Test Bank For Fundamentals of Nursing 4th Edition By Delaune – Ladner
MULTIPLE CHOICE
- The nurse is working with a client within the assessment phase of the nursing process. Which activity will the nurse NOT do during this phase?
| a. | Data collection | c. | Data documentation |
| b. | Data verification | d. | Data evaluation |
ANS: D
The essential elements of the assessment process include data collection, data verification, data organization, data interpretation, and data documentation. Data evaluation is not conducted during this phase of the nursing process.
PTS: 1 DIF: Application REF: Purpose of Assessment
- The nurse is preparing to conduct a comprehensive assessment with a client. This type of assessment is usually done:
| a. | on admission to a health care facility. |
| b. | on discharge from a health care facility. |
| c. | to focus in depth on a particular health care problem. |
| d. | to provide systematic monitoring and observation related to specific problems. |
ANS: A
A comprehensive assessment is usually performed upon admission to a health care agency and includes a complete health history to determine current needs of the client. A focused assessment is done to focus in depth on a particular health care problem. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. An assessment done on discharge from a health care facility is not an identified type of nursing assessment.
PTS: 1 DIF: Application REF: Types of Assessment
- A client is admitted to the emergency room for treatment of a severe laceration. The type of assessment most likely to be performed by the nurse is a(n):
| a. | comprehensive assessment. | c. | ongoing assessment. |
| b. | focused assessment. | d. | expansive assessment. |
ANS: B
A focused assessment is an assessment that is limited in scope in order to focus on a particular need or health care problem or potential health care risk. A comprehensive assessment is usually performed upon admission to a health care agency and includes a complete health history to determine current needs of the client. An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. There is no such category as expansive assessment.
PTS: 1 DIF: Application REF: Types of Assessment
- The nurse is collecting data from a client. Which of the following would be considered as being subjective data?
| a. | The client reports having nausea. |
| b. | The client’s blood pressure is 120/82. |
| c. | The client has a reddened area on the buttocks. |
| d. | The client’s blood sugar is 100 g/dL. |
ANS: A
Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data that would be subjective would be “the client reports having nausea.” The other data would be considered as being objective data.
PTS: 1 DIF: Analysis REF: Types of Data
