Question 1

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

Accepted Answer

Assessment is an ongoing process, and data should be collected continuously to ensure accurate and up-to-date information about the client's condition.

Question 2

Of the following information collected during a nursing assessment, which are subjective data?

Accepted Answer

Subjective data are those that are reported by the patient, such as feelings or symptoms. Nausea and abdominal pain are both subjective symptoms that the patient would report.

Question 3

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?

Accepted Answer

A

Question 4

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?

Accepted Answer

This question encourages the patient to provide more information about their pain and can help the healthcare provider understand the cause of the pain.

Answer: B
 This question assesses whether the patient's symptoms have improved or worsened, which is important in determining the effectiveness of current treatment or the need for further evaluation.

Answer: A and D
 These statements are not appropriate as they sound judgmental and may make the patient feel defensive or uncomfortable. It is important to maintain a non-judgmental attitude during the interview to encourage the patient to share as much information as possible.

Question 5

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

Accepted Answer

The purpose of the initial assessment is to establish a database or baseline of the client's health status, which will be used to identify both problems and strengths throughout their hospitalization. This data will inform the client's plan of care and help the healthcare team monitor their progress. Option A is incorrect because the assessment is not solely focused on a specific health problem, but rather a comprehensive evaluation of the client. Option B is incorrect because while identifying life-threatening problems is important, it is not the sole purpose of the initial assessment. Option C is incorrect because although the nurse may compare and contrast current health status to baseline data, the primary purpose is to gather data and establish a database.

Question 6

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make?

Accepted Answer

The safety of the client's immediate environment is an important observation for the nurse to make to ensure the client's well-being and prevent potential hazards or accidents. While the other options may be relevant in some contexts, they are not as important as the safety of the environment.

Question 7

When documenting subjective data, the nurse should do which of the following?

Accepted Answer

Using the client's own words in quotation marks when documenting subjective data promotes accurate communication and prevents misinterpretation or bias. It also helps to paint a clear picture of the client's experiences and perspective.

Question 8

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual?

Accepted Answer

Option C recognizes the client's value as an individual by directly addressing him, acknowledging his ability to care for himself, and asking for his input. The other options either ignore the client or suggest that he is not capable of contributing to the conversation.

Question 9

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?

Accepted Answer

The Human Needs (Maslow) model is based on a hierarchy of five life requirements universal to all persons, which the nurse is using as a guide for the systematic collection of assessment data.

Question 10

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Accepted Answer

The second assessment is a time-lapsed assessment, which is performed to track changes in the client's status over time and make necessary revisions in the plan of care.

Question 11

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?

Accepted Answer

Subjective data is information provided by the client that cannot be measured or observed, such as symptoms or feelings. Nausea is a subjective symptom that the client would report to the nurse, whereas the other options are all objective data that can be measured or observed directly.

Question 12

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?

Accepted Answer

Encouraging the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward is a form of peer review and validation, which can help prevent errors in interpretation. It also provides an opportunity for the novice nurse to learn from a more experienced peer. Encouraging the novice nurse to develop their own tool for data collection (B) may be helpful, but it does not address the incorrect interpretation issue. Repeatedly collecting and interpreting the data (C) may also be useful, but it is time-consuming and may not necessarily lead to a correct interpretation. Seeking mentoring for communication skills (D) is also important, but it may not directly address the issue of incorrect interpretation.

Question 13

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?

Accepted Answer

To confirm the inference of a fever, the nurse should measure the client's temperature. This will provide objective data to guide further interventions. Asking for assistance, providing comfort measures, or obtaining blood cultures may be appropriate, but the nurse should first confirm the fever with a temperature measurement.

Question 14

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?

Accepted Answer

Since the client has been seen for this problem before, the nurse would perform a focused assessment, which is a targeted assessment that focuses on the current issue or problem. This is different from an initial assessment, which is a comprehensive assessment done on a new client, an emergency assessment, which is done in a critical or life-threatening situation, and a time-lapsed assessment, which is done to evaluate changes over time.

Question 15

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status?

Accepted Answer

The nurse assessed respiratory status to identify a life-threatening problem. In this scenario, the resident's ability to breathe was compromised and required immediate intervention such as CPR.

Question 16

Which of the following questions or statements would be an appropriate termination of the health history interview?

Accepted Answer

Option B, "Can you think of anything else you would like to tell me?" is appropriate because it gives the patient an opportunity to share any additional information they think is important, ensuring that the health history is as comprehensive as possible. It demonstrates openness and encourages further communication.

Question 17

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?

Accepted Answer

Sitting at a 45-degree angle to the bed allows the nurse to maintain eye contact with the client and to have access to the client's medical chart and bedside table. This position also makes it easier for the nurse to hear the client and allows for ease of communication.

Question 18

What is the primary purpose of validation as a part of assessment?

Accepted Answer

The primary purpose of validation as a part of assessment is to plan appropriate nursing care. Validation helps to ensure that the data collected is accurate and relevant to the patient's current health status, which is essential for developing a comprehensive and effective nursing care plan. While effective nurse-client communication and maintaining relationships with coworkers are important aspects of nursing practice, these are not the primary purposes of validation.

Question 19

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond?

Accepted Answer

This response shows empathy and asks a relevant follow-up question to gain more information about the woman's constipation. It also acknowledges her concern and may help the nurse identify potential causes or solutions for her discomfort. The other answer choices are not appropriate or relevant to the woman's complaint.

Question 20

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?

Accepted Answer

Objective data is measurable and verifiable, and in this case, the inability to palpate a femoral pulse is a verifiable finding. The other choices include subjective data as they are based on the patient's own perceptions and feelings.

Quiz 11: Assessing