Chapter 1: Health Assessment and the Nurse
1.The steps in the nursing process include:
A)Assessment, strategic planning, negotiating, implementation, and evaluation.
B)History, planning, goal setting, and evaluation.
C)Current medical history, past medical history, and review of systems.
D)Assessment, diagnosis, planning, implementation, and evaluation.
2.Which of the following statements best describes the assessment step in the nursing process?
A)Data are analyzed to identify actual and potential health problems.
B)This step sets the tone for the rest of the nursing process.
C)This step involves setting goals and outcomes.
D)The patient's response is assessed based on set outcome criteria.
3.After gathering data, the nurse should:
A)Formulate potential nursing diagnoses.
B)Formulate actual nursing diagnoses.
C)Cluster the data into categories.
D)Make a plan.
4.Which step ensures that the assessment data are correct before proceeding with the nursing process?
A)Clustering data
B)Validation
C)Implementation
D)Evaluation
5.A preoperative patient is a two-pack-a-day smoker. What type of nursing diagnosis does the patient have related to airway problems during and after surgery?
A)Actual
B)Potential
C)Possible
D)Collaborative
6.Which diagnosis is a wellness diagnosis?
A)Body image disturbance
B)Risk for aspiration
C)Ineffective breastfeeding
D)Health-seeking behaviors
7.Planning should occur after:
A)Nursing diagnoses are prioritized.
B)Nursing diagnoses are identified.
C)Goals are set.
D)Evaluation has occurred.
8.Nursing actions are carried out during which step of the nursing process?
A)Assessment
B)Planning
C)Implementation
D)Evaluation
9.The nursing process uses which of the following approaches to problem solving?
A)Trial-and-error
B)Reflexive thinking
C)Intuition
D)Scientific method
10.What types of skills are most important in performing a physical assessment?
A)Psychomotor
B)Interpersonal
C)Ethical
D)Affective
11.Which legaldocument provides ethical decision-making guidelines for nurses?
A)Patient Bill of Rights
B)Advance Directives
C)American Nurses Association (ANA) Code for Nurses
D)Against Medical Advice
12.Which of the following activities is an example of secondary prevention?
A)Wound débridement
B)Immunization
C)Preoperative teaching
D)Long-term nasogastric feedings
13.Healthcare in an acute-care setting, such as the Emergency Room, is best described as:
A)Primary prevention.
B)Secondary prevention.
C)Tertiary prevention.
14.Which of the following findings is considered a symptom?
A)Rapid respirations
B)Sweaty palms
C)Belching
D)Palpitations
15.Who or what is considered the primary data source for a 2-year-old patient?
A)Toddler
B)Parent
C)Medical records
D)Other healthcare providers
16.A29-year-old, married female, Gravida 1, Para 0, is having contractions 5 minutes apart. She describes them as severe cramps. Her husband states, “I think her water broke on the way to the hospital.” Which type of assessment should the nurse begin?
A)Focused
B)Complete
C)Psychosocial
D)Personal
17.During the initial assessment interview, the nurse should allow for how much personal space?
A)0–18 inches
B)18 inches–3 feet
C)4–12 feet
D)12 or more feet
18.When utilizing an interpreter while taking the history, the nurse should realize:
A)The interview may take additional time.
B)Confidential content may not be covered.
C)Relatives are the best interpreters.
D)Children are the best interpreters.
19.A 25-year-old female patient complains of acute pain in her abdomen. The nurse touches her arm and she recoils. The nurse should recognize that touch:
A)Increases pain sensation.
B)Is offensive to most individuals.
C)Is very personal and should be avoided.
D)Is interpreted differently by each culture.
20.Restating the patient's main idea demonstrates that the nurse:
A)Is unclear about the patient's main complaint.
B)Is hard of hearing.
C)Is giving instructions.
D)Understands the patient's concerns.
21.Which of the following statements best demonstrates empathy?
A)“Ouch! I bet that hurts.”
B)“I understand that is painful.”
C)“Be brave. It will only hurt for a second.”
D)“On a scale from 1 to 10, how much does that hurt?”
22.Joe Keller, age 70, is brought to the emergency room with the chief complaint of chest pain for the past hour. Which question would be most useful in eliciting Mr. Keller's chief complaint?
A)Are you having chest pain?
B)Is the chest pain sharp?
C)Does the chest pain radiate to your arm?
D)What does the pain feel like?
23.What is the most effective way to assess the severity of Mr. Keller's pain?
A)Ask him what it feels like.
B)Ask him what makes it feel better.
C)Ask him to rate the pain on a scale of 0 to 10, with 10 being the worst.
D)Ask him what makes it feel worse.
24.Which type of question would be most effective in obtaining a patient's perception of his or her problem?
A)Open-ended question
B)Closed-ended question
C)Leading question
D)Probing question
25.During the interview, a patient states that she or he doesn't use many drugs. The nurse's best response to this statement is:
A)“Tell me about the drugs you use now.”
B)“To some people, six or seven is not many.”
C)“Do you mean legal drugs or illegal ones?”
D)“What kind of drugs are you talking about?”
26.During the interview, a patient tells the nurse that he rarely sleeps more than 4 hours a night and hasn't experienced any problems because of lack of sleep. An appropriate response by the nurse is:
A)“Okay, I see.”
B)“That can't be true, is it?”
C)“That's awful. Anyone needs more sleep than that.”
D)“Did I understand that you sleep only 4 hours every night?”
Answer Key
1.D
2.B
3.C
4.B
5.D
6.D
7.A
8.C
9.D
10.A
11.C
12.A
13.B
14.D
15.A
16.A
17.C
18.A
19.D
20.D
21.B
22.D
23.C
24.A
25.A
26.D
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