many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability?
A) the American Diabetic Association (ADA)
B) the American Heart Association (AHA)
C) the Alzheimer's Association (AA)
D) the American Ophthalmology Association (AAO)
18. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?
A) A client with chest pain and diaphoresis for 1 hour
B) A client who is crying because they think they are pregnant
C) A client with fever, rash, and sore throat
D) A client with a 3-inch shallow laceration on the leg
19. The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.
A) "I feel so tired sometimes."
B) Weight: 145 lbs
C) Lungs clear to auscultation
D) Client reports a headache
E) "My parent died of a heart attack."
F) Pupils equal, round, and reactive to light
20. The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply.
A) Spiritual
B) Physiologic
C) Recreational
D) Sociocultural
E) Psychological
F) Developmental
21. The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply.
A) the client's medical diagnosis
B) recent abnormal laboratory findings
C) the client's recent divorce
D) the client's tonsillectomy 45 years ago
E) recent changes in the client's blood pressure readings
22. The nurse has gathered objective and subjective data during the initial client assessment at an acute care facility. At the end of the assessment, the nurse will make informed clinical judgments. Which statement(s) reflects what the nurse will do next? Select all that apply.
A) Identify medical problems that require immediate referral.
B) Identify client problems that require nursing care.
C) Identify how the family is affected by the client's health status.
D) Identify collaborative problems that require interdisciplinary care.
E) Identify need for client teaching and health promotion.
23. A nurse is completing an assessment that will involve gathering subjective and objective information. Which data would the nurse identify as objective? Select all that apply.
A) health care provider's report
B) BP 135/78, heart rate 74 beats/min, respirations 16 breaths/min
C) reported symptoms
D) family history
E) client's name, age, and occupation
24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which action should the nurse prioritize during assessment?
A) Use as much information as possible to understand the client's health in context.
B) Compare the assessment of the client with other clients in their age group.
C) Corroborate the client's statements with trusted sources like family members.
D) Ask another nurse for a second opinion on assessment findings.
25. During an assessment of a client with type 1 diabetes, the nurse learns that the client is having trouble paying for their prescribed insulin. What should the nurse do next after completing the physical examination?
A) Analyze cues gathered in the assessment.
B) Refer the client to social services.
C) Determine the appropriate nursing diagnosis.
D) Document the client's concern verbatim.
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 2, ASSESSMENT: STEP 1 OF THE NURSING PROCESS
5. A. Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Apply
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 5, Preparing for the Assessment
6. B. The comprehensive health assessment focuses on how the client's health status affects the activities of daily living and how the client's activities and choices affect health status. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. In addition, the nurse assesses how clients interact within their family and community, and how the clients' health status affects the family and community. In contrast, the health care provider performing a medical examination focuses primarily on the client's physiologic development status, with less focus on psychological, sociocultural, or spiritual well-being.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Understand
Integrated Process: Teaching/Learning
Page and Header: 2, Focus of Health Assessment in Nursing
7. A. Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Remember
Integrated Process: Teaching/Learning
Page and Header: 2, ASSESSMENT: STEP 1 OF THE NURSING PROCESS
8. A. A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any
problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process) Page and Header: 4, Types of Health Assessment
9. C. Once the nurse has gathered some basic data about a client, they need to reflect on personal feelings to ensure keeping an open mind and avoiding premature judgments that may alter the ability to collect accurate data and maintain objectivity. The other listed actions may be necessary, but none is accomplished through reflection.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Understand Integrated Process: Caring Page and Header: 5, Preparing for the Assessment
10. C. Appearance can be directly observed by the nurse and is considered objective data. Present concern, family history, and occupation are considered subjective as they are reported by the client.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process) Page and Header: 6, Collecting Objective Data
11. D. Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by implementing both physicianand nurse-prescribed interventions to reduce further complications. Nutrition (oral fluids, bedtime snack) and hygiene are most often considered to be independent nursing concerns.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Apply
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 7, ANALYZING CUES TO IDENTIFY CLIENT CONCERNS: STEP 2 OF THE NURSING PROCESS
12. C. A focused assessment gathers specific data for a particular client problem usually discovered during the physical exam. This assessment "focuses" on the particular problem only and does not cover areas unrelated to the problem.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Remember
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 4, Types of Health Assessment
13. D. An initial comprehensive assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. It does not form the basis for medical treatment. The client's "ABCs" are included, but this is not the primary focus of an initial assessment.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 3, Types of Health Assessment
14. C. The frequency of ongoing assessment is determined by the acuity of the client. This factor is more important than the nurse's liability, the client's age, or the protocols of the unit.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Remember
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 4, Types of Health Assessment
15. A. A focused assessment may occur in all health care settings. It is smaller in scope than a comprehensive assessment, but more in depth related to the problem being presented. It usually involves one or two body systems. Data gathered and analyzed will determine the cause of the client's report. A comprehensive assessment includes the collection of objective data (data gathered during a step-by-step physical examination) and subjective data (the client's perception of the health of all body parts or systems, past health history, family history, lifestyle and health practices, including overall functioning). An emergency assessment is a very rapid assessment performed in life-threatening
situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Remember
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 4, Types of Health Assessment
16. D. Objective data may be obtained by direct observation or physical examination using the four examination techniques of inspection, auscultation, palpation, and percussion. Cerumen in the ear (ear wax) is a normal objective finding during a physical examination and does not require immediate attention. Acne lesions on the face and upper chest may be a chronic condition and do not require immediate attention. Moist nasal mucosa is a common finding and does not require immediate attention. Usually, lymph nodes are small, distinct, and mobile. An enlarged lymph node suggests inflammation and requires an immediate follow-up with a reexamination of the area where it drains.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 6, Collecting Objective Data
17. C. The best choice to assess the client's cognitive domain would be to obtain a screening tool from the Alzheimer's Association (AA), which offers assistance related to diseases affecting cognitive abilities. Many tools are available for nurses to use to screen clients for health risks. Although the ADA, AHA, and AAO provide screening tools for the nurse to identify at-risk clients with heart disease, diabetes, or eye disease, the ADA, AHA, and AAO would not be the best resources to elicit a screening tool for cognitive function.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Apply
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 3, Using Evidence to Promote Health and Prevent Disease
18. A. In situations such as chest pain, an immediate assessment is needed to provide prompt treatment. The major and only concern during this type of assessment is to determine the status of the client's life-sustaining physical functions. The other clients do not have life-threatening conditions necessitating an emergency assessment.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analyze
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 4, Types of Health Assessment
19. A, D, E. Subjective data include information obtained from the client through interviewing and therapeutic communication skills and are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Feeling tired, reports of a headache, and the statement about the client's parent dying of a heart attack reflect subjective information. Weight, lung sounds, and pupil reaction are examples of objective data.
Format: Multiple Selection
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Analyze
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 5, Collecting Subjective Data
20. A, B, D, E, F. The purpose of a nursing health assessment is to collect holistic data to determine a client's level of functioning and make professional clinical judgments. Holistic data includes spiritual, physiologic, sociocultural, psychological, and developmental data. Recreational data is not specifically identified when completing a holistic assessment.
Format: Multiple Selection
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Remember
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 2, Focus of Health Assessment in Nursing
21. A, B, E. Priority data that will be needed to assist the nurse in making informed clinical judgments include the client's medical diagnosis, recent abnormal lab findings, and recent changes in blood pressure readings. Objective data may be directly observed by the nurse as well as by using the four techniques of physical examination: inspection, auscultation, palpation, and percussion. Objective data are also available in the client's health record. The client's recent divorce and the tonsillectomy 45 years ago are not priority data needed to form a database on which an informed clinical judgment will be made.
Format: Multiple Selection
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 5, Preparing for the Assessment
22. A, B, D, E. Informed clinical judgments will be developed by the nurse when medical problems are identified, particularly those that require immediate referral, need nursing and interdisciplinary care, and require client teaching and health promotion. How the family is affected by the client's health status is important, but not a priority immediately following the completion of the health assessment.
Format: Multiple Selection
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Safe and Effective Care Environment: Management of Care
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process) Page and Header: 3, Framework for Health Assessment in Nursing
23. A, B. The nurse collects objective data through observation and uses the four physical examination techniques of inspection, palpation, percussion, and auscultation. These techniques provide objective data about the client's body functions, such as temperature, heart rate, and respirations, and may also be obtained from the client's medical record. The client's medical/health record also contains reports from other health care professionals. Family history, biographical information such as the client's name, age, and occupation, in addition to the reported symptoms, are part of the subjective information the nurse receives from the client during the interview.
Format: Multiple Selection
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Understand
Integrated Process: Nursing Process (Clinical Problem-solving Process) Page and Header: 6, Collecting Objective Data
24. A. The client must be viewed holistically. Many systems are operating to create the context in which the client exists and functions. The nurse sees an individual client, but the accurate interpretation of what the nurse sees depends on perceiving the client in context. Culture, family, and community operate as systems interacting to form the context. Information and assessments do not normally need to be corroborated. The client's age is not the nurse's primary focus, nor should they be understood only in comparison to others their age.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Health Promotion and Maintenance
Cognitive Level: Apply
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 7, CONTEXTUAL FACTORS INFLUENCING CLIENT’S HEALTH STATUS
25. A. There are four steps of the assessment phase of the nursing process. During step 1, the nurse collects subjective data based on the client's experiences, feelings, sensations, and expectations. During step 2 of the assessment phase, the nurse analyzes and identifies cues in the assessment that will lead to the identification of a client concern (nursing problem). It is not appropriate to take action, like reaching out to social services, until the assessment is complete. Documentation occurs at the end of the assessment.
Format: Multiple Choice
Chapter 1: The Nurse’s Role in Health Assessment
Client Needs: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analyze
Integrated Process: Nursing Process (Clinical Problem-solving Process)
Page and Header: 7, ANALYZING CUES TO IDENTIFY CLIENT CONCERNS: STEP 2 OF THE NURSING PROCESS