Chapter 9 Nursing Process/Documentation/Informatics

Chapter 9  Nursing Process/Documentation/Informatics

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A nurse is completing a client’s initial admission database by asking the client questions about his past and current state of health, family history, and physical exam. These actions are part of which step of the nursing process?
a.
assessment
c.
evaluation
b.
diagnosis
d.
planning

ANS: A
The purpose of assessment is to establish a database about a client. Data about a client’s physical, psychological, and emotional health are necessary to identify the client’s health-promoting behavior and actual or potential health problems. To obtain these data, a nurse determines such things as the client’s functional abilities, the normal activities of daily living, and lifestyle patterns. From these data, the nurse can identify client strengths and limitations that can affect treatment and recovery.

PTS: 1 DIF: Comprehension REF: White (2010)

2. Which of the following would a nurse expect to include in the assessment phase of the nursing process?
a.
determining the client’s intellectual level
b.
discussing any health care concerns or goals the client may have
c.
identifying difficulties within the client’s family
d.
selecting appropriate nursing interventions to assist the client to recover

ANS: B
The purpose of assessment is to establish a database about a client. Data about a client’s physical, psychological, and emotional health are necessary to identify the client’s health-promoting behavior and actual or potential health problems. To obtain these data, a nurse determines such things as the client’s functional abilities, the normal activities of daily living, and lifestyle patterns. From these data, the nurse can identify client strengths and limitations that can affect treatment and recovery.

PTS: 1 DIF: Comprehension REF: White (2010)

3. A client’s hospital admission assessment includes a health history and current health assessment. This type of assessment is known as:
a.
comprehensive
c.
ongoing
b.
focused
d.
primary

ANS: A
Comprehensive assessment, which is usually completed when a client is admitted for health care services, includes a complete client health history and current needs assessment and provides baseline data against which changes in health status can be compared. Assessment of the client’s physical and psychological health, the client’s perception of health, any health risk factors, and the client’s coping patterns is part of a comprehensive assessment.

PTS: 1 DIF: Knowledge REF: White (2010)

4. A client has been admitted with a history of dizzy spells and nausea. The client’s blood pressure is highly variable with an elevated temperature on 3 successive days. The physician has ordered vital-sign monitoring, including temperature, heart rate, respirations, and blood pressure every 4 hours. What type of assessment is this type of monitoring called?
a.
comprehensive
c.
ongoing
b.
focused
d.
primary

ANS: C
Ongoing assessment is done to confirm the validity of initial assessment data or to expand the original database; it includes systematic monitoring and observation of identified health problems, response to a plan of care that has been implemented, and identification of any new problems. Data collected during assessment are either subjective (obtained from the client’s perspective, including feelings, perceptions, and concerns) or objective (observable and measurable). The client’s health history (a review of functional health patterns prior to the current contact with the health care provider) comprises subjective data obtained primarily by interview. Objective data are obtained through standard assessment techniques performed during the client’s physical examination and from any laboratory and diagnostic testing.

PTS: 1 DIF: Comprehension REF: White (2010)

5. Which of the following is a primary source of client data?
a.
client
b.
client’s spouse, parent, or adult child
c.
initial source of data, whoever that may be
d.
health care provider

ANS: A
Data is collected from a variety of sources, but the client is considered the primary source of data as the major provider of information. As much information as possible should be gathered from the client, using both interview and physical assessment skills.

PTS: 1 DIF: Knowledge REF: White (2010)