Analyzing the already-collected subjective and objective data occurs in which phase of the nursing process?
Question 1 Analyzing the already-collected subjective and objective data occurs in which phase of the nursing process?
Assessment – wrong
Diagnosis
Planning
Implementation
Question 2What data would be considered subjective?
No current medications or treatments
Jugular venous pressure 2 cm
Apical heart rate 70 beats per minute
No heart murmurs noted
Question 3What should the nurse do immediately before beginning the physical exam?
Practice interviewing skills.
Collect all equipment essential to the exam.
Construct the client’s family genogram.
Establish the client’s reliability as historian.
Question 4When initiating the collection of the client subjective database, what initial step is most important for the nurse to implement?
Identifying health problems
Determining client strengths
Making inferences
Establishing a trusting relationship
Question 5 A surgical client’s pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information?
Compare the order with the standard timing and dosage of the analgesic.
Have another nurse read the order that the nurse has transcribed.
Compare the order to the client’s existing medication administration record (MAR).
Read the order back to the surgeon for confirmation.
Question 6 When documenting lung assessments, the nurse would correctly state:
No lung abnormalities noted.
Breath sounds clear over all lobes on inhalation and exhalation.
Lungs normal bilaterally.
Breath sounds good in all lobes on inspiration and expiration.
Question 7 Upon entering an exam room, the client states, “Well! I was getting ready to leave. My schedule is very busy and I don’t have time to waste waiting until you have the time to see me!” Which response by the nurse would be most appropriate?
“I am so sorry that you had to wait, but I am ready to begin your exam now.”
“I am so sorry! We are working short-handed today, and are doing our best to get everything done!”
“Our schedule is very busy also. We got to you as soon as we could.”
“No one is forcing you to be here, and you are free to leave at any time.”
Question 8 The nurse palpates a client’s pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. It had previously been regular. How should the nurse first follow up this assessment finding?
Notify the physician that the client may be in atrial fibrillation.
Palpate the client’s ulnar pulse and compare with the femoral pulse
Auscultate the client’s apical pulse for a full minute.
Reposition the client in a side-lying position.
Question 9 Which of the following dimensions of pain is being assessed by the question, “How does the pain you are experiencing seem to affect your overall mood?
Cognitive
Affective
Sensory
Sociobehavioral
Affective
Question 10 Match the terms with the correct description
Body Mass Index
Cachexia
Visceral fat
Triceps skinfold
Mid-arm circumference
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