Nursing Chapter 11 What Type Assessment Should The Nurse Complete

Question 18

Type: MCSA

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication

with this client?

1. Have a member of the housekeeping staff who speaks the same language translate.

2. Use the translation services supplied by the hospital.

3. Make sure a family member who does speak English is available.

4. Conduct the interview using hand gestures.

Question 19

Type: MCSA

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this

client?

1. “Hello, I’m your nurse and I’ll be taking care of you today.”

2. “You’re lucky—there are no students on the unit today.”

3. “Good morning, is there anything you need right now?”

4. “Hi. If you need anything, put on your call light.”

Question 20

Type: MCSA

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the

interview is in the closing phase?

1. “I’m going to set up your physical assessment now. Do you have any questions?”

2. “Tell me more about how you feel.”

3. “Could you give examples of what types of other treatments you’ve had?”

4. “Is there anything you’re worried about?”

Question 21

Type: MCSA

During an assessment interview, the client states that an elective surgical procedure will not be done because it

does not fit into the client’s life goals. Into which of Gordon’s functional health patterns should the nurse identify

this client’s comment?

1. Cognitive/perceptual pattern

2. Coping/stress-tolerance pattern

3. Health-perception/health-management pattern

4. Value/belief pattern

Question 22

Type: MCSA

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to

this conclusion?

1. Observation of cues

2. Validation

3. Inference

4. Judgment

Question 23

Type: MCMA

The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as

being the purpose of the diagnosis phase?

Standard Text: Select all that apply.

1. Develop a list of problems.

2. Identify client strengths.

3. Develop a plan.

4. Specify goals and outcomes.

5. Identify problems that can be prevented.

Page Number: 156

Question 24

Type: MCSA

The nurse decides to seek wound care alternatives for a client’s stasis ulcer that is not healing after treatment for 2

weeks. In which phase of the nursing process is the nurse functioning?

1. Diagnosis

2. Implementation

3. Evaluation

4. Assessment

Question 25

Type: MCSA

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations

have become shallow. What type of assessment should the nurse complete at this time?

1. Initial assessment

2. Problem-focused assessment

3. Emergency assessment

4. Time-lapsed assessment

Question 26

Type: MCSA

Unlicensed assistive personnel measure a newly admitted client’s vital signs to be: temperature = 99.3(F),

respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?

1. Retake the vital signs.

2. Call the physician.

3. Continue with the physical assessment as soon as possible.

4. Report the findings to the charge nurse.

Question 27

Type: MCMA

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as

being a part of the database?

Standard Text: Select all that apply.

1. Reports from physical therapy the client received as an outpatient

2. Documentation of the nurse’s physical assessment

3. Physician’s orders

4. A list of current medications

5. Information about the client’s cultural preferences

6. Discharge instructions

Question 28

Type: MCMA

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing

effective communication guidelines?

Question 29

Type: MCMA

The nurse manager observes a staff nurse perform actions within the nursing process. Which activities did the

manager observe the nurse perform?

Standard Text: Select all that apply.

1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature

2. Advocating for a client who is mentally incapable of expressing her needs

3. Deciding to increase a client’s nasal oxygen based on his current pulse oxygenation levels

4. Documenting all clients’ pain level responses after the administration of pain medication

5. Attending in-services on a new hydraulic lift to be used to support safe client care

New Questions:

Question 30

Type: MCMA

The nurse is completing a health history with a newly admitted client. What information should the nurse include

when asking about the history of the client’s present illness?

Standard text: Select all that apply.

1. Allergies

2. Immunization record

3. When the symptoms started

4. Exact location of the problem

5. Things that aggravate the problem

Question 31

Type: MCMA

Standard Text: Select all that apply.

1. Reviews client record

2. Establishes a database

3. Performs nursing actions

4. Reviews nursing literature

5. Determines client’s strengths, risks, and problems