A client comes to the health care provider's office for a visit.
The client has been seen in this office for the past five years and
arrives today complaining of a fever and sore throat. Which type
of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment Correct Answer C
A client is having difficulty describing a chief complaint of
chest pain. Which action by the nurse would be most
appropriate?
A) Ignore the complaint for now and return to it later.
B) Provide a laundry list of descriptive words.
C) Restate the question using simple terms.
D) Wait in silence until the client can determine the correct
words. Correct Answer B
A client who had a mastectomy is being discharged home. The
client lives alone. Which data would be most important to
validate for this client?
A) If the client has transportation for follow-up appointments
B) If the client usually functions independently
C) What support systems are in place to assist the client
D) If the client has a religious belief regarding illness Correct
Answer C
A group of nursing students are reviewing the purposes of
assessment documentation in preparation for a class discussion.
, The students demonstrate understanding of the information
when they identify which of the following as one of the primary
purposes?
A) It provides a chronologic source of client assessment data.
B) It creates a data base for care that was not rendered to the
client.
C) It replaces the client acuity classification system.
D) It directly formulates the nursing diagnoses. Correct
Answer A
A group of students is reviewing information about auscultation
in preparation for a test. The students demonstrate understanding
of the material when they identify which of the following?
A) Auscultation can be performed through clothing.
B) The diaphragm should be held firmly against the body part.
C) The bell of the stethoscope can detect bowel sounds.
D) The binaurals connect the tubing to the chest piece. Correct
Answer B
A new graduate nurse asks another more experienced nurse
about the best way to assess a client's dietary habits. Which
suggestion would be most appropriate?
A) Ask the client to explain the food pyramid.
B) Obtain a 24-hour diet recall.
C) Ask about the contents of one meal.
D) Determine how often the client eats. Correct Answer B
A nurse determines that a client's data indicate the need for
medical and nursing interventions. The nurse would identify
which of the following?
A) Actual nursing diagnosis