1.
The nurse is assessing a client's smoking behavior. During the interview, the nurse learns that the client wants to stop smoking but needs help with this behavior change. Which nursing theory would best support the care this client needs?
Correct Answer
A. Health promotion model
Explanation
The Health Promotion Model would best support the care this client needs because it focuses on empowering individuals to take control of their own health behaviors and make positive changes. This model emphasizes the importance of self-efficacy, or the belief in one's ability to successfully change behavior, which aligns with the client's desire to quit smoking but needing help to do so. By using this model, the nurse can provide the client with resources, support, and strategies to assist in their smoking cessation journey.
2.
After completing the health history, the nurse begins to ask more detailed questions to clarify points and follow up on concerns expressed by the client during the interview. This portion of the health assessment is:
Correct Answer
C. Focused interview
Explanation
A focused interview is the portion of the health assessment where the nurse asks more detailed questions to clarify points and follow up on concerns expressed by the client during the interview. This allows the nurse to gather more specific information and gain a deeper understanding of the client's health history and concerns. It helps the nurse to focus on specific areas of the client's health and gather objective data to further assess and interpret the findings.
3.
During the health assessment, the nurse reviews the client's laboratory data. This is an example of:
Correct Answer
D. A secondary source of information
Explanation
Laboratory data is considered a secondary source of information. Other secondary sources include charts, reports from diagnostic testing, and information from family and other members of the health team.
Constant data is information that does not change over time, such as race, gender, or blood type.
The primary source of information is the client.
Subjective data is information obtained from the client during the health history.
4.
After conducting the health interview, the nurse begins to measure the client's vital signs. The nurse is collecting:
Correct Answer
B. Objective data
Explanation
In this scenario, the nurse is measuring the client's vital signs, which are measurable and observable data such as blood pressure, heart rate, temperature, and respiratory rate. These vital signs can be collected through direct observation or by using medical instruments. Therefore, the nurse is collecting objective data, which refers to factual and measurable information that does not depend on personal opinions or interpretations.
5.
The nurse is documenting the findings from a health assessment. Which of the following demonstrates the documentation of subjective information?
Correct Answer
A. "It hurts when I put weight on my leg."
Explanation
The correct answer demonstrates the documentation of subjective information because it is a statement made by the patient about their own experience or perception of pain. Subjective information is based on personal feelings, beliefs, and opinions, and cannot be measured or observed by others. In contrast, the other options in the question are objective findings that can be measured, observed, or assessed by the nurse.
6.
The nurse begins to document approximately three hours after completing the health, and physical assessment of a client admitted with acute right lower quadrant abdominal pain. Which of the following might be true about this documentation?
Correct Answer
B. It may not be as detailed due to the time that has elapsed since the assessment.
Explanation
Documentation of data collected in a health assessment should be completed as soon as possible. With the delay of three hours, there is a chance that the information will not be highly accurate, focused, concise, thorough, or complete. Ideally, the nurse should document sooner than three hours after the assessment.
7.
After completing a health assessment, the nurse documents the findings on a flow sheet with checkmarks and short notations. The type of documentation this nurse is using is most likely:
Correct Answer
D. Charting by exception
Explanation
The nurse is most likely using charting by exception as a type of documentation. This method involves only documenting significant findings or exceptions to the normal assessment, rather than documenting every detail. It is often represented by checkmarks and short notations on a flow sheet. This approach allows for more efficient and streamlined documentation, as it focuses on deviations from the expected rather than repetitive normal findings.
8.
During the health interview, the client mentioned that she is "very stressed about her home situation." The nurse sees this information as impacting the client's level of pain control. Which approach is the nurse using during the health interview?
Correct Answer
B. Holistic
Explanation
The nurse is considering more than the physiologic health status of the client. Holism includes all factors that impact the client's physical and emotional well-being.
There is no information in the question that links the client's culture and home situation with pain.
The developmental level has an impact on health assessment. However, there is no information in the question that links the client's developmental level and home situation with pain.
Communication refers to the exchange of information.
9.
During a health interview, the client states that she becomes increasingly short of breath when sitting in city traffic. The nurse views this information as:
Correct Answer
C. An external environmental factor
Explanation
The client's statement about becoming short of breath when sitting in city traffic indicates that the external environment, specifically the air quality in the city, is affecting her breathing. This is supported by the fact that she experiences this symptom only when sitting in city traffic, suggesting that it is not related to her cultural background, internal body functions, or emotions.
10.
The nurse is looking at the information collected during the health interview in an effort to cluster or group the data together. The nurse is demonstrating which phase of the nursing process?
Correct Answer
B. Diagnosis
Explanation
The nurse is demonstrating the diagnosis phase of the nursing process. This phase involves analyzing and clustering the data collected during the health interview to identify patterns, problems, and potential nursing diagnoses. By grouping the data together, the nurse can identify commonalities and make connections to formulate a diagnosis and develop a plan of care.
11.
The nurse is phoning the physical therapy department to alter a client's scheduled therapy appointment. Afterward, the nurse coordinates the time for the same client's morning care and afternoon radiology appointment. This nurse is functioning as:
Correct Answer
D. A manager
Explanation
The nurse in this scenario is functioning as a manager. They are responsible for coordinating the client's therapy appointment, morning care, and radiology appointment. This involves organizing and scheduling these different aspects of the client's care, which is a managerial role.
12.
The staff on a rehabilitation unit is attending an educational session to review the newest treatment options for clients with knee injuries. This program is most likely being presented by:
Correct Answer
B. A clinical nurse specialist
Explanation
Clinical nurse specialists have advanced education and degrees in a specific aspect of practice. They provide direct client care, direct and teach other team members providing care, and conduct nursing research within the area of specialization.
The nurse researcher identifies problems regarding client care, designs plans of study, develops tools, analyzes findings, and disseminates knowledge.
Nurse practitioners provide client care independently in a variety of settings.
Nurse administrators have a variety of responsibilities, including staffing, budgets, client care, and consulting.
13.
During the interview with Ms. Wong, she complains of pain, vomiting, diarrhea, and fever. Which of Ms. Wong’s symptoms needs to be assessed first?
Correct Answer
A. Vomiting
Explanation
In the scenario where Ms. Wong reports symptoms of pain, vomiting, diarrhea, and fever, prioritizing which symptom to assess first depends on the severity and potential for rapid health deterioration. Each symptom is a concern, but some may indicate more severe underlying issues:
Fever could indicate an infection or inflammatory response and is crucial to assess, but it might not be the most immediately dangerous unless very high.
Vomiting and diarrhea can lead to dehydration quickly, especially if they are severe and persistent. Dehydration can cause significant health issues, including electrolyte imbalances and renal problems.
Given these considerations, vomiting often takes priority for assessment because it can rapidly lead to dehydration, making it potentially the most immediately dangerous symptom. Addressing vomiting can help prevent dehydration and stabilize the patient for further evaluation and treatment. Therefore, vomiting should be assessed first in this case.
14.
Based on the interview and physical examination of Ms. Wong, which of the following NANDAs would be the priority NANDA for this client?
Correct Answer
B. Fluid volume, the deficient risk for related to vomiting and diarrhea
Explanation
The Nursing Diagnosis (NANDA) is the basis for planning and implementing nursing care. The pain that Ms. Wong is experiencing is not related to activity intolerance.
15.
During the interview process and physical assessment of Ms. Wong, which of the following would alert the nurse of a possible fluid volume deficit?
Correct Answer
B. Lips and mucous membranes dry
Explanation
NANDA diagnoses are formulated by the nurse according to the PES (P – Problem, E – Etiology, and S – Symptoms) system. When the nurse collects the data, Ms. Wong’s lips’ being cracked and dry alerts the nurse to a potential problem with fluid volume.