1. A nurse on a postsurgical unit is admitting a client following the client's cholecystectom
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y (gall bladder removal). What is the overall purpose of assessment for this client?
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A) Collecting accurate data 9 9
B) Assisting the primary care provider 9 9 9 9
C) Validating previous data 9 9
D) Making clinical judgments 9 9 9
2. A client has presented to the emergency department (ED) with complaints of abdominal pa
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in. Which member of the care team would most likely be responsible for collecting the sub
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jective data on the client during the initial comprehensive assessment?
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A) Gastroenterologist
B) ED nurse 9 9
C) Admissions clerk 9
D) Diagnostic technician 9
3. The nurse has completed an initial assessment of a newly admitted client and is applying th
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e nursing process to plan the client's care. What principle should the nurse apply when usin
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g the nursing process?
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A) Each step is independent of the others. 9 9 9 9 9 9
B) It is ongoing and continuous.
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C) It is used primarily in acute care settings.
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D) It involves independent nursing actions.
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4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perf
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orm a comprehensive health assessment. Which of the following actions should the nurse
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perform first? 9
A) Review the client's medical record. 9 9 9 9 9
B) Obtain basic biographic data. 9 9 9
C) Consult clinical resources explaining the client's diagnosis.
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D) Validate information with the client. 9 9 9 9
5. Which of the following client situations would the nurse interpret as requiring an e
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mergency assessment? 9
A) A pediatric client with severe sunburn
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B) A client needing an employment physical
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C) A client who overdosed on acetaminophen
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D) A distraught client who wants a pregnancy test
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,6. In response to a client's query, the nurse is explaining the differences between the physici
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an's medical exam and the comprehensive health assessment performed by the nurse. Th
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e nurse should describe the fact that the nursing assessment focuses on which aspect of th
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e client's situation?
9 9
A) Current physiologic status 9 9
B) Effect of health on functional status 9 9 9 9 9 9
C) Past medical history 9 9
D) Motivation for adherence to treatment 9 9 9 9
7. After teaching a group of students about the phases of the nursing process, the instructor de
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termines that the teaching was successful when the students identify which phase as being
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foundational to all other phases? 9 9 9 9
A) Assessment 9
B) Planning
C) Implementation
D) Evaluation
8. The nurse has completed the comprehensive health assessment of a client who has been ad
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mitted for the treatment of community-
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acquired pneumonia. Following the completion of this assessment, the nurse periodically
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performs a partial assessment primarily for which reason?
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A) Reassess previously detected problems 9 9 9 9
B) Provide information for the client's record 9 9 9 9 9
C) Address areas previously omitted 9 9 9
D) Determine the need for crisis intervention 9 9 9 9 9
9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-
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city neighborhood. Which client would the nurse determine to be in most need of an em
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ergency assessment? 9
A) A 14-year-old girl who is crying because she thinks she is pregnant
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B) A 45-year-old man with chest pain and diaphoresis for 1 hour
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C) A 3-year-old child with fever, rash, and sore throat
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D) A 20-year-old man with a 3-inch shallow laceration on his leg
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,10. A nurse has completed gathering some basic data about a client who has multiple health pr
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oblems that stem from heavy alcohol use. The nurse has then reflected on her personal feeli
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ngs about the client and his circumstances. The nurse does this primarily to accomplish wh
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ich of the following?
9 9 9
A) Determine if pertinent data has been omitted 9 9 9 9 9 9
B) Identify the need for referral 9 9 9 9
C) Avoid biases and judgments 9 9 9 9
D) Construct a plan of care 9 9 9 9
11. The nurse is collecting data from a client who has recently been diagnosed with type 1 diab
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etes and who will begin an educational program. The nurse is collecting subjective and obj
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ective data. Which of the following would the nurse categorize as objective data?
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A) Family history 9
B) Occupation
C) Appearance 9
D) History of present health concern 9 9 9 9
12. An older adult client has been admitted to the hospital with failure to thrive resulting fro
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m complications of diabetes. Which of the following would the nurse implement in respo
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nse to a collaborative problem?
9 9 9 9
A) Encourage the client to increase oral fluid intake. 9 9 9 9 9 9 9
B) Provide the client with a bedtime protein snack. 9 9 9 9 9 9 9
C) Assist the client with personal hygiene. 9 9 9 9 9
D) Measure the client's blood glucose four times daily. 9 9 9 9 9 9 9 9
13. The nurse at a busy primary care clinic is analyzing the data obtained from the followin
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g clients. For which clients would the nurse most likely expect to facilitate a referral?
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A) An 80-year-old client who lives with her daughter
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B) A 50-year-old client newly diagnosed with diabetes
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C) An adult presenting for an influenza vaccination
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D) A teenager seeking information about contraception
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14. An instructor is reviewing the evolution of the nurse's role in health assessment. The instr
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uctor determines that the teaching was successful when the students identify which of the f
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ollowing as the major method used by nurses early in the history of the profession?
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A) Natural senses 9 9
B) Biomedical knowledge 9
C) Simple technology 9
D) Critical pathways 9
, 15. When describing the expansion of the depth and scope of nursing assessment over the pa
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st several decades, which of the following would the nurse identify as being the primary
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force?
A) Documentation
B) Informatics
C) Diversification
D) Technology 9
16. A group of nurses are reviewing information about the potential opportunities for nurses w
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ho have advanced assessment skills. When discussing phenomena that have contributed to
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9these increased opportunities, what should the nurses identify?
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A) Expansion of health care networks 9 9 9 9 9
B) Decrease in client participation in care 9 9 9 9 9
C) The shrinking cost of medical care
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D) Public mistrust of physicians 9 9 9
17. A nurse has documented the findings of a comprehensive assessment of a new client. W
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hat is the primary rationale that the nurse should identify for accurate and thorough docu
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mentation?
A) Guaranteeing a continual assessment process 9 9 9 9
B) Identifying abnormal data 9 9
C) Assuring valid conclusions from analyzed data 9 9 9 9 9 9
D) Allowing for drawing inferences and identifying problems 9 9 9 9 9 9
18. A nurse has received a report on a client who will soon be admitted to the medical unit fro
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m the emergency department. When preparing for the assessment phase of the nursing pr
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ocess, which of the following should the nurse do first?
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A) Collect objective data. 9 9
B) Validate important data. 9 9
C) Collect subjective data. 9 9 9
D) Document the data. 9 9
19. A community health nurse is assessing an older adult client in the client's home. When the
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9nurse is gathering subjective data, which of the following would the nurse identify?
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A) The client's feelings of happiness
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B) The client's posture 9 9
C) The client's affect 9 9
D) The client's behavior 9 9
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