The nurse is collecting data from a client. which of the following best reflects objective data?

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The nurse is collecting data from a client. Which of the following best reflects objective data?
A. Appearance B. Religion C. Occupation D. Age

A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
A. Focused assessment B. Emergency assessment C. Ongoing assessment D. Comprehensive assessment

What is a required component of a health assessment?
A. Critical decision making B. Critical thinking C. Critical judgment D. Critical analysis

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?
A. Inspection B. Sympathy C. Observation D. Empathy

The nurse is exhibiting critical thinking in which client care situation?
A. Notifying the healthcare provider of a critical lab result. B. Transcribing medication orders onto the nurse's medication administration record. C. Performing a focused assessemt on a client who is complaining of shortness of breath. D. Answering the client's call bell alarm while the nursing assistant is at lunch.

Performing a focused assessment on a client who is complaining of shortness of breath.

Before meeting the client and performing a comprehensive health assessment, which of the following would be most important for the nurse to do?
A. Review the client's medical record. B. Obtain basic biographic data. C. Validate information with the client. D. Consult essential resources.

Review the client's medical record.

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2020 indicator of responsible sexual behavior?
A. The importance of abstaining from sexual activity unless in a monogamous relationship B. The importance of using a condom when engaging in sexual activity C. The need to reduce the percentage of adolescents who are HIV positive D. The need for frequent diagnostic testing for sexually transmitted infections

The importance of using a condom when engaging in sexual activity

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:
A. Using reputable health-education strategies to reduce risk behaviours B. Understanding the health problems that clients experience in everyday life C. Ascertaining past and current use of health care services D. Determining client stress levels related to lifestyle choices

Using reputable health-education strategies to reduce risk behaviours

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?
A. Establish a baseline for the comparison of future health changes. B. Determine the most likely prognosis for the client's health problem. C. Identify the status of the client's airway, breathing, and circulation. D. Identify the most appropriate forms of medical intervention for the client.

Establish a baseline for the comparison of future health changes.

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
A. focused or problem-oriented assessment. B. initial comprehensive assessment. C. ongoing or partial assessment. D. emergency assessment.

focused or problem-oriented assessment.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
A. Assessment B. Evaluation C. Implementation D. Diagnosis

Which of the following is the best example of holistic data collection by a nurse?
A. Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test B. Performing an x-ray, ECG, exercise stress test, and complete blood count C. Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings D. Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?
A. Inspection B. Interviewing C. Therapeutic communication D. Active listening

Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?
A. Concentrate first on planning care for the problem identified initially by the client. B. Plan to reassess the client with the focus on the possible additional health issues. C. Interview the family about the existence of additional health-related issues when they visit. D. Extend the time originally allotted for the completion of the initial health assessment.

Extend the time originally allotted for the completion of the initial health assessment.

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
A. environmental B. social well-being C. developmental level D. physical

A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, “I have had a lot of pain in my abdomen.” What type of assessment would the nurse conduct?
A. focused B. emergency C. ongoing partial D. comprehensive

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?
A. Inspection B. Palpation C. Sympathy D. Empathy

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?
A. “I'm sorry, but assessment is ongoing and continuous.” B. “Fortunately, assessment only needs to be done at the beginning of your stay.” C. “Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end.” D. “I'll just need to evaluate you once more, at the end of your stay.”

“I'm sorry, but assessment is ongoing and continuous.”

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
A. Collaborate with the physician who is treating the client. B. Ask the client about the most recent experiences of pain. C. Review the client's medication administration record for analgesic use. D. Meet with the client's spouse and daughter to discuss the client's pain.

Ask the client about the most recent experiences of pain.

Student nurses are learning about evidence-based practice. What would they learn is the final step in this process?
A. Justifying the selection of interventions B. Identifying the issue or problem based on an analysis of current nursing knowledge and practice C. Evaluating research evidence using their own criteria D. Searching the literature for research

Justifying the selection of interventions

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?
A. Document the data B. Validate the data C. Collect objective data D. Collect subjective data

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
A. Evaluate whether outcomes of treatment are met B. Perform a rapid assessment for prompt treatment C. Determine any changes from the baseline data D. Collect subjective data related to the client's overall health

Determine any changes from the baseline data

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
A. Emergency assessment B. Focused assessment  C. Ongoing assessment D. Comprehensive assessment

Revising the plan as needed occurs in what part of the nursing process?
A. Assessment B. Diagnosis C. Planning D. Evaluation

What are nurses able to detect through the health assessment?
A. Areas in need of health adjustments B. Areas that need continuous care C. Areas that need referral to a specialist D. Areas that need in-hospital care

Areas in need of health adjustments

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
Take anthropometric measurements Perform a musculoskeletal examination Obtain a 24-hour diet recall Collect subjective data related to overall function

The nurse is collecting data from a client. Which of the following best reflects objective data?
A. Age B. Occupation C. Religion D. Appearance

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 posture  B. The client's feelings of happiness C, The client's affect D. The client's behavior

The client's feelings of happiness

When assisting a patient with health promotion, what must the nurse also nurture?
A. School/work attendance B. A healthy environment C. Knowledge of the Healthy People 2020 indicators D. Family communication

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?
A. Disability B. Breathing C. Circulation D. Airway

During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation?
A. Determining whether the client wants to stop smoking B. Educating the client on the detrimental effects smoking has on the entire body. C. Sharing with the client that there are various smoking cessation methods available. D. Identifying smoking as a modifiable risk factor for the client.

Determining whether the client wants to stop smoking

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. Measure the client's blood glucose four times daily. B. Assist the client with personal hygiene. C. Provide the client with a bedtime protein snack. D. Encourage the client to increase oral fluid intake.

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 adult presenting for an influenza vaccination B. An 80-year-old client who lives with her daughter C. A teenager seeking information about contraception D. A 50-year-old client newly diagnosed with diabetes

A 50-year-old client newly diagnosed with diabetes

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?
A. Assessment B. Diagnosis C. Planning D. Evaluation

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
A. ongoing or partial assessment.  B. focused or problem-oriented assessment. C. initial comprehensive assessment. D. emergency assessment.

focused or problem-oriented assessment.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next
A. cluster the data collected. B. check for the presence of defining characteristics. C. draw inferences and identify problems. D. document conclusions.

check for the presence of defining characteristics.

A group of students is reviewing information about the potential opportunities for nurses with advanced assessment skills. The students demonstrate that they understand the information when they identify which of the following as helping to promote this role?
A. Restraints in the cost of medical care B. Broadening of the base of biomedical data C. Decrease in client participation in care D. Expansion of health care networks

Expansion of health care networks

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?
A. Determine the most likely prognosis for the client's health problem. B. Identify the status of the client's airway, breathing, and circulation. C. Identify the most appropriate forms of medical intervention for the client. D. Establish a baseline for the comparison of future health changes.

Establish a baseline for the comparison of future health changes.

Revising the plan as needed occurs in what part of the nursing process?
A. Assessment B. Diagnosis C. Planning D. Evaluation

An assessment that concentrates on patterns of role performance that all humans share is called what?
A. Functional B. Body systems C. Focused D. Head-to-toe

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient?
A. Knowledge deficit B. Acute pain C. Nutrition: less than body requirements D. Ineffective coping

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
A. Secretary B. Technician
C. Nurse D. Physician

A nurse is conducting a health assessment. How will the information collected from the patient be used?
A. to facilitate nurse–patient caring B.  as a basis for the nursing process C. to illustrate nursing competence D. as one component of medical care

as a basis for the nursing process

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?
A. The client's medical comorbidities B. The client's learning style C. The client's motivation for change D. The client's prognosis for recovery

The client's motivation for change

What is the primary function of the health care team?
A. To decide the best overall care B. To develop an individual focus for each member C. To guide the patient’s care throughout times of crisis D. To work together to obtain maximum coverage

To decide the best overall care

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?
A. Involves the client's musculoskeletal system and activities of daily living B. Focuses primarily on the client's physiologic development status C. Physiologic, psychological, sociocultural, developmental, and spiritual data D. Focuses only on the client's psychological, sociocultural, and spiritual well-being

Physiologic, psychological, sociocultural, developmental, and spiritual data

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
A. Review of literature and consultation with faculty B. Individual student interview and questionnaire C. Physical assessment and health history D. Walk-through of education facility and faculty questionnaire

Individual student interview and questionnaire

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?
A. The nurse's potential for liability  B. The unit's protocols C. The client's acuity D. The client's age

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?
A. Assessment B. Diagnosis C. Planning D. Evaluation

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?
A. significantly impaired hearing B. lives alone C. greatly concerned about cost of services D. widowed 2 years ago

significantly impaired hearing

A nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client?
A. Healthy People 2020 B. Pender Health Promotion Model C. U.S. Preventive Services Task Force D. Health Belief Model

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. Identify the need for referral B. Construct a plan of care C. Determine if pertinent data has been omitted D. Avoid biases and judgments

Avoid biases and judgments

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. Provide the client with a bedtime protein snack. B. Encourage the client to increase oral fluid intake. C. Measure the client's blood glucose four times daily. D. Assist the client with personal hygiene.

Measure the client's blood glucose four times daily.

How does a nurse best facilitate the nursing health assessment?
A. Creating a nursing care plan B. Formulating a nursing diagnosis C. Maintaining privacy D. Asking the appropriate questions

Asking the appropriate questions

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
A. To collect subjective data related to the client's overall health  B. To evaluate whether outcomes of treatment are met C. To perform a rapid assessment for prompt treatment D. To determine any changes from the baseline data

To determine any changes from the baseline data

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. Obtain basic biographic data. B. Validate information with the client. C. Review the client's medical record. D. Consult clinical resources explaining the client's diagnosis.

Review the client's medical record.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
A. Ask the client about the most recent experiences of pain.  B. Meet with the client's spouse and daughter to discuss the client's pain. C. Collaborate with the physician who is treating the client.  D. Review the client's medication administration record for analgesic use.

Ask the client about the most recent experiences of pain.

Revising the plan as needed occurs in what part of the nursing process?
A. Assessment B. Diagnosis C. Planning D. Evaluation

What is the primary function of the health care team?
A. To guide the patient’s care throughout times of crisis B. To work together to obtain maximum coverage C. To decide the best overall care D. To develop an individual focus for each member

To decide the best overall care

Which of the following is the collecting objective data?

Which would be an example of objective data the patient is?

Which of the following is objective data in nursing assessment?

Which data will the nurse report as objective data?