Page 1
- A nurse on a postsurgical unit is admitting a client following the client’s
cholecystectomy (gall bladder removal). What is the overall purpose of assessment for
this client?
A) Collecting accurate data
B) Assisting the primary care provider
C) Validating previous data
D) Making clinical judgments - A client has presented to the emergency department (ED) with complaints of abdominal
pain. Which member of the care team would most likely be responsible for collecting
the subjective data on the client during the initial comprehensive assessment?
A) Gastroenterologist
B) ED nurse
C) Admissions clerk
D) Diagnostic technician - The nurse has completed an initial assessment of a newly admitted client and is applying
the nursing process to plan the client’s care. What principle should the nurse apply when
using the nursing process?
A) Each step is independent of the others.
B) It is ongoing and continuous.
C) It is used primarily in acute care settings.
D) It involves independent nursing actions. - The nurse who provides care at an ambulatory clinic is preparing to meet a client and
perform a comprehensive health assessment. Which of the following actions should the
nurse perform first?
A) Review the client’s medical record.
B) Obtain basic biographic data.
C) Consult clinical resources explaining the client’s diagnosis.
D) Validate information with the client. - Which of the following client situations would the nurse interpret as requiring an
emergency assessment?
A) A pediatric client with severe sunburn
B) A client needing an employment physical
C) A client who overdosed on acetaminophen
D) A distraught client who wants a pregnancy test
Chapter 1 Nurses Role in Health Assessment- Collecting and Analyzing Data
Page 2
- In response to a client’s query, the nurse is explaining the differences between the
physician’s medical exam and the comprehensive health assessment performed by the
nurse. The nurse should describe the fact that the nursing assessment focuses on which
aspect of the client’s situation?
A) Current physiologic status
B) Effect of health on functional status
C) Past medical history
D) Motivation for adherence to treatment - After teaching a group of students about the phases of the nursing process, the instructor
determines that the teaching was successful when the students identify which phase as
being foundational to all other phases?
A) Assessment
B) Planning
C) Implementation
D) Evaluation - The nurse has completed the comprehensive health assessment of a client who has been
admitted for the treatment of community-acquired pneumonia. Following the
completion of this assessment, the nurse periodically performs a partial assessment
primarily for which reason?
A) Reassess previously detected problems
B) Provide information for the client’s record
C) Address areas previously omitted
D) Determine the need for crisis intervention - 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 14-year-old girl who is crying because she thinks she is pregnant
B) A 45-year-old man with chest pain and diaphoresis for 1 hour
C) A 3-year-old child with fever, rash, and sore throat
D) A 20-year-old man with a 3-inch shallow laceration on his leg
Page 3
- A nurse has completed gathering some basic data about a client who has multiple health
problems that stem from heavy alcohol use. The nurse has then reflected on her personal
feelings about the client and his circumstances. The nurse does this primarily to
accomplish which of the following?
A) Determine if pertinent data has been omitted
B) Identify the need for referral
C) Avoid biases and judgments
D) Construct a plan of care - The nurse is collecting data from a client who has recently been diagnosed with type 1
diabetes and who will begin an educational program. The nurse is collecting subjective
and objective data. Which of the following would the nurse categorize as objective data?
A) Family history
B) Occupation
C) Appearance
D) History of present health concern - An older adult client has been admitted to the hospital with failure to thrive resulting
from complications of diabetes. Which of the following would the nurse implement in
response to a collaborative problem?
A) Encourage the client to increase oral fluid intake.
B) Provide the client with a bedtime protein snack.
C) Assist the client with personal hygiene.
D) Measure the client’s blood glucose four times daily. - The nurse at a busy primary care clinic is analyzing the data obtained from the
following clients. For which clients would the nurse most likely expect to facilitate a
referral?
A) An 80-year-old client who lives with her daughter
B) A 50-year-old client newly diagnosed with diabetes
C) An adult presenting for an influenza vaccination
D) A teenager seeking information about contraception - An instructor is reviewing the evolution of the nurse’s role in health assessment. The
instructor determines that the teaching was successful when the students identify which
of the following as the major method used by nurses early in the history of the
profession?
A) Natural senses
B) Biomedical knowledge
C) Simple technology
D) Critical pathways
Page 4
- When describing the expansion of the depth and scope of nursing assessment over the
past several decades, which of the following would the nurse identify as being the
primary force?
A) Documentation
B) Informatics
C) Diversification
D) Technology - A group of nurses are reviewing information about the potential opportunities for nurses
who have advanced assessment skills. When discussing phenomena that have
contributed to these increased opportunities, what should the nurses identify?
A) Expansion of health care networks
B) Decrease in client participation in care
C) The shrinking cost of medical care
D) Public mistrust of physicians - A nurse has documented the findings of a comprehensive assessment of a new client.
What is the primary rationale that the nurse should identify for accurate and thorough
documentation?
A) Guaranteeing a continual assessment process
B) Identifying abnormal data
C) Assuring valid conclusions from analyzed data
D) Allowing for drawing inferences and identifying problems - A nurse has received a report on a client who will soon be admitted to the medical unit
from the emergency department. When preparing for the assessment phase of the
nursing process, which of the following should the nurse do first?
A) Collect objective data.
B) Validate important data.
C) Collect subjective data.
D) Document the data. - A community health nurse is assessing an older adult client in the client’s home. When
the nurse is gathering subjective data, which of the following would the nurse identify?
A) The client’s feelings of happiness
B) The client’s posture
C) The client’s affect
D) The client’s behavior