Deck 11: Assessing

Question 1

The nurse is greeting a newly admitted client.What statement should the nurse make to establish rapport with this client?

A)"Hello,I'm your nurse and I'll be taking care of you today."
B)"You're lucky-there are no students on the unit today."
C)"Good morning,is there anything you need right now?"
D)"Hi.If you need anything,put on your call light."

Answer 1

"Hello,I'm your nurse and I'll be taking care of you today."

Question 2

The nurse documents: "Client avoids eye contact and gives only vague,nonspecific answers to direct ing by the professional staff.Is quite animated (laughs aloud,smiles,uses hand gestures)in conversation with spouse." Which method of data collection does this documentation demonstrate?

A)Examining
B)Interviewing
C)Listening
D)Observing

Answer 2

Observing

Question 3

A newly admitted client is angry because nursing staff continue to ask the same s.What should the nurse respond to this client?

A)"In order to make sure all of your information is complete,I need to ask these questions."
B)"You're right.Let me know if there's anything you need right now."
C)"I'll be done shortly,just give me a few more minutes."
D)"You shouldn't be upset.We're only doing our jobs."

Answer 3

"You're right.Let me know if there's anything you need right now."

Question 4

A client in the emergency department has a non-life-threatening wound.The unit is busy with other clients,families,and people in the waiting room.How should the nurse conduct an interview with this client?

A)Have the client wait until the department quiets down,as the wound is not too serious.
B)Tell the client to wait in the waiting room and fill out the paperwork.
C)Draw curtains around the client and nurse to provide as much privacy as possible.
D)Make sure the client's back is to the rest of the room so as not to be heard by passersby.

Question 5

During an initial interview,the client says "I don't understand why I have to have surgery;I'm really not that sick or in pain right now." How should the nurse respond to the client?

A)"It's OK to be worried.Surgery is a big step."
B)"What kind of questions do you have about your surgery?"
C)"I think these are things you should be asking your doctor."
D)"Have you had surgery before?"

Question 6

A client is coming in to the clinic for the first time.In order for the nurse to allow the client the most comfort during the interview,what should the nurse do?

A)Sit next to the client,a few feet apart.
B)Sit behind a desk.
C)Stand at the side of the client's chair.
D)Stand at the counter to take notes during the interview.

Question 7

The nurse is completing a health history with a client who has complications from chronic asthma.Which open-ended should the nurse use?

A)"How would you describe your sleep pattern?"
B)"Can you describe your coughing pattern?"
C)"Is there anything that makes your breathing worse?"
D)"What medications are you on?"

Question 8

The nurse has just completed an admission interview with a new client.Which nursing statement indicates that the interview is in the closing phase?

A)"I'm going to set up your physical assessment now.Do you have any questions?"
B)"Tell me more about how you feel."
C)"Could you give examples of what types of other treatments you've had?"
D)"Is there anything you're worried about?"

Question 9

A nurse has been assigned a new client who cannot speak English.How should the nurse facilitate communication with this client?

A)Have a member of the housekeeping staff who speaks the same language translate.
B)Use the translation services supplied by the hospital.
C)Make sure a family member who does speak English is available.
D)Conduct the interview using hand gestures.

Question 10

While conducting a dressing change,the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing.In which phase of the nursing process is the nurse working?

A)Assessment
B)Diagnosis
C)Implementation
D)Evaluation

Question 11

The nurse is assessing a client's level of pain.Which open-ended should the nurse use for this situation?

A)"Is your pain worse at night?"
B)"What brought you to the clinic?"
C)"How has the pain impacted your life?"
D)"You're feeling down about having pain,aren't you?"

Question 12

A new client has been admitted to the care area.How soon should the nurse plan to complete a physical assessment on this patient?

A)1 hour
B)12 hours
C)48 hours
D)24 hours

Question 13

During an assessment,a client who is not very talkative appears pale,diaphoretic,and restless in the bed,and says "leave me alone." Which subjective data should the nurse document?

A)Restlessness
B)"Leave me alone"
C)Not talkative
D)Pale and diaphoretic

Question 14

A nurse has worked in the trauma critical care area for several years.Which noise may become indiscriminate for this particular nurse?

A)A client with audible breathing
B)Moaning of a client in pain
C)Whirring of ventilators
D)Co-orkers discussing their clients' conditions

Question 15

The student is learning the steps of the nursing process.What is the first thing that the student should realize about the purpose of this process?

A)Deliver care to a client in an organized way.
B)Implement a plan that is close to the medical model.
C)Identify client needs and deliver care to meet those needs.
D)Make sure that standardized care is available to clients.

Question 16

Family of a client demonstrating confusion state that this is not the client's usual behavior.How should the nurse document this data?

A)Inference
B)Subjective data
C)Objective data
D)Secondary subjective data

Question 17

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain.Which phase of the nursing process is this nurse implementing?

A)Assessment
B)Diagnosis
C)Implementation
D)Evaluation

Question 18

A client has been using the call light routinely throughout the evening.Upon entering the room,the nurse observes the following details.Organize them according to priority sequencing (1 is first priority;5 is least priority).
Standard Text: Click and drag the options below to move them up or down.

A)The family is at the bedside.
B)The IV pump is running on battery.
C)The ECG monitor shows tachycardia.
D)The client reports being restless.
E)O₂ tubing is not attached to wall regulator.

Question 19

A client has been admitted for acute dehydration,secondary to nausea and diarrhea.When is the best time for the nurse to conduct this client's interview?

A)As soon as the client gets to the floor
B)After the client has settled in and been oriented to the room
C)When the family is available to help
D)After the client has been medicated

Question 20

The nurse is admitting an infant to the care area.The parents and grandmother are present.What should the nurse use as the best source of data for this client?

A)Medical record from the child's birth
B)Grandmother
C)Parents
D)Admitting physician

Question 21

While preparing a client for a procedure,the nurse notes that the client has become unresponsive and respirations have become shallow.What type of assessment should the nurse complete at this time?

A)Initial assessment
B)Problem-focused assessment
C)Emergency assessment
D)Time-lapsed assessment

Question 22

The nurse manager observes a staff nurse perform actions within the nursing process.Which activities did the manager observe the nurse perform?
Standard Text: Select all that apply.

A)Notifying the surgeon that a postoperative client is experiencing an increase in temperature
B)Advocating for a client who is mentally incapable of expressing her needs
C)Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels
D)Documenting all clients' pain level responses after the administration of pain medication
E)Attending in-services on a new hydraulic lift to be used to support safe client care

Question 23

The nurse is reviewing the nursing process with a first-year nursing student.What should the nurse explain as being the purpose of the diagnosis phase?
Standard Text: Select all that apply.

A)Develop a list of problems.
B)Identify client strengths.
C)Develop a plan.
D)Specify goals and outcomes.
E)Identify problems that can be prevented.

Question 24

The nurse decides to seek wound care alternatives for a client's stasis ulcer that is not healing after treatment for 2 weeks.In which phase of the nursing process is the nurse functioning?

A)Diagnosis
B)Implementation
C)Evaluation
D)Assessment

Question 25

The nurse manager observes a new graduate nurse complete assessment activities for a newly admitted client.Which actions indicate that the graduate needs assistance with the assessment process?
Standard Text: Select all that apply.

A)Reviews client record
B)Establishes a database
C)Performs nursing actions
D)Reviews nursing literature
E)Determines client's strengths,risks,and problems

Question 26

The nurse suspects that a client with a history of injuries is a victim of abuse.What did the nurse use to come to this conclusion?

A)Observation of cues
B)Validation
C)Inference
D)Judgment

Question 27

The nurse is completing a health history with a newly admitted client.What information should the nurse include when asking about the history of the client's present illness?
Standard text: Select all that apply.

A)Allergies
B)Immunization record
C)When the symptoms started
D)Exact location of the problem
E)Things that aggravate the problem

Question 28

The nurse is conducting an interview with a new client.Which actions indicate that the nurse is implementing effective communication guidelines?
Standard Text: Select all that apply.

A)Looking directly at the client to ensure good eye contact
B)Managing the conversation to avoid periods of silence
C)Providing personal experiences to help the client focus
D)Sitting in a chair next to the client who is in bed
E)Keeping arms unfolded and in a relaxed position

Question 29

During an assessment interview,the client states that an elective surgical procedure will not be done because it does not fit into the client's life goals.Into which of Gordon's functional health patterns should the nurse identify this client's comment?

A)Cognitive/perceptual pattern
B)Coping/stress-tolerance pattern
C)Health-perception/health-management pattern
D)Value/belief pattern