data. When is the BEST time to validate such data?
a. Both during the collection and at the end of the collection.
11. A nurse is preparing to interview a client who is newly admitted to the unit. Which
strategies will help establish a quiet, relaxed, and comfortable environment during the
interview? Select all that apply.
a. Leaving the door to the room open
b. Leaving the television on
c. Keeping the heat on high
d. Providing a proper seating arrangement
e. Maintaining a proper distance from the client
f. ANSWER: D, E
12. Which nursing skill uses all five senses?
a. Observation
13. The nursing is planning to do a physical assessment on a newly admitted client. The
assessment will review the systems. This means the nurse plans to:
a. Complete an exam of all body systems
14. A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue
is a client’s description of pain in the right leg?
a. Subjective
15. How should a nurse best document the assessment findings that have caused the nurse
to suspect that a client is depressed following a below-the-knee amputation?
a. “Client states, ‘I don’t see the point in trying anymore’.”
16. The nurse is assessing a 3-week-old infant who has not gained weight since birth. The
infant’s bowel sounds are present in all quadrants and breath sounds are clear to
auscultation. The infant’s mother reports that the child cries much of the night but sleeps
better in the daytime. The mother reports that the child only breastfeeds about four
times in a 24-hour time period and that the mother doesn’t seem to have much milk.
Which nursing diagnosis would be of highest priority for this client?
a. Ineffective breastfeeding
17. After conducting the initial assessment of a new resident of a long-term care facility, the
nurse is preparing to terminate the interview. Which question is the MOST appropriate
conclusion to the interview?
a. Is there anything else we should know in order to care for you better?
18. After collecting data from a client with respiratory distress, the nurse prioritizes the
client interventions to provide oxygen to the client first. This is an example of which
model for organizing data?
a. Hierarchy of Human Needs
