Chapter 16: Nursing Assessment Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. 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

ANS: 4

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

DIF: A REF: 236 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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:

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

ANS: 1

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 to more fully describe and identify the clients specific problems. Habits and lifestyle patterns such as smoking, alcohol use, 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. 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. 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 using a problem-oriented approach. This would include asking specific questions about the clients health problem, such as the nature and onset of symptoms.

DIF: A REF: 237 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

3. 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

ANS: 4

If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, and duration of the chest pain. In an emergency situation, the clients current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. 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. Asking the client about concerns regarding hospitalization is not the priority.

DIF: A REF: 241 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

4. 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

ANS: 1

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 relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis.

DIF: A REF: 234 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

5. The client recently became febrile and stated he felt hot. The nurse takes the clients 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

ANS: 3

Subjective data are clients perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. 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. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is an example of objective data. Becoming febrile can be determined by measurement, and therefore is an example of objective data.

DIF: A REF: 234 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

6. 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?

ANS: 3

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. This question limits the clients answers to one or two words. It is an example of a closed-ended question. 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. This option only requires a few words to form an answer. It does not use the open-ended question technique.

DIF: A REF: 239 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

7. 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

ANS: 2

The psychosocial history reveals the clients support system, if there are any recent losses or stressful events, and how the individual copes with such stressors. The loss of a job would fit the psychosocial history category. 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. The biographical history provides factual demographic data about the client. The environmental history provides data about the clients home and working environments.

DIF: A REF: 241 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

8. 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 physicians visit

2.

The time when the clients family are visiting

3.

Immediately before the clients scheduled MRI testing

4.

After the client has become comfortably oriented to the room

ANS: 4

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 where the client feels comfortable. Conducting the admission history after the clients orientation to the room and completion of lunch would be optimum because the client will not be distracted by hunger, and the interview will less likely be interrupted. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physicians visit would not be an optimum time. 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. Immediately before a clients testing would not be an optimum time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, and there may not be sufficient time allowed to gather all of the information.

DIF: A REF: 236 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

9. 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.

Gordons functional health patterns

4.

Biographical information database

ANS: 3

Utilizing 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). 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. A nursing health history is broader and includes 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. A biographical information database provides factual demographic data about the client, such as age, address, occupation, marital status, etc.

DIF: A REF: 233 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

10. 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

ANS: 2

Objective data are observations or measurements made by the data collector, such as a blood pressure reading. Subjective data are clients perceptions about their health problems, such as pain. Fear of surgery would be subjective data because it is the clients perception and not something the data collector can measure. Subjective data are clients perceptions about their health problems, such as discomfort during breathing. A respiratory rate would be an example of objective data.

DIF: A REF: 234 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

11. 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

ANS: 1

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. The physician may have knowledge of the clients medical problem, but the client is the primary source of information for completing an assessment. Family members can be interviewed as primary sources of information about infants or children or 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. 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 when completing a client assessment.

DIF: A REF: 234 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

12. 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

ANS: 2

The first step in establishing the database is to collect subjective information by interviewing the client. The physical examination follows the client interview so that data can be verified. 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. Discussion with other health team members may provide additional information and be used to relay information, but is not the first step in the process of data collection.

DIF: A REF: 236 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

13. During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients 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

ANS: 3

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. Channeling is where the nurse uses active listening techniques, such as all right, go on, or uh-huh, to indicate the nurse has heard what the client said and encourage the client to elaborate further. 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 their story and reveal what is important to them, it is not the most efficient method of obtaining specific information regarding a clients signs and symptoms of a health problem. In problem-seeking technique, the nurse takes the information provided in the clients story to more fully 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.

DIF: A REF: 239 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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. Youre wringing your hands constantly.

4.

Could you give me an example of how you handle stressors?

ANS: 4

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. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification.

DIF: A REF: 239 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

15. 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

ANS: 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.

DIF: A REF: 233 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

16. 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

ANS: 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 clients perception.

DIF: A REF: 234 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

17. 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?

ANS: 4

If a client presents to the emergency department with pain, the nurse should first ask the client about the onset, severity, and duration of the pain. In an emergency situation, the clients current health problem becomes the priority assessment. Gathering data about the problem currently affecting the client has greater priority, but a description of the pain does not have priority over onset. Asking the client about medical history is appropriate but not at this time. The priority is to assess the symptoms the client is experiencing. Gathering data about the problem currently affecting the client has greater priority, but attempted self-treatment does not have priority over onset.

DIF: C REF: 236-237 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Health Promotion and Maintenance

18. Which subjective assessment data are most supportive of a clients 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

ANS: 4

Subjective data are clients perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom.

DIF: C REF: 241 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

19. Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the clients 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?

ANS: 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 clients condition. While this is an open-ended question, it is not the best option because it is not directed towards assessment of the clients current complaint. While this is an open-ended question, it is not the best option because it is directed at the clients comfort, not towards assessing his current complaint.

DIF: C REF: 234 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

20. Which of the following statements best reflects the nurses correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?

1.

Im going to do the clients history before his family leaves so they can help with the admission history questions.

2.

You are scheduled for some x-rays, so Id like to complete this admission history interview before you have to leave.

3.

I have some questions to ask you regarding your admission history. Ill 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.

ANS: 3

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 where the client feels comfortable and the clients orientation to the room is completed. While this may be appropriate if the client requires help with answering the questions, it is not the best option because family and visitors can be distracting and may represent a confidentiality problem. While the history must be taken within a specific time period, rushing to complete it before the client goes to radiology is not appropriate. The interview requires the clients attention and cooperation. Attempting to complete it immediately after a treatment or other intervention would not be the best choice of time.

DIF: C REF: 239 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

21. 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?

ANS: 4

The nurse should ask relevant questions and collect relevant history and physical assessment data related to the clients presenting health care needs in order to produce the most inclusive, effective nursing care plan. The questions How long have you been dealing with GERD? and Are you currently taking any medications for your GERD? as well as Do you follow a particular diet to help manage your GERD? are directed towards the GERD itself and not towards conditions that might be related to the presence of GERD.

DIF: C REF: 236 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

22. A new graduate nurse missed cues regarding the clients 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; dont 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 wont miss those cues again in another client.

ANS: 3

It is possible to miss important cues when you conduct an initial overview. However, always try to interpret cues from the client to know how in-depth to make your assessment. Remember, thinking is human and imperfect. You will acquire appropriate thinking processes in the conduct of assessment, but expect to make mistakes in missing important cues. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. While this is true, it is not the most therapeutic option because it does not offer a reason for the omission. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate.

DIF: C REF: 240-241 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

23. 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 weve discussed?

ANS: 4

Once you complete the assessment, you thoroughly analyze the extent and nature of the clients problem so you are able to later develop a care plan. Identifying the degree of pain the client is experiencing has priority over the other options. While this option is an appropriate pain assessment question, it is more directed towards identifying contributing factors than the characteristics (nature) of the pain. While this option is an appropriate pain assessment question regarding the nature of the pain, it does not have priority over the degree of pain because that represents an issue that requires immediate intervention. While this option is an appropriate pain assessment question, it is more directed towards identifying effective self-treatment rather than the characteristics (nature) of the pain.

DIF: C REF: 236 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

24. When following up on a clients 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

ANS: 3

This option where the client was observed grimacing describes nonverbal actions that are associated with pain when the client is unaware of being observed and so represents the most conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staffs report of the clients pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options because the client is aware of being observed.

DIF: C REF: 240 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

25. 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

ANS: 3

This option where the 81-year-old is receiving follow-up treatment for a hip replacement presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other emotion/factor that would inhibit the free communication of subjective symptom data. The 50-year-old client is experiencing pain; this is likely to inhibit the communication process. The 70-year-old client is febrile; this could interfere with the communication process, especially for an older adult because it may cause confusion and the 22-year-old client may be experiencing guilt and/or embarrassment; both may interfere with the communication process.

DIF: C REF: 234 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

26. A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurses mentor?

1.

Conducting the interview with the clients 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; youve rated your pain a 9 out of 10?

ANS: 3

Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the clients permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of clients pain rating, a follow-up would be appropriate because a clients pain rating should not be questioned.

DIF: C REF: 234 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

27. Which of the following assessment data provided by a clients family will have the greatest impact on the clients 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 wifes sister died 4 months ago, and she is still grieving over her loss.

4.

My husband doesnt like to let people know his arthritis is bothering him.

ANS: 4

Family and friends can make important observations about the clients health status, changes, and needs that can affect the way care is delivered. Being aware of the clients reluctance to discuss his pain will impact the frequency and way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the clients morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the clients emotional needs, it does not have priority over pain assessment.

DIF: C REF: 237 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

28. What is the most appropriate method for the nurse to communicate a clients wishes to the nurses on the next shift?

1.

Document the request in the nursing notes.

2.

Include the clients request in the shift report.

3.

Place instructions regarding the clients wishes above the clients bed.

4.

Verbally inform the unit clerk of the clients request.

ANS: 2

In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate information to nurses on the next shift Documenting the request in the nursing notes is not appropriate for inclusion in the nursing notes because it does not reflect information regarding the clients condition, response to treatment, or current health status. Placing the instructions regarding the clients wishes above the bed is not appropriate because there is no guarantee that staff will see the posting, but more importantly there are confidentiality issues being ignored. While verbally informing the unit clerk of the clients request may result in the clients wishes being respected, it is not the most effective option.

DIF: C REF: 234-235 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

29. While discussing a clients 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 clients Kardex.

2.

Inform the provider of the clients possible allergy.

3.

Review the clients medical record for confirmation of the allergy.

4.

Tell the client to have all medications identified before taking them.

ANS: 3

The medical record is a valuable tool for checking the consistency and similarities of personal observations. Information such as a history of allergic reactions would be found in the medical record. Noting the allergy on the clients Kardex would be appropriate only after the allergy is confirmed; although if there was true concern, a notation of a possible allergy should be noted on the medication record. Informing the provider of the clients possible allergy would be appropriate after the medical record was reviewed and no mention of the allergy was confirmed or denied. While telling the client to have all medications identified before taking them is a safety measure appropriate for all clients, it is not the priority in this situation.

DIF: C REF: 235 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

30. The nurse realizes that in order to share information from a clients 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 clients 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

ANS: 3

Educational, military, and employment records may contain significant health care information. You need written permission from the client or guardian to access or transfer the records. Any information you obtain is confidential, and you treat it as part of the clients legal medical record. This process recognizes the clients right to confidentiality. The other three options, facilitating the exchange of information, ensuring the clients rights to have his medical information regarded as personal and confidential as well as guaranteeing the sharing of information will be only when required for client care purposes are outcomes of the process but not the primary reason for the consent.

DIF: C REF: 235-236 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

31. The nurse recognizes that a clients 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 clients needs

ANS: 2

When a client has limited hearing or visual deficits, it becomes more important for a nurse to use nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly and in a normal tone may make verbal communication more effective, but it will not have the greatest positive impact of the offered options. Relying heavily on touch is only one form of nonverbal communication that can positively impact the development of the relationship. While involving family in discussions may help in the identification of client needs, it does not necessarily have positive impact on developing a healthy nurse-client relationship.

DIF: C REF: 236 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

32. Which of the following questions will provide the nurse with the best understanding of a terminally ill clients 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?

ANS: 4

In asking if there are any spiritual needs that the client might need help with, you collect information about life goals, values, and religious practices; part of a clients spirituality. This option provides the client with an opportunity to discuss his needs if indeed he has any while reaffirming the nurses wish to meet his needs. Asking simply is a client has a religious preference is a closed-ended question and provides little encouragement to discuss spiritual needs. While asking if the client has given thought to their spiritual needs provides an opportunity to discuss any client needs, it does not allow for the nurse to be of help with attending to these needs. Inquiring about a particular clergy is a closed-ended question and provides little encouragement to discuss spiritual needs.

DIF: C REF: 237 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

MULTIPLE RESPONSE

1. Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.)

1.

Youre answers will be kept confidential.

2.

My name is Susan Smith and Im a registered nurse.

3.

We are here to make your hospitalization as pleasant as possible.

4.

I need to ask you some questions that will help with planning your care.

5.

Only those directly involved in your care will have access to this information.

6.

If there is anything you need or help you require simply use your call bell and someone will be right in.

ANS: 1, 2, 4, 5

The orientation phase begins with you introducing yourself and your position and explaining the purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain confidential and will be used only by health care professionals.

The statements We are here to make your hospitalization as pleasant as possible and I need to ask you some questions that will help with planning your care are more appropriate for the termination phase.

DIF: C REF: 241 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.)

1.

My work environment would depress anyone.

2.

It seems like almost anything can make me cry.

3.

Being here away from my family makes me sad.

4.

I just cant seem to get excited about anything anymore.

5.

The family always thought that my father was depressed.

6.

I like winter because I can just cover up on the couch and sleep.

ANS: 4, 5

I just cant seem to get excited about anything anymore and The family always thought that my father was depressed. Remember to always have supporting cues before you make an inference. These options relate a broad lack of interest in life and a family history of depression. While mentioning My work environment would depress anyone as a depressing situation, this option does not infer personal depression. While mentioning It seems like almost anything can make me cry as a potential sign of depression, this option is not a strong inference because crying can be a result of other emotions. While mentioning Being here away from my family makes me sad notes sadness, this option describes a normal reaction to being separated from loved ones. While mentioning I like winter because I can just cover up on the couch and sleep shows withdrawal behaviors, this option is not a strong inference because winter often evokes stay-at-home tendencies in people.

DIF: C REF: 241 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The goal of the orientation phase of a nursing interview is to: (select all that apply)

1.

Initiate the nurse-client relationship

2.

Begin identifying the clients needs

3.

Earn the trust and confidence of the client

4.

Assume the decision role for the client

5.

Welcome the client to the nursing unit

6.

Gather the clients demographic information

ANS: 1, 2, 3

Initiating the nurse-client relationship, beginning to identify the clients needs and earning the clients trust and confidence. During the orientation phase you establish trust and confidence with a client. One important goal for the initial interview is to make the foundation for understanding the clients primary needs. Another is to begin a relationship that allows the client to become an active partner in decisions about care. As the orientation phase proceeds, the client should begin to feel more comfortable speaking with you so the necessary information can be obtained. Assuming the decision role isnt correct as the client should be involved in all care decisions; assuming this role is not appropriate. While welcoming the client to the nursing unit is an expected outcome of the orientation phase of the interview process, it is not a goal. While gathering the clients demographic information is an expected outcome of the orientation phase of the interview process, it is not a goal.

DIF: C REF: 236-237 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Safe, Effective Care Environment

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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