Chapter 016

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 16: Nursing Assessment
MULTIPLE CHOICE
1. A client interview consists of three phases. The nurse recognizes that those phases are:
1. Orientation, working, termination
2. Introduction, controlling, selection
3. Introduction, assessment, conclusion
4. Orientation, documentation, database
ANS: 4
The three phases of an interview are orientation, working, and termination.
DIF: A
REF: 236
OBJ: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. During the admission history, the client states that he has trouble breathing at night. In
obtaining data for a problem-oriented database, the nurse should first question the client
about:
1. The onset and duration of his present breathing problem
2. His personal smoking, alcohol use, and exercise practices
3. Any extended family members who have diagnosed heart disease
4. Changes in other body systems that the client perceives as problematic
ANS: 1
A clients database originates with the clients perception of a symptom or health
problem. If an illness is present, the nurse gathers essential and relevant data about the
nature and onset of symptoms. The problem-seeking technique takes the information
provided in the clients story to more fully describe and identify the clients specific
problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be
assessed in an admission history. However, it is not the first question the nurse should ask
when obtaining data for a problem-oriented database after the client reports having a
health problem. Information regarding family history, such as members who had heart
disease, may be obtained in an admission history. However, if a client reports a problem,
the nurse should first follow-up with questions relevant to the nature and onset of
symptoms. The nurse may inquire about changes in other body systems during an
admission history; however, if the client reports a problem, the nurse should first followup using a problem-oriented approach. This would include asking specific questions
about the clients health problem, such as the nature and onset of symptoms.
DIF: A
REF: 237
OBJ: Comprehension
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
16-2
3. The nurse begins the assessment of a client that has come to the emergency department
experiencing chest pain by asking the client about:
1. A family history of heart problems
2. Medications currently being taken at home
3. Questions or concerns about hospitalization
4. The onset, severity, and duration of the chest pain
ANS: 4
If a client comes to the emergency department with chest pain, the nurse should first ask
the client about the onset, severity, and duration of the chest pain. In an emergency
situation, the clients current health problem becomes the priority assessment. Initially,
the nurse should not ask questions regarding family history. Gathering data about the
problem currently affecting the client has greater priority. Asking the client about
medications taken at home is appropriate, but not at this time. The priority is to assess the
symptoms the client is experiencing. Asking the client about concerns regarding
hospitalization is not the priority.
DIF: A
REF: 241
OBJ: Comprehension
4. A nurse seeks to organize the data obtained from the client in a logical manner. The
organizational method that identifies relationships between factors and symptoms in the
database is known as:
1. Clustering data
2. Validating data
3. Peer reviewing
4. Problem statement
ANS: 1
Clustering data means the nurse organizes the information obtained into meaningful
clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When
clustering data, the nurse identifies relationships between factors and symptoms.
Validating data means to compare the data obtained with another source to ensure its
accuracy. Peer review is the evaluation of the quality of the work effort of an individual
by his or her peers. After validating data and clustering data, the nurse may formulate a
problem statement, usually in the form of a nursing diagnosis.
DIF: A
REF: 234
OBJ: Comprehension
5. The client recently became febrile and stated he felt hot. The nurse takes the clients
temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute,
and his blood pressure is 168/80 mm Hg. Which of the following is an example of
subjective data?
1. Pulse rate of 88 beats per minute
Test Bank
16-3
2. Blood pressure of 168/80 mm Hg

3. The statement regarding his feeling hot
4. The supported fact that he became febrile
ANS: 3
Subjective data are clients perceptions about their health problems. The statement by the
client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats
per minute is an example of objective data. Objective data are observations or
measurements made by the data collector. A blood pressure of 168/80 mm Hg is
something that can be measured, and therefore is an example of objective data. Becoming
febrile can be determined by measurement, and therefore is an example of objective data.
DIF: A
REF: 234
OBJ: Comprehension
6. The nurse decides to interview the client using the open-ended question technique. Which
of the following statements reflects this type of questioning?
1. Is your pain worse or better than it was an hour ago?
2. Do you believe that your nausea is from the new antibiotic?
3. What do you think has been causing your current depression?
4. What have you done to alleviate the side effects from your medications?
ANS: 3
An open-ended question prompts the client to describe a situation in more than one or
two words. This option demonstrates the open-ended question technique. This question
limits the clients answers to one or two words. It is an example of a closed-ended
question. The question in this option limits the clients answer to one or two words such
as yes or no. It is an example of a closed-ended question. This option only requires a
few words to form an answer. It does not use the open-ended question technique.
DIF: A
REF: 239
OBJ: Comprehension
7. The nurse is gathering a nursing health history on the client. The client tells the nurse that
he just lost his job. Job loss best fits into which of the following categories?
1. Family history
2. Psychosocial history
3. Biographical history
4. Environmental history
ANS: 2
Test Bank
16-4
The psychosocial history reveals the clients support system, if there are any recent losses
or stressful events, and how the individual copes with such stressors. The loss of a job
would fit the psychosocial history category. Family history is used to obtain data about
immediate and blood relatives to determine whether the client is at risk for illnesses of a
genetic or familial nature. It also provides information about the family itself. The
biographical history provides factual demographic data about the client. The
environmental history provides data about the clients home and working environments.
DIF: A
REF: 241
OBJ: Comprehension
8. The nurse is going to perform the admission history for a newly admitted client on the
medical unit. The optimum time for completion of the history is planned for:
1. Coordination with the physicians visit
2. The time when the clients family are visiting
3. Immediately before the clients scheduled MRI testing
4. After the client has become comfortably oriented to the room
ANS: 4
Completion of the admission history is scheduled for a time when interruptions by other
staff or visiting family members are minimal. The nurse should create an environment
where the client feels comfortable. Conducting the admission history after the clients
orientation to the room and completion of lunch would be optimum because the client
will not be distracted by hunger, and the interview will less likely be interrupted. The
admission history should be scheduled for a time when interruptions by other staff are
minimal. During the physicians visit would not be an optimum time. The nurse should
provide an environment private enough to allow the client to be comfortable when
providing personal information. Inclusion of family members should be left up to the
client to decide. Information obtained should remain confidential. Immediately before a
clients testing would not be an optimum time for obtaining a nursing history. The client
may feel more anxious about the upcoming test, impeding communication, and there may
not be sufficient time allowed to gather all of the information.
DIF: A
REF: 236
OBJ: Comprehension
9. The nurse has completed an assessment and found that the client has an activity and
exercise abnormality. This type of wording indicates that which of the following
organizing formats has been used?
1. Review of systems
2. Nursing health history
3. Gordons functional health patterns
4. Biographical information database
ANS: 3
Test Bank
16-5
Utilizing Gordons functional health patterns format, the nurse organizes information and
makes an assessment identifying functional patterns (client strengths) and dysfunctional
patterns (such as an activity and exercise abnormality). The review of systems is a
systematic method for collecting data on all body systems. The nurse asks the client about
the normal functioning of each body system and any noted changes. A nursing health
history is broader and includes information about the clients current level of wellness, a
review of body systems, family and health history, sociocultural history, spiritual health,
and mental and emotional reactions to illness. A biographical information database
provides factual demographic data about the client, such as age, address, occupation,
marital status, etc.
DIF: A
REF: 233
OBJ: Comprehension
10. After visiting with the client, the nurse documents the assessment data. Both objective
and subjective information has been obtained during the assessment. Which of the
following is classified as objective data?
1. Pain in the left leg
2. Elevated blood pressure
3. Fear of impending surgery
4. Discomfort upon breathing
ANS: 2
Objective data are observations or measurements made by the data collector, such as a
blood pressure reading. Subjective data are clients perceptions about their health
problems, such as pain. Fear of surgery would be subjective data because it is the clients
perception and not something the data collector can measure. Subjective data are clients
perceptions about their health problems, such as discomfort during breathing. A
respiratory rate would be an example of objective data.
DIF: A
REF: 234
OBJ: Comprehension
11. The primary source of information when completing an assessment of a client that is alert
and oriented as he is admitted to the medical center for diagnostic testing is the:
1. Client
2. Physician
3. Family member
4. Experienced unit nurse
ANS: 1
Test Bank
16-6
A client is usually the best source of information. The client who is oriented and answers
questions appropriately can provide the most accurate information about health care
needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes
in activities of daily living. The physician may have knowledge of the clients medical
problem, but the client is the primary source of information for completing an
assessment. Family members can be interviewed as primary sources of information about
infants or children or critically ill, mentally handicapped, disoriented, or unconscious
clients. Usually, however, they are secondary sources of information and can confirm
findings provided by the client. The client in this situation is capable of being the primary
source of information. An experienced nurse on the unit may offer insight into a clients
health care needs and care, but is not the primary source of information when completing
a client assessment.
DIF: A
REF: 234
OBJ: Comprehension
12. The process of data collection should begin with the nurse performing a:
1. Physical exam
2. Client interview
3. Review of medical records
4. Discussion with other health team members
ANS: 2
The first step in establishing the database is to collect subjective information by
interviewing the client. The physical examination follows the client interview so that data
can be verified. A review of medical records is not the first step the nurse should take in
the process of data collection. The medical record is a valuable tool for checking the
consistency and congruency of personal observations made during the client interview.
Discussion with other health team members may provide additional information and be
used to relay information, but is not the first step in the process of data collection.
DIF: A
REF: 236
OBJ: Comprehension
13. During an interview, the nurse needs to obtain specific information about the signs and
symptoms of the clients health problem. To obtain these data most efficiently, the nurse
should use:
1. Channeling
2. Open-ended questions
3. Closed-ended questions
4. Problem-seeking responses
ANS: 3
Test Bank
16-7
Using closed-ended questions helps the nurse to acquire specific information about health
problems such as symptoms, precipitating factors, or relief measures in an efficient
manner. Channeling is where the nurse uses active listening techniques, such as all
right, go on, or uh-huh, to indicate the nurse has heard what the client said and
encourage the client to elaborate further. Using open-ended questions prompts the client
to describe a situation in more than one or two words. Because it allows the client the
opportunity to tell their story and reveal what is important to them, it is not the most
efficient method of obtaining specific information regarding a clients signs and
symptoms of a health problem. In problem-seeking technique, the nurse takes the
information provided in the clients story to more fully describe and identify the clients
specific problems. Using closed-ended questions would be the most efficient method for
obtaining specific information about the signs and symptoms of a clients health problem.
DIF: A
REF: 239
OBJ: Comprehension
14. The nurse is conducting an interview with the client and wants to clarify information that
the client has shared. Which response by the nurse is an example of the clarifying
technique of communication?
1. I understand how you must feel.
2. This medication is used to lower your blood pressure.
3. You appear anxious. Youre wringing your hands constantly.
4. Could you give me an example of how you handle stressors?
ANS: 4
In this option, the nurse is seeking further clarification of information by asking the client
to provide an example. Clarification helps the nurse to gain accurate understanding of a
clients situation. This is not an example of clarifying information. This response
provides information. The nurse is not using the clarifying technique of communication.
In this option the nurse describes his or her observations. It does not seek clarification.
DIF: A
REF: 239
OBJ: Comprehension
15. When clustering data according to functional health patterns, the nurse determines that
the client is only able to ambulate short distances without becoming fatigued and requires
rest periods during morning care. The health pattern that requires intervention is
identified by the nurse as:
1. Respiratory
2. Activity and exercise
3. Sleep and rest pattern
4. Self-care deficit: activities of daily living
ANS: 2
Test Bank
16-8
Using the functional health pattern format, the nurse clusters data that pertain to a
functional health category. Fatigue upon ambulating short distances and requiring
frequent periods of rest are examples of data belonging to the category of activity and
exercise. Respiratory would be found in a systems approach of health assessment, not a
functional health pattern assessment. The functional health pattern category of sleep and
rest would focus more on the number of hours of sleep the client obtains, use of sleep
aids, and any difficulties associated with sleep. Self-care deficit: activities of daily living
would include such aspects as bathing, feeding, and dressing self. The symptoms
described would be clustered more accurately under the functional health pattern
category of activity and exercise.
DIF: A
REF: 233
OBJ: Comprehension
16. After visiting with the client, the nurse documents the assessment data. Both objective
and subjective information have been obtained during the assessment. Which of the
following is classified as subjective data?
1. Client appears sleepy
2. No physical distress noted
3. Abdomen soft and non-tender
4. States feels anxious and tense
ANS: 4
Subjective data are clients perceptions about their health problems. Feeling anxious and
tense is information that only the client can provide. Objective data are observations or
measurements made by the data collector. In this example, the data collector is making
the observation that the client appears sleepy. No physical distress noted is an example
of objective data because it is an observation made by the data collector. Abdomen soft
and non-tender is an example of objective data because it is an observation made by the
data collector, not a clients perception.
DIF: A
REF: 234
OBJ: Comprehension
17. An ER nurse is interviewing a client who complains of abdominal pain. Which of the
following questions asked by the nurse has priority at this time?
1. Can you describe your pain?
2. Have you had this problem before?
3. What have you done to ease the pain?
4. When did your abdominal pain begin?
ANS: 4
Test Bank
16-9
If a client presents to the emergency department with pain, the nurse should first ask the
client about the onset, severity, and duration of the pain. In an emergency situation, the
clients current health problem becomes the priority assessment. Gathering data about the
problem currently affecting the client has greater priority, but a description of the pain
does not have priority over onset. Asking the client about medical history is appropriate
but not at this time. The priority is to assess the symptoms the client is experiencing.
Gathering data about the problem currently affecting the client has greater priority, but
attempted self-treatment does not have priority over onset.
DIF: C
REF: 236-237
OBJ: Analysis
18. Which subjective assessment data are most supportive of a clients diagnosis of anxiety?
1. Diaphoretic and cool skin
2. An apical pulse rate of 120 beats per minute
3. Reports needing to leave now
4. Claims something is terribly wrong
ANS: 4
Subjective data are clients perceptions about their health problems. The statement by the
client regarding his sense of impending doom is the best example of subjective data
regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin
is an example of objective data. Objective data are observations or measurements made
by the data collector. A pulse rate is an example of objective data. Objective data are
observations or measurements made by the data collector. While a client statement
regarding the need to leave the hospital is subjective in nature, it is not as strong an
indicator of anxiety as is the verbalization of impending doom.
DIF: C
REF: 241
OBJ: Analysis
MSC: NCLEX test plan designation: Safe, Effective Care Environment
19. Which of the following questions asked by the nurse during the assessment process is
best directed towards gathering information regarding the clients depression?
1. Have you ever felt this depressed before?
2. What do you believe is the cause of your depression?
3. What makes you feel that you are experiencing depression?
4. What can we do to make you comfortable while you are here?
ANS: 2
Test Bank
16-10
This option is an open-ended question that encourages the client to express his insight
regarding his condition. This option is a closed-ended question requiring only a yes or no
response and so provides minimal information regarding the clients condition. While this
is an open-ended question, it is not the best option because it is not directed towards
assessment of the clients current complaint. While this is an open-ended question, it is
not the best option because it is directed at the clients comfort, not towards assessing his
current complaint.
DIF: C
REF: 234
OBJ: Analysis
20. Which of the following statements best reflects the nurses correct understanding of the
importance of selecting the optimum time for interviewing a client newly admitted to the
unit?
1. Im going to do the clients history before his family leaves so they can help with
the admission history questions.
2. You are scheduled for some x-rays, so Id like to complete this admission history
interview before you have to leave.
3. I have some questions to ask you regarding your admission history. Ill be back
once you are settled in and comfortable.
4. Please let me know when the blood lab is finished with the new client so I can
complete his admission history interview.
ANS: 3
Completion of the admission history is scheduled for a time when interruptions by other
staff or visiting family members are minimal. The nurse should create an environment
where the client feels comfortable and the clients orientation to the room is completed.
While this may be appropriate if the client requires help with answering the questions, it
is not the best option because family and visitors can be distracting and may represent a
confidentiality problem. While the history must be taken within a specific time period,
rushing to complete it before the client goes to radiology is not appropriate. The interview
requires the clients attention and cooperation. Attempting to complete it immediately
after a treatment or other intervention would not be the best choice of time.
DIF: C
REF: 239
OBJ: Analysis
21. The nurse is conducting an admissions history interview with a client who has a history
of gastroesophageal reflux disease (GERD). Which of the following questions shows the
best example of relevant questioning by the nurse?
1. How long have you been dealing with GERD?
2. Are you currently taking any medications for your GERD?
3. Do you follow a particular diet to help manage your GERD?
4. Do you have any other gastrointestinal problems besides GERD?
Test Bank
16-11
ANS: 4
The nurse should ask relevant questions and collect relevant history and physical
assessment data related to the clients presenting health care needs in order to produce the
most inclusive, effective nursing care plan. The questions How long have you been
dealing with GERD? and Are you currently taking any medications for your GERD?
as well as Do you follow a particular diet to help manage your GERD? are directed
towards the GERD itself and not towards conditions that might be related to the presence
of GERD.
DIF: C
REF: 236
OBJ: Analysis
22. A new graduate nurse missed cues regarding the clients emotional state at the time of
admission. The most therapeutic response to the nurse by her mentor is:
1. That is why we perform assessments at least daily; so we can catch missed cues.
2. Everyone has missed cues; dont be too hard on yourself and just keep trying.
3. You will be less likely to miss client cues as you acquire more experience with
assessments.
4. The positive side to making this mistake is that you wont miss those cues again in
another client.
ANS: 3
It is possible to miss important cues when you conduct an initial overview. However,
always try to interpret cues from the client to know how in-depth to make your
assessment. Remember, thinking is human and imperfect. You will acquire appropriate
thinking processes in the conduct of assessment, but expect to make mistakes in missing
important cues. While this may be true, it is not the most therapeutic option because it
does not address the issue personally for the new graduate. While this is true, it is not the
most therapeutic option because it does not offer a reason for the omission. While this
may be true, it is not the most therapeutic option because it does not address the issue
personally for the new graduate.
DIF: C
REF: 240-241
OBJ: Analysis
23. The nurse is performing a problem-focused assessment when the client reports pain in his
left shoulder. Which of the following nursing questions has priority when determining the
nature of the pain?
1. What makes the pain worse?
2. When did you first notice the pain?
3. What do you do to lessen the pain?
4. Can you rate your pain using the pain scale that weve discussed?
ANS: 4
Test Bank
16-12
Once you complete the assessment, you thoroughly analyze the extent and nature of the
clients problem so you are able to later develop a care plan. Identifying the degree of
pain the client is experiencing has priority over the other options. While this option is an
appropriate pain assessment question, it is more directed towards identifying contributing
factors than the characteristics (nature) of the pain. While this option is an appropriate
pain assessment question regarding the nature of the pain, it does not have priority over
the degree of pain because that represents an issue that requires immediate intervention.
While this option is an appropriate pain assessment question, it is more directed towards
identifying effective self-treatment rather than the characteristics (nature) of the pain.
DIF: C
REF: 236
OBJ: Analysis
24. When following up on a clients report of hip pain during an admission assessment, the
most nursing conclusive observation would be:
1. The client tearing when being ambulated to the chair
2. A report from the ancillary staff that the client is reporting pain
3. The client observed grimacing when positioning self in the bed
4. Overhearing the client discuss hip pain with family on the phone
ANS: 3
This option where the client was observed grimacing describes nonverbal actions that are
associated with pain when the client is unaware of being observed and so represents the
most conclusive follow-up evidence of pain. The options where the client is tearing when
ambulated to the chair, the ancillary staffs report of the clients pain as well as
overhearing the client discuss hip pain may well be an observation of pain, but they are
not the most conclusive of the options because the client is aware of being observed.
DIF: C
REF: 240
OBJ: Analysis
25. When obtaining subjective assessment data, the nurse recognizes which of the following
client scenarios as being the most likely to produce accurate, credible information?
1. A 50-year-old in the ED reporting chest pain
2. A 70-year-old admitted with fever of unknown origin
3. A 81-year-old receiving follow-up treatment for a hip replacement
4. A 22-year-old being treated at a clinic for a sexually transmitted disease
ANS: 3
Test Bank
16-13
This option where the 81-year-old is receiving follow-up treatment for a hip replacement
presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any
other emotion/factor that would inhibit the free communication of subjective symptom
data. The 50-year-old client is experiencing pain; this is likely to inhibit the
communication process. The 70-year-old client is febrile; this could interfere with the
communication process, especially for an older adult because it may cause confusion and
the 22-year-old client may be experiencing guilt and/or embarrassment; both may
interfere with the communication process.
DIF: C
REF: 234
OBJ: Analysis
26. A nurse is observed conducting an assessment interview for a newly admitted client.
Which of the following would require immediate follow-up by the nurses mentor?
1. Conducting the interview with the clients boyfriend present
2. Stopping the interview to answer a page from the nursing station
3. Frequently checking the time while waiting for the client to answer
4. Heard asking the client, Am I correct; youve rated your pain a 9 out of 10?
ANS: 3
Clients are less likely to fully reveal the nature of their health care problems when nurses
show little interest, appear rushed, or are easily distracted by activities around them. As
long as the nurse had the clients permission, this would not require follow-up. While
interrupting an assessment is not recommended, a page is an example of an acceptable
exception and so this would not require follow-up. If the nurse were confirming the
information, it would not require follow-up. If the mentor felt the nurse was questioning
the validity of clients pain rating, a follow-up would be appropriate because a clients
pain rating should not be questioned.
DIF: C
REF: 234
OBJ: Analysis
27. Which of the following assessment data provided by a clients family will have the
greatest impact on the clients care while hospitalized?
1. Mom falls asleep fastest with the television on.
2. Dad starts off the day with hot coffee; it regulates his bowels.
3. My wifes sister died 4 months ago, and she is still grieving over her loss.
4. My husband doesnt like to let people know his arthritis is bothering him.
ANS: 4
Test Bank
16-14
Family and friends can make important observations about the clients health status,
changes, and needs that can affect the way care is delivered. Being aware of the clients
reluctance to discuss his pain will impact the frequency and way his pain is assessed.
While this information will affect the way the staff prepares the client for sleep, it does
not have priority over pain assessment. While this information will allow the staff to meet
the clients morning coffee need, it does not have priority over pain assessment. While
this information will affect the way the staff address the clients emotional needs, it does
not have priority over pain assessment.
DIF: C
REF: 237
OBJ: Analysis
28. What is the most appropriate method for the nurse to communicate a clients wishes to
the nurses on the next shift?
1. Document the request in the nursing notes.
2. Include the clients request in the shift report.
3. Place instructions regarding the clients wishes above the clients bed.
4. Verbally inform the unit clerk of the clients request.
ANS: 2
In the acute care setting, the change-of-shift report is the way for nurses from one shift to
communicate information to nurses on the next shift Documenting the request in the
nursing notes is not appropriate for inclusion in the nursing notes because it does not
reflect information regarding the clients condition, response to treatment, or current
health status. Placing the instructions regarding the clients wishes above the bed is not
appropriate because there is no guarantee that staff will see the posting, but more
importantly there are confidentiality issues being ignored. While verbally informing the
unit clerk of the clients request may result in the clients wishes being respected, it is not
the most effective option.
DIF: C
REF: 234-235
OBJ: Analysis
29. While discussing a clients medication history, the client tells the nurse that she thinks she
is allergic to a particular type of medication. Which of the following nursing actions has
priority in this situation?
1. Note the allergy on the clients Kardex.
2. Inform the provider of the clients possible allergy.
3. Review the clients medical record for confirmation of the allergy.
4. Tell the client to have all medications identified before taking them.
ANS: 3
Test Bank
16-15
The medical record is a valuable tool for checking the consistency and similarities of
personal observations. Information such as a history of allergic reactions would be found
in the medical record. Noting the allergy on the clients Kardex would be appropriate
only after the allergy is confirmed; although if there was true concern, a notation of a
possible allergy should be noted on the medication record. Informing the provider of the
clients possible allergy would be appropriate after the medical record was reviewed and
no mention of the allergy was confirmed or denied. While telling the client to have all
medications identified before taking them is a safety measure appropriate for all clients, it
is not the priority in this situation.
DIF: C
REF: 235
OBJ: Analysis
30. The nurse realizes that in order to share information from a clients medical record with
another facility, the client must provide written consent. The primary reason for this
requirement is to:
1. Facilitate the exchange of information between appropriate parties
2. Minimize the opportunity for this information to be assessed inappropriately
3. Ensure the clients right to have his medical information regarded as personal and
confidential
4. Guarantee that the information will be shared with only those requiring it for client
care purposes
ANS: 3
Educational, military, and employment records may contain significant health care
information. You need written permission from the client or guardian to access or transfer
the records. Any information you obtain is confidential, and you treat it as part of the
clients legal medical record. This process recognizes the clients right to confidentiality.
The other three options, facilitating the exchange of information, ensuring the clients
rights to have his medical information regarded as personal and confidential as well as
guaranteeing the sharing of information will be only when required for client care
purposes are outcomes of the process but not the primary reason for the consent.
DIF: C
REF: 235-236
OBJ: Analysis
31. The nurse recognizes that a clients hearing deficits impact the development of the nurseclient relationship. Which of the following has the greatest impact on minimizing this
obstacle?
1. Speaking slowly, clearly, and in a normal tone
2. Using various forms of nonverbal communication
3. Relying heavily on touch to convey caring and interest
4. Involving family in discussions concerning meeting clients needs
ANS: 2
Test Bank
16-16
When a client has limited hearing or visual deficits, it becomes more important for a
nurse to use nonverbal communication when establishing nurse-client relationships.
Speaking slowly, clearly and in a normal tone may make verbal communication more
effective, but it will not have the greatest positive impact of the offered options. Relying
heavily on touch is only one form of nonverbal communication that can positively impact
the development of the relationship. While involving family in discussions may help in
the identification of client needs, it does not necessarily have positive impact on
developing a healthy nurse-client relationship.
DIF: C
REF: 236
OBJ: Analysis
32. Which of the following questions will provide the nurse with the best understanding of a
terminally ill clients spiritual needs?
1. Do you have a religious preference?
2. Have you given thought to your spiritual needs?
3. Is there a particular clergy you would like to visit with?
4. Are there any spiritual needs you have that I may help with?
ANS: 4
In asking if there are any spiritual needs that the client might need help with, you collect
information about life goals, values, and religious practices; part of a clients spirituality.
This option provides the client with an opportunity to discuss his needs if indeed he has
any while reaffirming the nurses wish to meet his needs. Asking simply is a client has a
religious preference is a closed-ended question and provides little encouragement to
discuss spiritual needs. While asking if the client has given thought to their spiritual
needs provides an opportunity to discuss any client needs, it does not allow for the nurse
to be of help with attending to these needs. Inquiring about a particular clergy is a closedended question and provides little encouragement to discuss spiritual needs.
DIF: C
REF: 237
OBJ: Analysis
MULTIPLE RESPONSE
1. Which of the following statements made by the nurse should be included in the
orientation phase of a nursing interview? (Select all that apply.)
1. Youre answers will be kept confidential.
2. My name is Susan Smith and Im a registered nurse.
3. We are here to make your hospitalization as pleasant as possible.
4. I need to ask you some questions that will help with planning your care.
5. Only those directly involved in your care will have access to this information.
6. If there is anything you need or help you require simply use your call bell and
someone will be right in.
Test Bank
16-17
ANS: 1, 2, 4, 5
The orientation phase begins with you introducing yourself and your position and
explaining the purpose of the interview. Explain to clients why you are collecting data
(e.g., for a nursing history or for a focused assessment) and assure them that any
information obtained will remain confidential and will be used only by health care
professionals.
The statements We are here to make your hospitalization as pleasant as possible and I
need to ask you some questions that will help with planning your care are more
appropriate for the termination phase.
DIF: C
REF: 241
OBJ: Analysis
2. The nurse has determined that the assessment data have resulted in a strong inference that
the client is suffering from depression. Which of the following client responses to nursing
questions best supports the possibility of depression? (Select all that apply.)
1. My work environment would depress anyone.
2. It seems like almost anything can make me cry.
3. Being here away from my family makes me sad.
4. I just cant seem to get excited about anything anymore.
5. The family always thought that my father was depressed.
6. I like winter because I can just cover up on the couch and sleep.
ANS: 4, 5
I just cant seem to get excited about anything anymore and The family always
thought that my father was depressed. Remember to always have supporting cues before
you make an inference. These options relate a broad lack of interest in life and a family
history of depression. While mentioning My work environment would depress anyone
as a depressing situation, this option does not infer personal depression. While
mentioning It seems like almost anything can make me cry as a potential sign of
depression, this option is not a strong inference because crying can be a result of other
emotions. While mentioning Being here away from my family makes me sad notes
sadness, this option describes a normal reaction to being separated from loved ones.
While mentioning I like winter because I can just cover up on the couch and sleep
shows withdrawal behaviors, this option is not a strong inference because winter often
evokes stay-at-home tendencies in people.
DIF: C
REF: 241
OBJ: Analysis
3. The goal of the orientation phase of a nursing interview is to: (select all that apply)
1. Initiate the nurse-client relationship
2. Begin identifying the clients needs
3. Earn the trust and confidence of the client
4. Assume the decision role for the client
Test Bank
16-18
5. Welcome the client to the nursing unit

6. Gather the clients demographic information
ANS: 1, 2, 3
Initiating the nurse-client relationship, beginning to identify the clients needs and
earning the clients trust and confidence. During the orientation phase you establish trust
and confidence with a client. One important goal for the initial interview is to make the
foundation for understanding the clients primary needs. Another is to begin a
relationship that allows the client to become an active partner in decisions about care. As
the orientation phase proceeds, the client should begin to feel more comfortable speaking
with you so the necessary information can be obtained. Assuming the decision role isnt
correct as the client should be involved in all care decisions; assuming this role is not
appropriate. While welcoming the client to the nursing unit is an expected outcome of the
orientation phase of the interview process, it is not a goal. While gathering the clients
demographic information is an expected outcome of the orientation phase of the
interview process, it is not a goal.
DIF: C
REF: 236-237
OBJ: Analysis

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Potter & Perry: Fundamentals of Nursing, 7th Edition

2. Blood pressure of 168/80 mm Hg

5. Welcome the client to the nursing unit

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