Fundamentals Of Nursing 8th Edition By Taylor – Test Bank
1. Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
A) “Assessment data about the client should be collected continuously.”
B) “Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses.”
C) “Assess your client at least hourly if the client’s vital signs are unstable, and every two hours if the vital signs are stable.”
D) “Assessment data should be collected prior to the physician rounding on the unit.”
Data about the client are collected continuously because the client’s health status can change quickly.
2. The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
A) Human Needs (Maslow) model
B) Functional Health Patterns model
C) Human Response Patterns model
D) Body System model
The nurse is following the Human Needs model based on Maslow’s Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.
3. A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?
A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
B) Encourage the novice nurse to develop his or her own tool for data collection.
C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation.
D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.
4. When documenting subjective data, the nurse should do which of the following?
A) Use the client’s own words placed in quotation marks.
B) Paraphrase the information stated by the client.
C) Validate the information with the client’s family prior to documentation.
D) Record the information using nonspecific words.
Subjective data should be recorded using the client’s own words, whenever possible. Quotation marks should be used around the client’s statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.
5. The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
A) Measure the client’s oral temperature.
B) Ask a colleague for assistance.
C) Give the client a clean gown and warm blankets.
D) Obtain an order for blood cultures.
An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client’s temperature. This should precede interventions such as blood work or even providing a warm blanket.
6. The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
A) To gather data about a specific and current health problem
B) To identify life-threatening problems that require immediate attention
C) To compare and contrast current health status to baseline data
D) To establish a database to identify problems and strengths
An initial assessment is performed shortly after the client is admitted to a health care agency or service. The purpose of the initial assessment is to establish a complete database for problem identification and care planning.
7. A client comes to her health care provider’s office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
A) Initial assessment
B) Focused assessment
C) Emergency assessment
D) Time-lapsed assessment
A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.
8. A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
A) To identify a life-threatening problem
B) To establish a database for medical care
C) To practice respiratory assessment skills
D) To facilitate the resident’s ability to breathe
When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).
9. A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
The time-lapsed assessment is scheduled to compare a client’s current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess health status and to make necessary revisions in the plan of care.
10. Of the following information collected during a nursing assessment, which are subjective data?
A) vomiting, pulse 96
B) respirations 22, blood pressure 130/80
C) nausea, abdominal pain
D) pale skin, thick toenails
Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data.