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20 Cards in this Set

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The nurse records the following subjective data in the client’s medical record:
A. Breath sounds clear to auscultation
B. Amber urine in sufficient quantities
C. Pain intensity 8 out of 10
D. Skin warm and dry
C
The nurse records the following objective data in the client’s medical record:
A. Increasing hair loss over past 2 months
B. Expelled one tablespoon of yellow sputum
C. Anxious over upcoming test
D. Performs breast self-examination monthly
B
A client who is alert and awake is being transferred to another hospital with a copy of his medical records. Before the transfer the nurse must:
A. Obtain written permission to copy the medical records for the receiving hospital
B. Discuss the need to copy the medical records with the client’s family
C. Ask the hospital lawyer if this requires risk management approval
D. Be certain that the physician writes an order for the record to be copied
A
When interviewing a client, the nurse uses the following open-ended style sentence:
A. Do you have any concerns right now?
B. Is your family worried about you being in the hospital?
C. How many times do you get up to go to the bathroom at night?
D. What do you mean when you say, “I don’t feel quite right?”
D
When the nurse asks the client about the presence or absence of allergies, this is an example of:
A. Biographical information
B. History of present illness
C. Environmental history data
D. Health history data
D
The nursing assessment is the __________ phase of the nursing process.
A. First
B. Second
C. Third
D. Fourth
A
The nurse asks the client’s spouse, “Mrs. Williams, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?”

The above statement is an example of __________________ of assessment data.
VALIDATION
A review of systems (ROS) is information obtained from the client during the interview and is an example of ______________ data.
SUBJECTIVE
Place the following sentences in proper sequence according to the phases of interviewing.
a. “As your nurse, I am pleased to see that you are going home to be with your family over the holidays.”
b. “Mr. Smith, my name is Jane, and I will be asking you some questions that are important for us to care for you properly.”
c. “Mrs. Jones, tell me what brought you to see the nurse practitioner today.”
B, C , A
During the assessment of a client with anemia the nurse clusters the following data:
A. Skin pale
B. Respiratory rate, 22 breaths per minute
C. Capillary refill 2 seconds
D. Hypoactive bowel sounds
E. Report of need for two pillows when sleeping
F. Heart sounds regular
A, B, E
THE PURPOSE OF ASSESSMENT IS TO;
A. ESTABLISH A DATABASE CONCERNING THE CLIENT
B. TEACH THE CLIENT ABOUT HIS OR HER HEALTH
C. IMPLEMENT NURSING CARE
D. DELEGATE NUSRING RESPONSABILITY
A. ESTABLISH A DATABASE CONCERNING THE CLIENT
CRITICAL THINKING IS THE ACTIVE, ORGANIZED, COGNITIVE PROCESS USED TO CAREFULLY EXAMINE ONE'S THINKING. UTILIZING CRITICAL THINKING DURING ASSESSMENT ALLOWS THE NURSE TO.
A. REVIEW THE ASSESSMENT WITH OTHER HEALTHCARE PROVIDERS
B. DETERMINE THE NURSING CARE WAS DELIVERED
C. IDENTIFY THE ANTICIPATED CLIENT RESPONSE TO CARE
D. DIRECT THE ASSESSMENT IN A MEANINGFUL AND PURPOSEFUL WAY
D. DIRECT THE ASSESSMENT IN A MEANINGFUL AND PURPOSEFUL WAY
ASSESSMENT DATA MUST BE DESCRIPTIVE, CONCISE, AND COMPLETE. AN ASSESSMENT SHOULD NOT INCLUDE:
A. INFERENCES OR INTERPRETATIVE STATEMENTS THAT ARE UNSUPPORTED WITH DATA
B. A DETAILED PHYSICAL EXAMINATION
C. THE USE OF INTERPERSONAL COGNITIVE SKILLS
D. SUBJECTIVE DATA FROM THE CLIENT
A. INFERENCES OR INTERPRETATIVE STATEMENTS THAT ARE UNSUPPORTED WITH DATA
DATA COLLECTION INCLUDES THE GATHERING OF SUBJECTIVE AND OBJECTIVE DATA FROM OR ABOUT THE CLIENT. SUBJECTIVE DATA ARE:
A. OBSERVATIONS MADE BY THE DATA COLLECTOR
B. ANCILLARY REPORTS FROM OTHER SERVICES
C. CLIENT'S PERCEPTIONS ABOUT THEIR HEALTH PROBLEMS
D. OBTAINED FROM THE PHYSICIAN HISTORY AND PHYSICAL FORM
C. CLIENTS PERCEPTIONS ABOUT THEIR HEALTH PROBLEMS
ONE OF THE MOST IMPORTANT SKILLS NEEDED TO OBTAIN ACCURATE INFORMATION FROM YOUR CLIENT IS (ARE)
A. TEACHING AND ASSESSMENT
B. COGNITIVE AND TEACHING
C. GOOD COMMUNICATION AND CRITICAL THINKING
D. PSYCHOMOTOR
C. GOOD COMMUNICATION AND CRITICAL THINKING
THE FIRST STEP IN ESTABLISHING A DATABASE IS TO COLLECT SUBJECTIVE INFORMATION BY INTERVEIWING THE CLIENT. AN INTERVIEW IS:
A. AN ORGANIZED CONVERSATION WITH THE CLIENT
B. IMPLEMATION OF PHYSICIAIN ORDERS
C. DETERMINING SPECIFIC NURSING ACTIONS
D. DELEGATING PERSONNEL RESPONSIBLE FOR CARE
A. AN ORGANIZED CONVERSATION WITH CLIENT
AN INTERVEIW WITH A CLIENT INCLUDES THREE PHASES, SIMILIAR TO THOSE OF A THERAPEUTIC RELATIONSHIP. THESE PHASES INCLUDE:
A. ORIENTATION, WORKING, AND TERMINATION
B. ORIENTATION, ASSESSMENT, AND DELEGATION
C. PLANNING, EVALUATION, AND ASSESSMENT
D. TRUST, PLANNING, HONESTY
A. ORIENTATION, WORKING AND TERMINATION
DURING DATA CLUSTERING THE NURSE:
A. IMPLEMENTS THE NURSING PROCESS
B. PROVIDES DOCUMENTATION OF NURSING CARE
C. ORGANIZES DATA AND FOCUSES ATTENTION ON CLIENT FUNCTIONS
D. REVIEWS THE DATA WITH OTHER HEALTHCARE PROVIDERS
C. ORGANIZES DATA AND FOCUSES ATTENTION ON CLIENT FUNCTIONS
A NURSE MIGHT ASK,"DO YOU HAVE PAIN OR CRAMPING?" THIS IS AN EXAMPLE OF:
A. PROBLEM SEEKING QUESTIONING
B. OPEN-ENDED QUESTIONING
C. CLOSED-ENDED QUESTIONING
D. ACTIVE LISTENING
C. CLOSED ENDED QUESTIONING
A TECHNIQUE THAT ALLOWS FOR DISCUSSION IS THE USE OF
A. USE OF CLOSED-ENDED QUESTIONS
B. USE OF OPEN-ENDED QUESTIONS
C. BACK CHANNELING
D. PROBLEM SEEKING
B. USE OF OPEN-ENDED QUESTIONS