Deck 16: Nursing Assessment

Question 1

After visiting with the client,the nurse documents the assessment data.Both objective and subjective information have been obtained during the assessment.Which of the following is classified as subjective data?
1) "Client appears sleepy"
2) "No physical distress noted"
3) "Abdomen soft and non-tender"
4) "States feels anxious and tense"

Answer 1

4
Subjective data are clients' perceptions about their health problems.Feeling anxious and tense is information that only the client can provide.Objective data are observations or measurements made by the data collector.In this example,the data collector is making the observation that the client appears sleepy."No physical distress noted" is an example of objective data because it is an observation made by the data collector."Abdomen soft and non-tender" is an example of objective data because it is an observation made by the data collector,not a client's perception.

Question 2

Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression?
1) "Have you ever felt this depressed before?"
2) "What do you believe is the cause of your depression?"
3) "What makes you feel that you are experiencing depression?"
4) "What can we do to make you comfortable while you are here?"

Answer 2

2
This option is an open-ended question that encourages the client to express his insight regarding his condition.This option is a closed-ended question requiring only a yes or no response and so provides minimal information regarding the client's condition.While this is an open-ended question,it is not the best option because it is not directed towards assessment of the client's current complaint.While this is an open-ended question,it is not the best option because it is directed at the client's comfort,not towards assessing his current complaint.

Question 3

When clustering data according to functional health patterns,the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care.The health pattern that requires intervention is identified by the nurse as:
1) Respiratory
2) Activity and exercise
3) Sleep and rest pattern
4) Self-care deficit: activities of daily living

Answer 3

2
Using the functional health pattern format,the nurse clusters data that pertain to a functional health category.Fatigue upon ambulating short distances and requiring frequent periods of rest are examples of data belonging to the category of activity and exercise."Respiratory" would be found in a systems approach of health assessment,not a functional health pattern assessment.The functional health pattern category of sleep and rest would focus more on the number of hours of sleep the client obtains,use of sleep aids,and any difficulties associated with sleep.Self-care deficit: activities of daily living would include such aspects as bathing,feeding,and dressing self.The symptoms described would be clustered more accurately under the functional health pattern category of activity and exercise.

Question 4

The client recently became febrile and stated he "felt hot." The nurse takes the client's temperature and finds it to be 38.2° C.In addition,the pulse rate is 88 beats per minute,and his blood pressure is 168/80 mm Hg.Which of the following is an example of subjective data?
1) Pulse rate of 88 beats per minute
2) Blood pressure of 168/80 mm Hg
3) The statement regarding his feeling hot
4) The supported fact that he became febrile

Question 5

The nurse is going to perform the admission history for a newly admitted client on the medical unit.The optimum time for completion of the history is planned for:
1) Coordination with the physician's visit
2) The time when the client's family are visiting
3) Immediately before the client's scheduled MRI testing
4) After the client has become comfortably oriented to the room

Question 6

The nurse has completed an assessment and found that the client has "an activity and exercise abnormality." This type of wording indicates that which of the following organizing formats has been used?
1) Review of systems
2) Nursing health history
3) Gordon's functional health patterns
4) Biographical information database

Question 7

The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the:
1) Client
2) Physician
3) Family member
4) Experienced unit nurse

Question 8

An ER nurse is interviewing a client who complains of abdominal pain.Which of the following questions asked by the nurse has priority at this time?
1) "Can you describe your pain?"
2) "Have you had this problem before?"
3) "What have you done to ease the pain?"
4) "When did your abdominal pain begin?"

Question 9

The nurse decides to interview the client using the open-ended question technique.Which of the following statements reflects this type of questioning?
1) "Is your pain worse or better than it was an hour ago?"
2) "Do you believe that your nausea is from the new antibiotic?"
3) "What do you think has been causing your current depression?"
4) "What have you done to alleviate the side effects from your medications?"

Question 10

The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about:
1) A family history of heart problems
2) Medications currently being taken at home
3) Questions or concerns about hospitalization
4) The onset,severity,and duration of the chest pain

Question 11

During the admission history,the client states that he has trouble breathing at night.In obtaining data for a problem-oriented database,the nurse should first question the client about:
1) The onset and duration of his present breathing problem
2) His personal smoking,alcohol use,and exercise practices
3) Any extended family members who have diagnosed heart disease
4) Changes in other body systems that the client perceives as problematic

Question 12

A nurse seeks to organize the data obtained from the client in a logical manner.The organizational method that identifies relationships between factors and symptoms in the database is known as:
1) Clustering data
2) Validating data
3) Peer reviewing
4) Problem statement

Question 13

Which of the following statements best reflects the nurse's correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?
1) "I'm going to do the client's history before his family leaves so they can help with the admission history questions."
2) "You are scheduled for some x-rays,so I'd like to complete this admission history interview before you have to leave."
3) "I have some questions to ask you regarding your admission history.I'll be back once you are settled in and comfortable."
4) "Please let me know when the blood lab is finished with the new client so I can complete his admission history interview."

Question 14

The nurse is conducting an interview with the client and wants to clarify information that the client has shared.Which response by the nurse is an example of the clarifying technique of communication?
1) "I understand how you must feel."
2) "This medication is used to lower your blood pressure."
3) "You appear anxious.You're wringing your hands constantly."
4) "Could you give me an example of how you handle stressors?"

Question 15

After visiting with the client,the nurse documents the assessment data.Both objective and subjective information has been obtained during the assessment.Which of the following is classified as objective data?
1) Pain in the left leg
2) Elevated blood pressure
3) Fear of impending surgery
4) Discomfort upon breathing

Question 16

During an interview,the nurse needs to obtain specific information about the signs and symptoms of the client's health problem.To obtain these data most efficiently,the nurse should use:
1) Channeling
2) Open-ended questions
3) Closed-ended questions
4) Problem-seeking responses

Question 17

The nurse is gathering a nursing health history on the client.The client tells the nurse that he just lost his job.Job loss best fits into which of the following categories?
1) Family history
2) Psychosocial history
3) Biographical history
4) Environmental history

Question 18

The process of data collection should begin with the nurse performing a:
1) Physical exam
2) Client interview
3) Review of medical records
4) Discussion with other health team members

Question 19

A client interview consists of three phases.The nurse recognizes that those phases are:
1) Orientation,working,termination
2) Introduction,controlling,selection
3) Introduction,assessment,conclusion
4) Orientation,documentation,database

Question 20

Which subjective assessment data are most supportive of a client's diagnosis of anxiety?
1) Diaphoretic and cool skin
2) An apical pulse rate of 120 beats per minute
3) Reports "needing to leave now"
4) Claims "something is terribly wrong"

Question 21

The nurse realizes that in order to share information from a client's medical record with another facility,the client must provide written consent.The primary reason for this requirement is to:
1) Facilitate the exchange of information between appropriate parties
2) Minimize the opportunity for this information to be assessed inappropriately
3) Ensure the client's right to have his medical information regarded as personal and confidential
4) Guarantee that the information will be shared with only those requiring it for client care purposes

Question 22

Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs?
1) "Do you have a religious preference?"
2) "Have you given thought to your spiritual needs?"
3) "Is there a particular clergy you would like to visit with?"
4) "Are there any spiritual needs you have that I may help with?"

Question 23

What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift?
1) Document the request in the nursing notes.
2) Include the client's request in the shift report.
3) Place instructions regarding the client's wishes above the client's bed.
4) Verbally inform the unit clerk of the client's request.

Question 24

A new graduate nurse missed cues regarding the client's emotional state at the time of admission.The most therapeutic response to the nurse by her mentor is:
1) "That is why we perform assessments at least daily;so we can catch missed cues."
2) "Everyone has missed cues;don't be too hard on yourself and just keep trying."
3) "You will be less likely to miss client cues as you acquire more experience with assessments."
4) "The positive side to making this mistake is that you won't miss those cues again in another client."

Question 25

The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder.Which of the following nursing questions has priority when determining the nature of the pain?
1) "What makes the pain worse?"
2) "When did you first notice the pain?"
3) "What do you do to lessen the pain?"
4) "Can you rate your pain using the pain scale that we've discussed?"

Question 26

The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship.Which of the following has the greatest impact on minimizing this obstacle?
1) Speaking slowly,clearly,and in a normal tone
2) Using various forms of nonverbal communication
3) Relying heavily on touch to convey caring and interest
4) Involving family in discussions concerning meeting client's needs

Question 27

Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized?
1) "Mom falls asleep fastest with the television on."
2) "Dad starts off the day with hot coffee;it regulates his bowels."
3) "My wife's sister died 4 months ago,and she is still grieving over her loss."
4) "My husband doesn't like to let people know his arthritis is bothering him."

Question 28

When obtaining subjective assessment data,the nurse recognizes which of the following client scenarios as being the most likely to produce accurate,credible information?
1) A 50-year-old in the ED reporting chest pain
2) A 70-year-old admitted with fever of unknown origin
3) A 81-year-old receiving follow-up treatment for a hip replacement
4) A 22-year-old being treated at a clinic for a sexually transmitted disease

Question 29

When following up on a client's report of hip pain during an admission assessment,the most nursing conclusive observation would be:
1) The client tearing when being ambulated to the chair
2) A report from the ancillary staff that the client is reporting pain
3) The client observed grimacing when positioning self in the bed
4) Overhearing the client discuss hip pain with family on the phone

Question 30

The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD).Which of the following questions shows the best example of relevant questioning by the nurse?
1) "How long have you been dealing with GERD?"
2) "Are you currently taking any medications for your GERD?"
3) "Do you follow a particular diet to help manage your GERD?"
4) "Do you have any other gastrointestinal problems besides GERD?"

Question 31

While discussing a client's medication history,the client tells the nurse that she thinks she is allergic to a particular type of medication.Which of the following nursing actions has priority in this situation?
1) Note the allergy on the client's Kardex.
2) Inform the provider of the client's possible allergy.
3) Review the client's medical record for confirmation of the allergy.
4) Tell the client to have all medications identified before taking them.

Question 32

A nurse is observed conducting an assessment interview for a newly admitted client.Which of the following would require immediate follow-up by the nurse's mentor?
1) Conducting the interview with the client's boyfriend present
2) Stopping the interview to answer a page from the nursing station
3) Frequently checking the time while waiting for the client to answer
4) Heard asking the client,"Am I correct;you've rated your pain a 9 out of 10?"