Chapter 15: Nursing Assessment Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. A client interview consists of three phases. The nurse recognizes that those phases are:

a.

Introduction, assessment, conclusion

b.

Orientation, documentation, database

c.

Introduction, controlling, selection

d.

Orientation, working, termination

ANS: d

d. The three phases of an interview are orientation, working, and termination.

a. These are not the three phases of an interview.

b. These are not the three phases of an interview.

c. These are not the three phases of an interview.

REF: Text Reference: p. 285

2. 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:

a.

The onset and duration of his present breathing problem

b.

His smoking and exercise practices

c.

Any family members who have heart disease

d.

Changes in other body systems

ANS: a

a. A clients database originates with the clients perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the clients story more fully to describe and identify the clients specific problems.

b. Habits and lifestyle patterns such as smoking and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem.

c. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow up with questions relevant to the nature and onset of symptoms.

d. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow up by using a problem-oriented approach. This would include asking specific questions about the clients health problem, such as the nature and onset of symptoms.

REF: Text Reference: p. 283, Text Reference: p. 290

3. The client has come to the emergency department experiencing chest pain. In this situation the nurse begins the assessment by asking the client about:

a.

A family history of heart problems

b.

Medications taken at home

c.

Concerns about hospitalization

d.

The severity and duration of the chest pain

ANS: d

d. If a client appears in the emergency department with chest pain, the nurse should first ask the client about the severity and duration of the chest pain. In an emergency situation, the clients current health problem becomes the priority assessment.

a. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority.

b. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing.

c. Asking the client about concerns regarding hospitalization is not the priority.

REF: Text Reference: p. 283

4. A nurse seeks to organize the data obtained from the client in a logical manner. This organization that identifies relations between factors and symptoms in the database is known as:

a.

Clustering data

b.

Validating data

c.

Formulating a problem statement

d.

Performing a peer review

ANS: a

a. Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relations between factors and symptoms.

b. Validating data means to compare the data obtained with another source to ensure its accuracy.

c. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis.

d. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers.

REF: Text Reference: p. 293

5. The client recently became febrile and stated he felt hot. You take the clients temperature and find it to be 38.2 c. In addition, the pulse is 88/beats per minute, and his blood pressure is 168/80. Which of the following is an example of subjective data?

a.

Pulse of 88/beats per minute

b.

Blood pressure of 168/80

c.

The statement regarding his feeling hot

d.

The fact that he became febrile

ANS: c

c. Subjective data are clients perceptions about his or her health problems. The statement by the client regarding his feeling hot is an example of subjective data.

a. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector.

b. A blood pressure of 168/80 is something that can be measured and therefore is an example of objective data.

d. Becoming febrile can be determined by measurement and therefore is an example of objective data.

REF: Text Reference: p. 284

6. The nurse decides to interview the client by using the open-ended question technique. Which of the following statements reflects this type of questioning?

a.

Is your pain worse or better than it was an hour ago?

b.

Do you believe that your nausea is from the new antibiotic?

c.

What do you think has been causing your depression?

d.

What effects have you had with the medications, and what have you done to alleviate them?

ANS: c

c. An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique.

a. This question limits the clients answers to one or two words. It is an example of a closed-ended question.

b. The question in this option limits the clients answer to one or two words such as yes or no. It is an example of a closed-ended question.

d. This option basically consists of two questions, both of which only require a few words to form an answer. It is does not use the open-ended question technique.

REF: Text Reference: p. 288

7. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job and that his son has newly diagnosed juvenile-onset diabetes. Which of the following categories best fits the loss of the job?

a.

Family history

b.

Psychosocial history

c.

Environmental history

d.

Biographical history

ANS: b

b. The psychosocial history reveals the clients support system, if any recent losses or stressful events exist, and how the individual copes with such stressors. Loss of a job would fit the psychosocial history category.

a. Family history is used to obtain data about immediate and blood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It also provides information about the family itself.

c. The environmental history provides data about clients home and working environments.

d. The biographical history provides factual demographic data about the client.

REF: Text Reference: p. 291

8. The nurse is going to perform the admission history for the newly admitted client on the medical unit. The optimal time for completion of the history is planned for:

a.

Coordination with the physicians visit

b.

The time that the clients friends and family are visiting

c.

Immediately before the clients magnetic resonance imaging (MRI) testing

d.

After the client has become oriented to the room and completed lunch

ANS: d

d. Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment in which the client feels comfortable. Conducting the admission history after the clients orientation to the room and completion of lunch would be optimal because the client will not be distracted by hunger, and the interview will less likely be interrupted.

a. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physicians visit would not be an optimal time.

b. The nurse should provide an environment private enough to allow the client to be comfortable when providing personal information. Inclusion of family members should be left up to the client to decide. Information obtained should remain confidential.

c. Immediately before a clients testing would not be an optimal time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, and sufficient time may not exist to gather all of the information.

REF: Text Reference: p. 285

9. The nurse has completed an assessment and found that the client has an activity and exercise abnormality. This type of documentation indicates that the following organizing format has been used:

a.

Review of systems

b.

Nursing health history

c.

Gordons functional health patterns

d.

Biographical information database

ANS: c

c. By using Gordons functional health patterns format, the nurse organizes information and makes an assessment identifying functional patterns (client strengths) and dysfunctional patterns (such as an activity and exercise abnormality).

a. The review of systems is a systematic method for collecting data on all body systems. The nurse asks the client about the normal functioning of each body system and any noted changes.

b. A nursing health history is more broad, including information about the clients current level of wellness, a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness.

d. A biographic information database provides factual demographic data about the client, such as age, address, occupation, marital status, etc.

REF: Text Reference: p. 291

10. 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 objective data?

a.

Pain in the left leg

b.

Elevated blood pressure

c.

Fear of surgery

d.

Discomfort on breathing

ANS: b

b. Objective data are observations or measurements made by the data collector, such as a blood pressure reading.

a. Subjective data are clients perceptions about their health problems, such as pain.

c. Fear of surgery would be subjective data because it is the clients perception and not something the data collector can measure.

d. Subjective data are clients perceptions about their health problems, such as discomfort on breathing. A respiratory rate would be an example of objective data.

REF: Text Reference: p. 284

11. An alert, oriented client is admitted to the medical center for diagnostic testing. The primary source of information when completing an assessment for this client is the:

a.

Client

b.

Physician

c.

Family member

d.

Experienced nurse on the unit

ANS: a

a. A client is usually the best source of information. The client who is oriented and answers questions appropriately can provide the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living.

b. The physician may have knowledge of the clients medical problem, but the client is the primary source of information for completing an assessment.

c. Family members can be interviewed as primary sources of information about infants or children and critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information and can confirm findings provided by the client. The client in this situation is capable of being the primary source of information.

d. An experienced nurse on the unit may offer insight into a clients health care needs and care but is not the primary source of information for a client assessment.

REF: Text Reference: p. 284

12. On beginning the process of data collection, the first step the nurse should take is the:

a.

Physical exam

b.

Client interview

c.

Review of medical records

d.

Discussion with other health team members

ANS: b

b. The first step in establishing the database is to collect subjective information by interviewing the client.

a. The physical examination follows the client interview so that data can be verified.

c. A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview.

d. Discussion with other health team members may provide additional information and be used to relay information, but it is not the first step in the process of data collection.

REF: Text Reference: p. 285

13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most efficiently, the nurse should use:

a.

Channeling

b.

Open-ended questions

c.

Closed-ended questions

d.

Problem-seeking responses

ANS: c

c. Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner.

a. Channeling occurs when the nurse uses active listening techniques such as all right, go on, or uh-huh, to indicate that the nurse has heard what the client said and to encourage the client to elaborate further.

b. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell his or her story and reveal what is important, it is not the most efficient method of obtaining specific information regarding a clients signs and symptoms of a health problem.

d. In problem-seeking technique, the nurse takes the information provided in the clients story more fully to describe and identify the clients specific problems. Using closed-ended questions would be the most efficient method for obtaining specific information about the signs and symptoms of a clients health problem.

REF: Text Reference: p. 289

14. The nurse is conducting an interview with the client and wants to clarify information that the client has shared in the discussion. Which response by the nurse is an example of the clarifying technique of communication?

a.

I understand how you must feel.

b.

This medication is used to lower your blood pressure.

c.

You appear anxious. Youre wringing your hands constantly.

d.

Im not sure that I understand. Could you give me an example of how the pain feels?

ANS: d

d. In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a clients situation.

a. This is not an example of clarifying information.

b. This response provides information. The nurse is not using the clarifying technique of communication.

c. In this option, the nurse describes his or her observations. It does not seek clarification.

REF: Text Reference: p. 292

15. When clustering data according to functional health patterns, the nurse determines that the client is able to ambulate only short distances without becoming fatigued and requires rest periods during AM care. The health pattern that requires intervention is identified by the nurse as:

a.

Respiratory

b.

Activity and exercise

c.

Sleep and rest pattern

d.

Self-care deficit: activities of daily living

ANS: b

b. With the functional health pattern format, the nurse clusters data that pertain to a functional health category. Fatigue on ambulating short distances and requiring frequent periods of rest are examples of data belonging to the category of activity and exercise.

a. Respiratory would be found in a systems approach of health assessment, not a functional health pattern assessment.

c. 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.

d. 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.

REF: Text Reference: p. 293, Text Reference: p. 294

16. 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 subjective data?

a.

Client appears sleepy

b.

No distress noted

c.

Abdomen soft and non-tender

d.

States feels anxious and tense

ANS: b

d. Subjective data are clients perceptions about their health problems. Feeling anxious and tense is information that only the client can provide.

a. Objective data are observation or measurements made by the data collector. In this example, the data collector is making the observation that the client appears sleepy.

b. No distress noted is an example of objective data because it is an observation made by the data collector.

c. Abdomen soft and non-tender is an example of objective data because it is an observation made by the data collector, not a clients perception.

REF: Text Reference: p. 284

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