Deck 34: Nursing Assessment

Question 1

What are the goals for performing a nursing assessment? Select all that apply.

A) Determining a client's health status
B) Identifying the client's possible risk factors
C) Confirming the client's actual problems
D) Using a structured format
E) Planning necessary interventions

Answer 1

Determining a client's health status
Identifying the client's possible risk factors
Confirming the client's actual problems

Question 2

What is an example of subjective data?

A) Twitching
B) Frowning
C) Tremoring
D) Cyanosis

Answer 2

Frowning

Question 3

Which information about the client's condition should the nurse identify as objective data?

A) Client is anxious
B) Size, location, and color of the wound
C) Client complaint of pain in the lower leg
D) Client reports urinary frequency

Answer 3

Size, location, and color of the wound

Question 4

Which statement identifies objective data concerning the client?

A) "My blood pressure is usually 130/82"
B) "I really feel nauseated."
C) "I've been really down since my brother died."
D) "It is such a beautiful day."

Question 5

A nurse is obtaining information about a client's heart condition. Which intervention should the nurse implement when assessing the client?

A) Consider the client's family history of similar ailments.
B) Conduct a physical examination only in the presence of the primary care provider.
C) Focus on physiologic factors when assessing the client.
D) Avoid questions about any folk remedies the client may be using.

Question 6

What type of observation is the nurse making when assessing a rash on the client's hands?

A) Olfactory
B) Auditory
C) Tactile
D) Visual

Question 7

Which assessment question should a nurse ask as part of the auditory observation of a client?

A) "I'm interested in hearing what you think the problem is?"
B) "Is it alright to listen to your heart?"
C) "Do you have any problems with your hearing?"
D) "Do you ever hear rumbling in your stomach?"

Question 8

A nurse is observing the progress of an older adult client started on a new medication for dementia. Which is a critical point for the nurse to consider when collecting subjective data about the client and the response to the new medication for dementia?

A) Assessing the client's body language and nonverbal gestures.
B) Exploring the importance of a cross that the client continuously holds.
C) Asking the client concise direct questions because of the dementia.
D) Requesting that a family member be present during the assessment.

Question 9

The nurse is preparing for the admission interview of the client. When collecting data, what information should the nurse classify as objective data? Select all that apply.

A) Vital signs
B) Laboratory tests
C) Client is afraid
D) Client reasons for seeking care
E) The client is a welder by trade

Question 10

The nurse is preparing for the admission interview of the client. When collecting data, what information should the nurse classify as subjective data? Select all that apply.

A) The client's height and weight
B) The client's description of their pain
C) Client's concern about paying for the visit
D) Client reasons for delaying the visit for 2 days
E) The client's temperature

Question 11

What information would be included in the documentation of the client's biographical data? Select all that apply.

A) Symptoms of recent disease
B) Birth date
C) Name
D) Family history of disease
E) Age

Question 12

What information would be documented in the recent health history of a client? Select all that apply.

A) Hypoactive bowel sound
B) Appendectomy 5 years ago
C) No bowel movement in 48 hours
D) Rate abdominal pain as a 6/10
E) Family history of colitis

Question 13

A nurse is conducting the nursing health interview with a client. Which types of information would be included in the activities of daily living section of the nursing history? Select all that apply.

A) Typical eating and drinking habits of the client
B) Psychosocial stability of the client
C) Symptoms of recent diseases or hospitalizations
D) Exercise routines practiced by the client
E) Sleep patterns of the client

Question 14

A nurse is analyzing the data collected from a client's medical interview. The client reported a prolonged cough that had lasted for one month, along with chest pain. The nurse reports the matter to the physician who concludes that the problem requires medical treatment. Which conclusion should the nurse make regarding the client's condition?

A) The client needs to put on a carbohydrate-restricted diet.
B) Additional information is needed before making a diagnosis.
C) The client's problems require a nursing diagnosis.
D) The client's problems require a medical diagnosis.

Question 15

A nurse is conducting the admission interview with a sexually active female client who is reporting warts in the vaginal area. What information should the nurse group with the above data to form a data cluster? Select all that apply.

A) Instances of unprotected sex
B) Number of sexual partners
C) Sexual orientation
D) Family history of sexual infections
E) Onset of menses

Question 16

A female client arrives at a healthcare facility stating, "I have a really bad case of heartburn." Which question should the nurse ask initially to validate this interpretation?

A) What was the last food you ate?
B) When did you eat last?
C) Do you have a history of digestive problems?
D) Can you rate your abdominal discomfort for me?

Question 17

A nurse is conducting the health interview with a client. While interpreting the data obtained from the health interview, which action should the nurse take to provide the most effective interpretation of this data?

A) Assigning equal significance to all the information.
B) Grouping similar data from the interview into clusters.
C) Refraining from revealing the conclusion of the interview to the client.
D) Focusing on the client's problems instead of the client's strengths.

Question 18

Which are examples of objective data? Select all that apply.

A) Restlessness
B) "Get out of my room and leave me alone"
C) Very quiet
D) Diaphoretic
E) Pale

Question 19

While recording the client's condition, what information should the nurse classify as subjective data? Select all that apply.

A) Client's blood pressure
B) Complains of nausea
C) Upset about brother's death
D) Client's frame of mind
E) Client's skin rash

Question 20

What is the nurse's primary responsibility to the client after collecting assessment data?

A) Admitting the client and initiating the medical record
B) Notifying healthcare provider of the client's health status
C) Working to identify nursing diagnoses and a plan of care.
D) Answering any questions the admitting primary care provider may have regarding the client's physical assessment.