Which individual typically would be responsible for collecting the subjective data on a client
during the initial comprehensive assessment?
B. Nurse
When performing the steps of the assessment phase of the nursing process, which of the
following would the nurse do first?
C. Collect subjective data
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An instructor is describing a comprehensive nursing health assessment to a group of students.
The instructor determines that the teaching was successful when the students identify which of
the following as the overall purpose?
D. Make a clinical judgment
A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy. What
is the overall purpose of assessment for this client?
D. Making clinical judgments
A client has presented to the emergency department (ED) with complaints of abdominal pain.
Which member of the care team would most likely be responsible for collecting the subjective
data on the client during the initial comprehensive assessment?
B. ED nurse
,The nurse has completed an initial assessment of a newly admitted client and is applying the
nursing process to plan the client's care. What principle should the nurse apply when using the
nursing process?
B. It is ongoing and continuous.
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. Review the client's medical record.
In response to a client's query, the nurse is explaining the differences between the physician's
medical exam and the comprehensive health assessment performed by the nurse. The nurse
should describe the fact that the nursing assessment focuses on which aspect of the
client'ssituation?
B. Effect of health on functional status
After teaching a group of students about the phases of the nursing process, the instructor
determines that the teaching was successful when the students identify which phase as being
foundational to all other phases?
A. Assessment
The nurse has completed the comprehensive health assessment of a client who has been
admitted for the treatment of community-acquired pneumonia. Following the completion of this
assessment, the nurse periodically performs a partial assessment primarily for which reason?
A. Reassess previously detected problems
The nurse is working in an ambulatory care clinic that is located in a busy, inner-city
neighborhood. Which client would the nurse determine to be in most need of an emergency
assessment?
B. A 45-year-old man with chest pain and diaphoresis for 1 hour
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?
C. Avoid biases and judgments
,The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes
and who will begin an educational program. The nurse is collecting subjective and objective
data. Which of the following would the nurse categorize as objective data?
C. Appearance
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?
D. 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 client would the nurse most likely expect to facilitate a referral?
B. A 50-year-old client newly diagnosed with diabetes
A 38-year-old client has been admitted to the emergency department (ED) with reports of
abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse
complete on this client?
A. focused assessment
When the nurse collects objective data, which finding requiresimmediate follow-up?
D. enlarged lymph node in the neck
The obstetric nurse is performing an initial assessment of a pregnant woman. Which subjective
data will the nurse include in the assessment? Select all that apply.
B. health care practices
C. personal medical history
D. number of pregnancies
A nurse has documented the findings of a comprehensive assessment of a new client. What is
the primary rationale that the nurse should identify for accurate and thorough documentation?
C. Assuring valid conclusions from analyzed data
A community health nurse is assessing an older adult client in their home. When gathering
subjective data, which of the following would the nurse identify?
A. The client's feelings of happiness
, A nurse on the subacute medical unit is planning to perform a client's focused assessment.
Which of the following statements should inform the nurse's practice?
C. The focused assessment addresses a particular client problem.
The nurse is reviewing a client's health history and the results of the most recent physical
examination. Which of the following data would the nurse identify as being subjective? Select all
that apply.
A. "I feel so tired sometimes."
D. Client complains of a headache
E. "My father died of a heart attack."
A nurse is completing an assessment that will involve gathering subjective and objective
information. Which data would the nurse identify as objective? Select all that apply.
B. physician's report
C. B/P 135/78, heart rate 74 beats/min, respirations 16 breaths/min
The nurse is performing a health assessment on a community-dwelling client who is recovering
from hip replacement surgery. Which of the following actions should the nurse prioritize during
assessment?
B. Interpret the information about the client in context.
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?
C. Focused assessment
After assessing a type 1 diabetic client who states they are unable to pay for their prescribed
insulin, the nurse includes this information in the cluster of cues collected during the
assessment. In which phase of the nursing process will this take place?
B. Step 2
The nurse is completing an assessment on a new client at the community health clinic and
would like to screen the client's cognitive ability. There are many resources that provide
screening tools for nurses. Which agency would be most helpful in directing the nurse to a
screening tool to assess the client's cognitive ability?
C. the Alzheimer's Association (AA)
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