Questions
1. 1.ID: 18630134746
A nurse assisting with data collection of a client gathers both subjective and objective data. Which
finding would the
... [Show More] nurse document as subjective data?
A. The client appears anxious. Incorrect
B. Blood pressure is 170/80 mm Hg.
C. The client states that he has a rash. Correct
Rationale: The purpose of a physical assessment is to collect both subjective and objective
data. Subjective data, collected during the health history, consist of information that the
client gives about himself or herself. Objective data are obtained through physical
examination and vital signs measurements, what the nurse observes, and laboratory study
and diagnostic test results.
Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike
options that include data that the nurse would obtain during the physical examination.
Review the difference between subjective and objective data if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
D. The client has diminished reflexes in the legs.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 18630134750
A nurse is reviewing the findings of a physical examination that have been documented in a client’s
record. Which piece of information does the nurse recognize as objective data?A. The client is allergic to strawberries.
B. The last menstrual period was 30 days ago.
C. The client takes acetaminophen (Tylenol) for headaches.
D. A 1 × 2-inch scar is present on the lower right portion of the
abdomen. Correct
Rationale: Subjective data, collected during the health history, consist of information that
the client gives about himself or herself. Objective data are obtained through physical
examination and vital signs measurements, what the nurse observes, and laboratory study
and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the
reported use of medication for headaches are all subjective data.
Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike
options that include data that the nurse would obtain from the client during the health
history. Review the difference between subjective and objective data if you had difficulty
with this question.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 18630134760
A nurse is reading the report from the registered nurse for an initial home visit to a client with chronic
obstructive pulmonary disease. The client was recently discharged from the hospital. Which type of
database does the nurse read that contains this information from the client?
A. Episodic
B. Follow-up Incorrect
C. Emergency
D. Complete Correct
Rationale: A complete database includes a complete health history and a full physical
examination. It describes the client’s current and past state of health and forms a baseline
against which all future changes can be measured. The complete database is collected in
a primary care setting, such as a pediatric or family practice clinic; an independent or
group private practice; a college health service; a women’s health care agency; a visiting
nurse agency; or a community health agency. An episodic database is compiled for a
limited or short-term problem and is focused mainly on one problem or one body system. A
follow-up database is used to evaluate an identified problem at regular and appropriateintervals. An emergency database involves the rapid collection of the data that are often
compiled as lifesaving measures are being performed.
Test-Taking Strategy: Use the process of elimination. Noting the strategic words “initial
home visit” in the question will direct you to the correct option. Review the different types of
databases if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 18630134758
A 25-year-old client was seen in the clinic 2 weeks ago for symptoms of a cold and is now
complaining of chest congestion and cough. The nurse should assist with the data collection by
collecting which information?
A. Data related to follow-up care
B. A complete (total health) database
C. Data related to the respiratory system Correct
Rationale: An episodic database is compiled for a limited or short-term problem and is
focused mainly on one problem or body system. The history and examination will be
focused primarily on the respiratory system in this client. A complete database includes a
complete health history and a full physical examination. It describes the client's current and
past state of health and forms a baseline against which all future changes can be
measured. A follow-up database is used to evaluate an identified problem at regular and
appropriate intervals.
Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question
and noting the words “now complaining of chest congestion and cough” will direct you to
the correct option. Review the different types of databases if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data CollectionContent Area: Health Assessment/Physical Exam
D. Data related to the treatment for the cold
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 18630134722
A client is brought to the emergency department after a motor vehicle accident. The client is alert
and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with
data collection?
A.
Collect health history information first, then perform the physical examination.
B.
Ask health history questions while performing the examination and initiating emergency
measures.
Correct
Rationale: If the client is alert and cooperative and if the situation is not life-threatening, the
nurse should attempt to obtain as much subjective and objective data as possible while
caring for the client. Collecting health history information and then performing the physical
examination does not address the priority, which is treating the client. Collecting all data
requested on the history does not specifically address the client's immediate problems.
Performing emergency measures and not asking any health history questions does not
address data collection before treatment.
Test-Taking Strategy: Use the process of elimination. Focus on the data in the question
and note the strategic words “alert and cooperative.” Noting that the client has not
sustained life-threatening injuries will direct you to the correct option. Review the different
types of databases if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
C.
Collect all information requested on the history form, including social support, strengths,
and coping patterns.
D.Perform emergency measures and not ask any health history questions until the client’s
fractures have been treated in the operating room.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 18630133996
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup.
Which type of database does the nurse use in performing an assessment?
A. Emergency
B. Follow-up Correct
Rationale: A follow-up database is compiled to evaluate the status of an identified problem
at regular and appropriate intervals. An emergency database calls for rapid collection of
the data, often at the same time lifesaving measures are being performed. A complete
database includes a complete health history and a full physical examination. It describes
the client's current and past state of health and forms a baseline against which all future
changes can be measured. An episodic database (problem-centered) is compiled for a
limited or short-term problem. It is focused mainly on one problem or body system.
Test-Taking Strategy: Focus on the data in the question. Noting the strategic words “at the
clinic for a checkup” in the question will direct you to the correct option. Review the
different types of databases if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
C. Complete (total)
D. Problem-centered
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 18630133962
A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The
nurse understands which primary purpose of including cultural information in the health
assessment?
A.
Confirm the medical diagnosis.
B.
Make accurate nursing diagnoses.C.
Identify any hereditary traits related to the epilepsy.
Incorrect
D.
Determine what the client believes has caused the epilepsy.
Correct
Rationale: The primary purpose for including cultural information in the health assessment
is to determine what the client believes has caused the illness. In Mexican American
culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may
obtain data related to family history (hereditary) and formulate nursing diagnoses, these
are not the primary reasons for including cultural information in the health assessment. A
nurse gathers assessment data but does not confirm a medical diagnosis.
Test-Taking Strategy: Use knowledge of the subject, Mexican American cultural beliefs, to
begin the process of elimination. Eliminate the option that indicates to confirm a medical
diagnosis because this is not the role of the nurse. To select from the remaining options,
recall that cultural beliefs exist in relation to the cause of a disease; this will direct you to
the correct option. Review the nurse’s role in data collection and cultural considerations if
you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Cultural Diversity
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 18630134740
A nurse assisting with data collection uses the back of the hand to feel the client’s skin on both arms
and notes that the skin is warm. The nurse makes which determination?
A.
The client has a fever.
B.
The skin temperature is normal.
Correct
Rationale: To assess skin temperature, the nurse would first note the temperature of his or
her own hands, then use the backs (dorsa) of the hands to palpate the client’s skin
bilaterally. The skin should be warm, and the temperature should be equal bilaterally;warmth suggests normal circulatory status. The hands and feet may feel slightly cooler in a
cool environment. Giving the client additional fluids, removing the blanket, and checking for
a fever are all incorrect responses to this finding.
Test-Taking Strategy: Focus on the data in the question. Note the strategic word “warm.”
Recalling that warmth suggests normal circulatory status will direct you to the correct
option. Review normal skin temperature if you had difficulty with this question.
Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Integumentary
C.
The client needs to drink additional fluids.
D.
The client needs to have the blanket removed.
Incorrect
Awarded 0.0 points out of 1.0 possible points.
9. 9.ID: 18630133918
A nurse assisting with data collection notes that the client’s skin is very dry. The nurse documents
this finding using which term?
A. Xerosis Correct
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or
sebum and is often marked by a pattern of fine lines, scaling, and itching. Causes include
too-frequent bathing, low humidity, and decreased production of sebum in aging skin.
Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to
scratch the skin. Seborrhea is one of several common skin conditions in which an
overproduction of sebum results in excessive oiliness or dry scales. Actinic keratoses are
red-tan scaly plaques that grow over the years, becoming raised and roughened. A silverywhite scale may adhere to the plaque. They occur on sun-exposed surfaces and are
directly related to sun exposure. Actinic keratoses are premalignant and may develop into
squamous cell carcinoma.
Test-Taking Strategy: Knowledge of the subject, the characteristics of various skin
conditions and lesions, is needed to answer this question. This knowledge and noting the
words “very dry” in the question will direct you to the correct option. Review the skin
conditions identified in the options if you had difficulty with this question.Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Adult Health/Integumentary
B. Pruritus
C. Seborrhea
D. Actinic keratoses
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 18630134702
A nurse is preparing to assist the health care provider examine a client’s skin with the use of a Wood
light. In preparing for this diagnostic test, the nurse should perform which action?
A. Darken the room Correct
Rationale: A handheld long-wavelength ultraviolet (black) light, or Wood light, is sometimes
used during physical examination of the skin. Areas of blue-green or red fluorescence are
associated with certain skin conditions. Hypopigmented skin appears more prominent
when it is viewed under black light, greatly facilitating the evaluation of pigment changes in
fair-skinned clients. Examination of the skin is always carried out in a darkened room. The
test is noninvasive, and the nurse should reassure the client that no discomfort is
associated with a Wood light examination.
Test-Taking Strategy: Use data in the question to focus on the name of the test. Recalling
that this test is noninvasive will assist you in eliminating the incorrect options. Review the
procedure for performing a Wood light test if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Integumentary
B. Obtain informed consent from the client
C. Obtain a scalpel and a slide for diagnostic evaluation
D. Obtain medication to anesthetize the skin area before proceeding with
the examination Incorrect
Awarded 0.0 points out of 1.0 possible points.11. 11.ID: 18630133966
A nurse assisting with data collection for a client with kidney failure notes that the client has the
appearance of generalized edema over the entire body. The nurse documents this finding using
which terminology? [Show Less]