Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 11
Question 1
Type: MCSA
The student is learning the steps of the nursing process. What is the first thing that the student should realize about
the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Question 2
Type: MCSA
While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape
used to secure the dressing. In which phase of the nursing process is the nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Question 3
Type: MCSA
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says
“leave me alone.” Which subjective data should the nurse document?
1. Restlessness
2. “Leave me alone”
3. Not talkative
4. Pale and diaphoretic
Question 4
Type: MCSA
Family of a client demonstrating confusion state that this is not the client’s usual behavior. How should the nurse
document this data?
1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data
Question 5
Type: MCSA
The nurse provides a back rub to a client after administering a pain medication with the hope that these two
actions will help decrease the client’s pain. Which phase of the nursing process is this nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Question 6
Type: MCSA
A new client has been admitted to the care area. How soon should the nurse plan to complete a physical
assessment on this patient?
1. 1 hour
2. 12 hours
3. 48 hours
4. 24 hours
Question 7
Type: MCSA
The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse
use as the best source of data for this client?
1. Medical record from the child’s birth
2. Grandmother
3. Parents
4. Admitting physician
Question 8
Type: MCSA
A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse
respond to this client?
1. “In order to make sure all of your information is complete, I need to ask these questions.”
2. “You’re right. Let me know if there’s anything you need right now.”
3. “I’ll be done shortly, just give me a few more minutes.”
4. “You shouldn’t be upset. We’re only doing our jobs.”
Question 9
Type: MCSA
The nurse documents: “Client avoids eye contact and gives only vague, nonspecific answers to direct questioning
by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with
spouse.” Which method of data collection does this documentation demonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing
Question 10
Type: MCSA
A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for
this particular nurse?
1. A client with audible breathing
2. Moaning of a client in pain
3. Whirring of ventilators
4. Co-orkers discussing their clients’ conditions
Question 11
Type: SEQ
A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse
observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least
priority).
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The family is at the bedside.
Choice 2. The IV pump is running on battery.
Choice 3. The ECG monitor shows tachycardia.
Choice 4. The client reports being restless.
Choice 5. O2 tubing is not attached to wall regulator.
Question 12
Type: MCSA
During an initial interview, the client says “I don’t understand why I have to have surgery; I’m really not that sick
or in pain right now.” How should the nurse respond to the client?
1. “It’s OK to be worried. Surgery is a big step.”
2. “What kind of questions do you have about your surgery?”
3. “I think these are things you should be asking your doctor.”
4. “Have you had surgery before?”
Question 13
Type: MCSA
The nurse is completing a health history with a client who has complications from chronic asthma. Which open-
ended question should the nurse use?
1. “How would you describe your sleep pattern?”
2. “Can you describe your coughing pattern?”
3. “Is there anything that makes your breathing worse?”
4. “What medications are you on?”
Question 14
Type: MCSA
The nurse is assessing a client’s level of pain. Which open-ended question should the nurse use for this situation?
1. “Is your pain worse at night?”
Kozier & Erb’s Fundamentals of Nursing, 10/E Test Bank
Copyright 2016 by Pearson Education, Inc.
2. “What brought you to the clinic?”
3. “How has the pain impacted your life?”
4. “You’re feeling down about having pain, aren’t you?”
Question 15
Type: MCSA
A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort
during the interview, what should the nurse do?
1. Sit next to the client, a few feet apart.
2. Sit behind a desk.
3. Stand at the side of the client’s chair.
4. Stand at the counter to take notes during the interview.
Question 16
Type: MCSA
A client in the emergency department has a non-life-threatening wound. The unit is busy with other clients,
families, and people in the waiting room. How should the nurse conduct an interview with this client?
1. Have the client wait until the department quiets down, as the wound is not too serious.
2. Tell the client to wait in the waiting room and fill out the paperwork.
3. Draw curtains around the client and nurse to provide as much privacy as possible.
4. Make sure the client’s back is to the rest of the room so as not to be heard by passersby.
Question 17
Type: MCSA
A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the
nurse to conduct this client’s interview?
1. As soon as the client gets to the floor
2. After the client has settled in and been oriented to the room
3. When the family is available to help
4. After the client has been medicated