Online Practice Test 11

Your Results for: "NCLEX® Review"

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 11 > NCLEX® Review Date/Time Submitted: July 6, 2012 at 2:22 PM (UTC/GMT)

Summary of Results 67% Correct of 9 Scored items: 6 Correct:  67% 3 Incorrect:  33% 1 question not scored. 9 scored questions. More information about scoring

1.		When the client states that "my head hurts and my vision is blurry," what type and source of data is this? Your Answer: Primary and subjective
		Objective: Identify the four major activities associated with the assessment process. Rationale: The source is primary (the client) and the data are subjective (symptoms). In Answer 1, the source is primary, but the data are not objective. In Answer 3, the source is primary (the client) and the data are not objective. In answer 4, the source is primary (the client) and the data are subjective. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
2.		Which of the following data should the nurse validate? Your Answer: The client says, "I feel like my blood sugar is high."
		Objective: Differentiate objective and subjective data and primary and secondary data. Rationale: The nurse should make an attempt to validate subjective data (symptoms) from the client. Answer 3 is subjective data that the nurse should validate by checking the client's blood sugar. The client's temperature of 101.2 is objective data. The chart's saying the client is allergic to penicillin is objective data. The client's pulse of 104 is objective data. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Consider subjective vs objective data.
3.		What kind of assessment is being performed when the nurse asks the client, "Why did you come to the clinic today?"  Your Answer: Initial assessment
		Objective: Contrast various frameworks used for nursing assessment. Rationale: The nurse performs various types of assessments depending on the nature of the situation. In this case, it is gathering information for an initial database. The emergency assessment does not indicate the client came to the clinic for an emergency, life-threatening condition. The problem-focused assessment does not indicate the client has an established problem. The time-lapsed reassessment does not indicate the client has previous baseline data. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
4.		Which of the following is an example of objective data? Your Answer: The client's abdomen is round and soft.
		Objective: Differentiate objective and subjective data and primary and secondary data. Rationale: Objective data are those that are detectable by an observer or can be measured or tested against an accepted standard. Information that is reported to the nurse by someone else is subjective. The client's complaining of nausea is subjective data, a symptom that is reported by the client. That the client's spouse asked that he be returned to bed because he is tired is subjective data, reported to the nurse by another person. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
5.		The nurse asks a client, "What happened to your leg?" This is an example of: Your Answer: An open-ended question
		Objective: Compare directive and nondirective approaches to interviewing. Rationale: Nurses use various types of questions in interviews. When a nurse wants a client to give a more complete answer and to elaborate, an open-ended question is frequently used. A neutral question is one that is non-directive, and allows the client to explore feelings. A leading question is directive, and gives the client less opportunity to decide if the answer is true. A closed question invites only a yes, no, or short, factual answer. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
6.		Which of the following positions assumed by the nurse and the client facilitates an easy exchange of information? Your Answer: Seated; the nurse places the chairs at right angles to one another, about a foot apart Correct Answer: The client is in bed and the nurse sits on a chair at a 45-degree angle to the bed
		Objective: Describe important aspects of the interview setting. Rationale: The nurse strives for a less formal atmosphere, where the nurse and client can feel on more equal terms. In Answer 1, the nurse may intimidate the client, who feels the nurse has greater status. Answer 2 is less formal; the nurse and client are too close together for the client to feel comfortable. The client may feel that his personal space is being invaded. When the client is in bed and the nurse stands at the side of the bed, the nurse is in a position where the client may feel intimidated because the nurse is not at eye level. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
7.		Which of the following questions is likely to elicit specific information? Your Answer: "When did the pain start?"
		Objective: Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each. Rationale: Specific information tends to be elicited by closed questions. Leading questions direct the client's answers. Neutral questions invite the client to explore feelings. Open-ended questions allow the client to elaborate on responses. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
8.		During which stage of the interview should the nurse ask, "How long have you had this symptom?" Your Answer: Examination Correct Answer: Body
		Objective: Describe important aspects of the interview setting. Rationale: The part of the interview that is focused on gathering data from the client is the body. The nurse uses open and closed questions. The opening is the part of the interview when the nurse establishes rapport with the client. The closing is the conclusion of the interview. The examination is the gathering of objective data. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		Which of the following is an example of a leading question? Your Answer: "What do you know about your upcoming surgery?" Correct Answer: "You are excited about going home, aren't you?"
		Objective: Compare directive and nondirective approaches to interviewing. Rationale: A leading question is used in a directive interview and directs the client's answer. Answer 1 is an open-ended question that can be answered without direction or pressure from the nurse. Answer 2 is an open-ended question that requires the client to elaborate. Answer 3 is a closed question that requires a factual answer. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
10.		List the four major activities associated with the assessment process. Your Answer: (blank)