Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim – Test Bank
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Sample Test
Chapter 3, The Nursing Process
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1. |
Which of the following is a
true statement about critical thinking in nursing? |
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A) |
It involves purposeful,
outcome-directed thinking. |
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B) |
It shows trends and
patterns in client status. |
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C) |
It makes judgments based on
conjecture. |
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D) |
It supplies validation for
reimbursement. |
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Ans: |
A |
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Feedback: |
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In nursing, critical
thinking involves purposeful, outcome-directed thinking. Critical thinking
makes judgments based on evidence rather than conjecture. Providing a
foundation for evaluation and quality improvement and showing trends and
patterns in client status are functions served by documentation. |
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2. |
Which of the following is
involved in the implementation step of the nursing process? |
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A) |
Selecting nursing
interventions |
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B) |
Documenting nursing care
and client responses |
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C) |
Documenting the plan of
care |
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D) |
Identifying measurable
outcomes |
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Ans: |
B |
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Feedback: |
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The implementation step in
the nursing process involves documenting nursing care and client responses.
Planning involves selecting nursing interventions, documenting the plan of
care, and identifying measurable outcomes. |
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3. |
Which of the following is
an important element of implementation? |
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A) |
Client database |
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B) |
Critical thinking |
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C) |
Nursing orders |
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D) |
Documentation |
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Ans: |
D |
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Feedback: |
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An important element of implementation
is documentation. The client database includes all the information obtained
from the medical and nursing history. Physical examination and diagnostic
studies are not an important element of implementation. Critical thinking is
intentional, contemplative, and outcome-directed thinking. Developing good
critical thinking skills will make nurses more efficient and effective at
resolving situations necessitating multiple interventions. Nursing orders are
specific nursing directions so that all healthcare team members understand
what to do for the client; therefore, they are not an important element of
implementation. |
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4. |
Which of the following
pieces of information is included in the client database? |
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A) |
Nursing care |
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B) |
Diagnostic studies |
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C) |
Plan of care |
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D) |
Collaborative problems |
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Ans: |
B |
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Feedback: |
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The client database
includes all the information obtained from the medical and nursing history,
physical examination, and diagnostic studies. The client database does not
include nursing care, plan of care, or collaborative problems. |
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5. |
Which type of nursing
diagnosis statement begins with the stem readiness for enhanced and does not
include related factors or supporting data? |
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A) |
Health promotion |
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B) |
Syndrome |
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C) |
Risk |
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D) |
Actual |
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Ans: |
A |
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Feedback: |
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Health promotion nursing
diagnoses reflect clinical judgment of a client’s motivation and behavior to
increase well-being and enhance health-seeking behaviors. Risk nursing
diagnoses identify potential problems and use the stem risk for, as in Risk
for Impaired Skin Integrity related to inactivity. Actual nursing diagnoses
identify existing problems. Syndrome diagnoses describe specific diagnoses
that occur as a group and are best addressed as a group of collective
interventions. |
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6. |
Which of the following is
the highest level of human need according to Maslow (1968)? |
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A) |
Physiologic |
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B) |
Love and belonging |
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C) |
Esteem and self-esteem |
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D) |
Self-actualization |
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Ans: |
D |
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Feedback: |
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The highest level need is
self-actualization. The first level of need is physiological needs. Love and
belonging are third-level needs. Esteem and self-esteem are fourth-level
needs. |
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7. |
Which phase of the nursing
process enables the nurse to compare the actual outcomes with the expected
outcomes? |
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A) |
Assessment |
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B) |
Planning |
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C) |
Implementation |
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D) |
Evaluation |
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Ans: |
D |
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Feedback: |
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Evaluation is assessment
and review of the quality and suitability of the care given and the client’s
responses to that care. Assessment is careful observation and evaluation of a
client’s health status. Planning involves setting priorities, defining
expected (desired) outcomes (goals), determining specific nursing
interventions, and recording the plan of care. Implementation means carrying
out the written plan of care; performing interventions; monitoring the
client’s status; and assessing and reassessing the client before, during, and
after treatments. |
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8. |
Which of the following is a
true statement about critical thinking according to Alfaro-LeFevre (2010)? |
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A) |
It makes judgments based on
conjecture. |
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B) |
It is based on the medical
model. |
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C) |
It considers only the
client’s needs. |
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D) |
It is guided by
professional standards and codes of ethics. |
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Ans: |
D |
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Feedback: |
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Critical thinking is guided
by professional standards and codes of ethics. It is based on principles of
the nursing process and scientific methods. Critical thinking makes judgments
based on evidence rather than conjecture. It considers client, family, and
community needs. |
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9. |
Which type of nursing
diagnosis has a goal to increase well-being and enhance specific health
behaviors? |
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A) |
Health promotion |
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B) |
Risk |
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C) |
Wellness |
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D) |
Actual |
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Ans: |
A |
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Feedback: |
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Health promotion nursing
diagnoses look for ways to enhance health. Risk nursing diagnoses identify
potential problems and use the stem risk
for, as in Risk for Impaired Skin Integrity related to
inactivity. In wellness diagnoses, the diagnostic statement begins with the
stem readiness for
enhanced and does not include related factors or supporting
data. Actual nursing diagnoses identify existing problems. |
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10. |
Which of the following
identify a diagnosis associated with a cluster of other diagnoses? |
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A) |
Risk nursing diagnoses |
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B) |
Actual nursing diagnoses |
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C) |
Syndrome diagnoses |
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D) |
Health promotion nursing
diagnoses |
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Ans: |
C |
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Feedback: |
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Syndrome diagnoses identify
a diagnosis associated with a cluster of other diagnoses, such as Disuse
Syndrome. Risk nursing diagnoses identify potential problems and use the
stem risk for,
as in Risk for Impaired Skin Integrity related to inactivity. Health
promotion nursing diagnoses reflect clinical judgment of a client’s motivation
and behavior to increase well-being and enhance health-seeking behaviors.
Actual nursing diagnoses identify existing problems. |
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11. |
The LPN states to an RN, “I
don’t know why we have to follow a care plan. No one even uses it, and it
just means more paperwork. What’s the purpose?” What is the best response by
the RN? |
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A) |
“I agree with you, and we
should talk to the manager about eliminating them from our required
paperwork.” |
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B) |
“I think it is something we
have always done, and we have to continue to use them.” |
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C) |
“It helps to provide a
systematic method for us to plan and implement care so that we achieve
positive outcomes.” |
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D) |
“Physicians use our care
plans in order to see what we are doing for the clients.” |
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Ans: |
C |
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Feedback: |
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The purpose of the nursing
process is to provide a systematic method for nurses to plan and implement
client care to achieve desired outcomes. “Without learning principles of
critical thinking and nursing process, it’s like using a calculator without
understanding what is means to add, subtract, multiply, or divide” and is why
the process should be complete with the paperwork. The other two answers are
vague and offer no explanation for the importance of the process. |
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12. |
A client is admitted to the
hospital for control of diabetes mellitus. When does the LPN understand the
nursing process begins? |
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A) |
When the client enters the
healthcare system |
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B) |
Prior to the client being
discharged |
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C) |
After the RN initiates the
plan of care |
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D) |
When the physician writes
the first order for care |
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Ans: |
A |
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Feedback: |
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The nursing process begins
when a client enters the healthcare system. The other three options are
incorrect. |
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13. |
The RN is obtaining a
health history and performing a physical assessment for a client who is
admitted to the hospital with complaints of chest pain. What part of the
nursing process does the LPN understand the RN is performing? |
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A) |
Planning |
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B) |
Implementation |
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C) |
Evaluation |
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D) |
Assessment |
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Ans: |
D |
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Feedback: |
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Assessment is the careful
observation and evaluation of a client’s health status. The nurse collects
information to determine abnormal function and risk factors that contribute
to health problems as well as client strengths. Planning is establishing the
outcomes and actions that will help achieve the overall goals. Implementation
is putting the plan into action. Evaluation is determining the client’s
responses to the care provided. |
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14. |
The RN develops an outcome
standard of “client will ambulate with an assistive device 60 feet with
assistance twice a day” for a patient who had a hip replacement. What part of
the nursing process is involved with this outcome statement? |
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A) |
Assessment |
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B) |
Planning |
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C) |
Implementation |
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D) |
Evaluation |
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Ans: |
B |
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Feedback: |
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Establishing the outcomes
and actions will help the client achieve the overall goals of care.
Assessment is the careful observation and evaluation of a client’s health
status by the collection of data. Implementation is putting the plan into
action, and evaluation is determining the client’s responses to the care
provided. |
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15. |
A client has been admitted
to the hospital with a large sacral pressure ulcer. The physician orders the wound
care protocol to be performed twice a day. What would be a statement on the
plan of care that would address the implementation phase of the nursing
process for this patient? |
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A) |
A 6 cm × 4 cm wound with
malodorous, yellow exudate |
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B) |
The client’s wound will
heal by 1 cm by the end of 5 days. |
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C) |
The client’s wound has
healed by 0.5 cm on day 3 of wound care. |
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D) |
Turn the client every 2
hours. |
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Ans: |
D |
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Feedback: |
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Turning the client every 2
hours is implementing care to allow the pressure ulcer to heal and prevent
another formation of a wound. Option A is the assessment phase of the nursing
process. Option B is the planning phase of the nursing process, and option C
is the evaluation phase of the nursing process. |
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16. |
The LPN plays a vital role
in the development of a nursing diagnosis for a client. What role does the
LPN have? |
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A) |
Report information that
suggests actual or potential health problems. |
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B) |
Examine and analyze the
client database to formulate nursing diagnosis. |
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C) |
Inform the physician about
the specific development of the nursing diagnosis. |
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D) |
Evaluate the effectiveness
of the nursing diagnosis and how it pertains to the data collected. |
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Ans: |
A |
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Feedback: |
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As in other phases of the nursing
process, the nurse’s role depends on his or her level of practice. LPN/LVNs
report information that suggests actual or potential health problems. RNs
examine and analyze the client database to formulate a nursing diagnosis. The
physician is generally not involved in the nursing process and care planning
of the client. The RNs role is to evaluate the effectiveness or resolving of
the nursing diagnosis. |
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17. |
The RN is attempting to
formulate a nursing diagnosis for a client but does not find where the
problem fits into a North American Nursing Diagnosis Association
(NANDA)–approved diagnosis. What is the best option for the nurse? |
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A) |
Gather other data so that
it will fit into a NANDA approved diagnosis. |
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B) |
The nurse will have to
forgo applying a nursing diagnosis. |
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C) |
Pick a NANDA-approved
diagnosis as long as it somewhat fits. |
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D) |
Use his or her own
terminology. |
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Ans: |
D |
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Feedback: |
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If a client’s problem does
not fit into any of the NANDA-approved diagnoses, the nurse can use her or
his own terminology. The nurse is not able to forgo, pick any diagnosis as
long as it comes close to fitting, or try gathering new data so that a
diagnosis will be chosen. |
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18. |
The nurse gathers data for
a client who has dehydration and formulates a nursing diagnosis of Fluid
Volume Deficit related to diarrhea and vomiting as evidenced by poor skin
turgor, lethargy, and altered fluid and electrolyte balance. What type of
nursing diagnosis is identified with this client? |
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A) |
Risk nursing diagnosis |
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B) |
Syndrome diagnosis |
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C) |
Health promotion nursing
diagnosis |
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D) |
Actual nursing diagnosis |
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Ans: |
D |
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Feedback: |
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Actual nursing diagnoses
identify existing problems, such as Urinary Retention or Anxiety. Health promotion
nursing diagnoses reflect clinical judgment of a client’s motivation and
behavior to increase well-being and enhance health-seeking behaviors.
Syndrome diagnoses describe diagnoses that occur as a group and are best
addressed as a group with collective interventions. Risk nursing diagnoses
identify potential problems and use the stem risk for, as in Risk for Impaired Skin
Integrity related to inactivity. |
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19. |
The nurse is developing a
care plan for a client who has had a stroke and is unable to assist with care
at this time. Which problem would the nurse deem a top priority? |
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A) |
Risk for development of a
pressure ulcer |
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B) |
Risk for Injury |
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C) |
Ineffective Breathing
Pattern |
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D) |
Social Isolation |
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Ans: |
C |
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Feedback: |
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Nurses must rank any
problem that poses a threat to physiologic functioning first. For example,
nursing diagnoses such as Ineffective Breathing Pattern and Deficient Fluid
Volume demand the nurse’s attention more than other diagnoses because these
situations may be life threatening. The other diagnoses are second level and
higher. This relates to Maslow’s hierarchy. |
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20. |
In order to establish
specific and realistic outcomes so that the client does not become frustrated
in trying to achieve them, who should be involved in establishing these
outcomes? |
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A) |
The client and family |
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B) |
The physician |
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C) |
The certified nursing
assistant (CNA) |
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D) |
Case management |
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Ans: |
A |
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Feedback: |
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The nurse includes the
client and family in establishing outcomes. Outcomes are specific and
realistic, so the client can attain them and not become frustrated, and
measurable, so the nurse can reliably determine to what extent the client is
meeting the goals. The physician, CNA, and case management do not play a role
in the development of nursing outcomes. |
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21. |
The nurse is prioritizing
the care of a client who has diagnoses of uncontrolled diabetes and may have
the left foot amputated related to a nonhealing ulcer. What need would the
nurse place at the lowest level while prioritizing this client’s care? |
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A) |
Physiologic needs |
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B) |
Safety and security needs |
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C) |
Love and belonging needs |
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D) |
Self-actualization needs |
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Ans: |
D |
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Feedback: |
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Self-actualization needs
are the fifth and last level. Physiologic needs are the first level, safety
and security needs are the second level, and love and belonging needs are the
third level. |
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22. |
The nurse has developed a
plan of care for a client who is having a surgical procedure and is at risk
for the development of pneumonia. The nurse devises the outcome statement to
read: “The client will have clear lungs by the third postoperative day.” On
the third postoperative day, the patient has left lower lobe crackles and
infiltrates on the chest x-ray. What conclusion does the nurse reach for this
client? |
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A) |
The outcome is achieved,
the problem is solved, and the nursing orders are discontinued. |
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B) |
The outcome is not met, but
progress is being made, and the plan of care is continued or revised with minor
change. |
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C) |
The outcome is not
achieved, and the plan requires critical reevaluation and major revision. |
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D) |
The outcome will be
reassessed in 2 more days. |
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Ans: |
C |
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Feedback: |
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The client has not achieved
the outcome and in fact has developed pneumonia. The plan will require
critical reevaluation, and new outcomes will be required to assist with
resolving the pneumonia. The other evaluation criteria are not correct for
this particular client’s condition. |
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23. |
The nursing student says to
the instructor, “I always hear about critical thinking and how to develop it.
How will this benefit me as a nurse?” What is the best response by the
instructor? |
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A) |
“If you have critical thinking
skills, you won’t make mistakes.” |
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B) |
“You will never make it
through nursing school without those skills.” |
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C) |
“Without good critical
thinking skills, you won’t be able to make a decision.” |
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D) |
“Acquiring critical
thinking skills will help you become more efficient and effective at
resolving problems.” |
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Ans: |
D |
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Feedback: |
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Developing good critical
thinking skills will make nurses more efficient and effective at resolving
problems. This careful, deliberate, outcome-directed thinking has predictable
features that nurses can practice and learn. Having critical thinking skills
does not mean that mistakes won’t be made but can be learned from. Options B
and C are nontherapeutic responses to the student. |
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24. |
The nurse is developing a
concept care map for a client with multiple medical problems. What would the
nurse take as the first step in developing and using a concept care map? |
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A) |
Assessment |
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B) |
Assessment/Diagnosis |
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C) |
Diagnosis/Planning |
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D) |
Planning/Implementation |
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Ans: |
A |
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Feedback: |
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The first step in
developing and using a concept care map involves identifying the primary
reasons for a client’s admission to a health care facility. The second step
is the assessment/diagnosis, the third step is diagnosis/planning, and the
fourth step is planning/implementation. |
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25. |
The student nurse is
developing a concept care map for her client with multiple sclerosis. In what
phase does the student determine the relationship among the nursing diagnoses
and begin to see the client holistically? |
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A) |
Assessment |
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B) |
Assessment/diagnosis |
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C) |
Diagnosis/Planning |
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D) |
Planning/Implementation |
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Ans: |
C |
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Feedback: |
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In diagnosis/planning, the
nurse determines relationships among nursing diagnoses. It provides a means
to “see” the client holistically. Assessment is the beginning phase where the
nurse begins collecting the data. In assessment/diagnosis, the diagnoses are
being formed and the relationships are not clear at this point.
Planning/implementation cannot begin until the relationship is formed. |
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26. |
The nurse understands that
one of the characteristics of critical thinking is flexibility. What can the
nurse do to achieve this characteristic? |
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A) |
Listen to new ideas and
other viewpoints. |
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B) |
Modify priorities and adapt
to change. |
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C) |
Accept that answers may not
come easily. |
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D) |
Foresee probable outcomes. |
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Ans: |
B |
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Feedback: |
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In order to demonstrate
flexibility, the nurse must be able to modify previous priorities as well as
adapt to change. Listening to new ideas and other viewpoints is an example of
being open minded. Accepting that answers may not come easily is an example
of perseverance, and being able to foresee probable outcomes is an example of
the ability to weigh advantages and disadvantages before making decisions. |
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27. |
A new graduate nurse is
assigned six clients to care for on a medical unit. Without asking anyone for
help, by the end of the shift, the nurse is visibly upset and states, “I
can’t do this anymore.” What characteristic of critical thinking has this
nurse not developed? |
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A) |
Show confidence |
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B) |
Aware of their own
limitations |
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C) |
Humble |
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D) |
Willing to persevere |
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Ans: |
B |
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Feedback: |
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The new graduate has not
developed the awareness of limitation and does not know when to ask for help.
Showing confidence is being aware of their strengths and capabilities. Being
humble is not having to know everything all of the time. Perseverance is
accepting that answers may not come easily. |
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28. |
The LPN is assisting with
the admission of a client scheduled for surgery the next day. What role does
the LPN have in the planning phase of the nursing process? |
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A) |
Gathers more extensive
biopsychosocial data |
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B) |
Draws conclusions, uses
judgment, and makes diagnosis |
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C) |
Establishes priorities,
sets short- and long-term goals |
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D) |
Contributes to the
development of care plans |
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Ans: |
D |
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Feedback: |
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The role of the LPN allows
for the contribution of the development of care plans. The other answers are
within the scope of practice of an RN. |
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29. |
The RN has developed the
plan of care for a client and shares the plan with the LPN. What can the LPN
provide in the implementation phase for this client? Select all that apply. |
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A) |
Basic therapeutic and
preventive nursing measures |
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B) |
Manages client care such as
delegation |
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C) |
Provides client and family
teaching |
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D) |
Records and exchanges
information with healthcare team |
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Ans: |
A, C |
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Feedback: |
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The role of the LPN in the
implementation phase is to provide basic therapeutic and preventive nursing
measures, provide client education, and record information. The other answers
are within the scope of practice of an RN. |
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30. |
A client has a nursing
diagnosis of Risk for Impaired Skin Integrity related to prescribed bed rest
and decreased sensation and mobility of the lower extremities. What type of
nursing diagnosis is this classified as? |
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A) |
Actual diagnosis |
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B) |
Health promotion diagnosis |
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C) |
Risk diagnosis |
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D) |
Syndrome diagnosis |
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Ans: |
C |
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Feedback: |
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The client does not have an
actual problem but is at risk for the development of impaired skin integrity
due to the bed rest. The client does not have a syndrome nor is this a
promotion of health. |
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31. |
The LPN is collecting data
so that the RN may develop the plan of care for the client. What is the
importance of accurate gathering of baseline data? |
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A) |
The physician will be able
to make a diagnosis. |
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B) |
A comparison for future
signs and symptoms |
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C) |
The RN will be able to make
the assignments based on the baseline data. |
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D) |
The RN will know what type
of medication the client will receive. |
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Ans: |
B |
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Feedback: |
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The client database includes
all the information obtained from the medical and nursing history, physical
examination, and diagnostic studies. Baseline data serve as a comparison for
future signs and symptoms and provide a reference for determining if a
client’s health is improving. The physician does not use the care plan for
his diagnosis. |
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32. |
A client being cared for by
the healthcare team has a large open abdominal wound after having a surgical
procedure. The wound had to be reopened due to the development of infection
and is left to heal with packing and dressing changes twice daily. What would
be an appropriate measurable short-term outcome for this client? |
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A) |
The wound will heal before
the client is discharged. |
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B) |
The client will change his
own dressing twice a day. |
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C) |
The client will have no
fever and no purulent discharge in 3 days. |
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D) |
Dressing changes will be
done twice a day using aseptic technique. |
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Ans: |
C |
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Feedback: |
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The client having no fever
or purulent discharge in 3 days is a realistic measurable goal. The wound is
large and will not heal within the time frame of discharge. It is unrealistic
to have an outcome that the client will be able to change his own dressing
after a surgical procedure. Dressing changes twice a day is a nursing
intervention. |
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33. |
The RN determines the
interventions for a client with pneumonia and writes them in the written plan
as nursing orders. What would be an appropriate nursing order for this
client? |
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A) |
Force fluids. |
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B) |
Offer the client 100 mL of
fluid every hour while awake. |
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C) |
Offer fluids prn. |
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D) |
Give adequate amounts of
fluid throughout the day. |
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Ans: |
B |
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Feedback: |
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|
Nursing orders are specific
nursing directions so that all healthcare team members understand exactly
what to do for the client. Different people are likely to interpret a vague
nursing order such as “Encourage fluids” differently, resulting in
inconsistent care. The other answers are not specific and are open to
different interpretations. Forcing a patient to do anything is not
therapeutic or ethical for nurses. |
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34. |
A client is being admitted
to the medical floor, and the RN is too busy to do the full assessment. The
RN delegates the LPN to care for the patient until the RN can see the
patient. What function is within the scope of practice for the LPN? |
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A) |
The LPN can gather the
data. |
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B) |
The LPN can draw
conclusions and use judgment to make a diagnosis. |
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C) |
The LPN can establish
priorities. |
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D) |
The LPN can manage the client’s
care. |
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Ans: |
A |
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Feedback: |
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|
The role of the LPN in the
nursing process for assessment is to gather data, perform assessment, and
identify the client’s strengths. The other answers are within the RN scope of
practice. |
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35. |
The nurse has developed a
nursing diagnosis of Risk for Complications (RC) of Thrombophlebitis for a
client. This is a problem that will be monitored and managed by the nurse
using physician-prescribed and nursing-prescribed interventions. What type of
nursing problem is this considered? |
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A) |
Syndrome diagnosis |
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B) |
Collaborative problem |
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C) |
Actual diagnosis |
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D) |
Risk diagnosis |
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Ans: |
B |
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Feedback: |
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|
A collaborative problem is
monitored and managed by the nurse using physician-prescribed and nursing-prescribed
interventions. This client does not have a syndrome or an actual problem with
thrombophlebitis. The difference between the risk diagnosis and the
collaborative is the medical diagnosis that is in the diagnostic statement. |
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Chapter 4, Interviewing and Physical Assessment
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1. |
Which of the following
should the nurse use during an admission interview? |
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A) |
Give the client suggestions
for the answers and avoid making eye contact during the interview. |
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B) |
Allow the client ample time
to answer each question and maintain eye contact. |
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C) |
Set a time limit to answer
each question and proceed to the next question if the client fails to do so. |
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D) |
Provide the client with a
self-help guide to look for answers and maintain eye contact occasionally. |
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Ans: |
B |
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Feedback: |
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|
The nurse should give the
client ample time to answer each question and maintain eye contact to
facilitate the interview. Giving the client suggestions for answers and
avoiding eye contact during the interview might make the client
uncomfortable. Giving the client a time limit to answer each question and
proceeding to the next question if the client fails to do so might make the
client anxious. Giving the client a self-help guide may hinder interaction
between the nurse and the client. |
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2. |
Which of the following is
important to do at the end of an interview with the client? |
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A) |
Call the client’s family
members to give them information. |
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B) |
Call the physician to
discuss findings and establish a plan of care. |
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C) |
Conduct a physical
examination immediately after the interview. |
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D) |
Summarize the information
and thank the client for cooperating. |
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Ans: |
D |
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Feedback: |
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|
A nurse should end an
interview with the client by summarizing what occurred and thanking the
client for cooperating. The nurse should not discuss the information obtained
through the interview with the client’s family. It may not be necessary to
call the doctor for further consultation or to conduct a physical examination
immediately after the interview. |
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3. |
Which portion of the
interview determines how well the client can perform activities of daily
living (ADLs)? |
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A) |
Cultural history |
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B) |
Functional assessment |
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C) |
Chief complaint |
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D) |
Psychosocial history |
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Ans: |
B |
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Feedback: |
|
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|
A functional assessment
determines how well the client can perform ADLs. The psychosocial history and
cultural history include the client’s age, occupation, religious affiliation,
cultural background, and health beliefs. The chief complaint is the current
reason the client is seeking care. |
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4. |
When asking questions about
the client’s marital status, the nurse is gathering information about which
of the following? |
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A) |
Present illness |
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B) |
Functional assessment |
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C) |
Chief complaint |
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D) |
Psychosocial history |
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Ans: |
D |
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Feedback: |
|
|
|
The psychosocial history
and cultural history include the client’s age, occupation, religious
affiliation, cultural background, health beliefs, marital status, and home
and working environments. When gathering information about the history of the
present illness, the nurse asks the client to describe all present problems,
including the onset, frequency, and duration of symptoms. A functional
assessment determines how well the client can perform activities of daily
living. The chief complaint is the current reason the client is seeking care. |
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5. |
Which assessment technique
involves a systematic observation of the client? |
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A) |
Auscultation |
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B) |
Inspection |
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C) |
Palpation |
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D) |
Percussion |
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Ans: |
B |
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Feedback: |
|
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|
Inspection is the
systematic and thorough observation of the client and specific areas of the
body. Auscultation involves listening with a stethoscope for normal and
abnormal sounds generated by organs and structures such as the heart, lungs,
and intestines. Palpation is assessing the characteristics of an organ or
body part by touching and feeling it with the hands or fingertips. Percussion
is tapping a portion of the body to determine whether there is tenderness or
to elicit sounds that vary according to the density of underlying structures. |
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6. |
Which of the following are
statements the client makes about how he or she feels? |
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A) |
Objective data |
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B) |
Cultural data |
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C) |
Cognitive data |
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D) |
Subjective data |
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Ans: |
D |
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Feedback: |
|
|
|
Subjective data are
statements the client makes about what he or she feels. Objective data are
facts obtained through observation, physical examination, and diagnostic
testing. Cultural data include cultural background and health beliefs. |
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7. |
The nurse is completing a
physical examination on a client complaining of abdominal pain. Which of the
following are facts obtained during the physical examination? |
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A) |
Symptoms |
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B) |
Objective data |
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C) |
Subjective data |
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D) |
Complaints |
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Ans: |
B |
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Feedback: |
|
|
|
Objective data are facts
obtained through observation, physical examination, and diagnostic testing.
Feelings related to subjective data are symptoms. Subjective data are
statements the client makes about what he or she feels. Complaints are
reasons the client is seeking care. |
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8. |
Questions about current and
past use of prescription medications would probably be part of which of the
following? |
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A) |
The client’s past health
history |
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B) |
The client’s history of
present illness |
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C) |
The client’s chief
complaint |
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|
D) |
The functional assessment |
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Ans: |
A |
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Feedback: |
|
|
|
The client’s past health
history includes identifying childhood diseases and prior hospitalizations.
History of present illness is gathered when the nurse asks the client to
describe all present problems, including the onset, frequency, and duration
of symptoms. A chief complaint is the current reason the client is seeking
care. A functional assessment determines how well the client can perform
activities of daily living. |
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