HA Chapter 1-3: Analysis phase of nursing process;
Subjective vs. Objective Data Questions With Complete
Solutions
A 20-year-old female client has presented to the clinic, and the
nurse is preparing to perform a comprehensive assessment. The
client states, I'd really like to have my mom in the room. That's
okay, isn't it? How should the nurse best respond to the client's
request?
A) Of course. There's a chair in the exam room where she can
sit.
B) That's no problem. I'll just have to get you to sign a privacy
waiver first.
C) That's fine, but be aware that some of the examinations might
be embarrassing for you or her.
D) It's best to undergo the examination alone in order to make
sure I get accurate data, but if you really want her present, we
can do that. Correct Answers Of course. There's a chair in the
exam room where she can sit.
A 60-year-old woman with a bunion will undergo surgery later
today. The client tells the nurse in the surgical daycare admitting
department, "I'm sure I've been asked these questions before.
Can't we just focus on my foot and not all these other topics?"
How should the nurse best explain the rationale for obtaining a
health history?
A) "In general, it's necessary for us to gather as much
information about each client as possible."
B) "We want to make sure your nursing care matches your needs
as closely as possible."
,C) "The care team needs to cross-reference your diagnostic
testing with the information that I'm asking you about."
D) "We don't want to make the mistake of focusing solely on the
medical problem that brought you here." Correct Answers
"We want to make sure your nursing care matches your needs as
closely as possible."
A 71-year-old woman has been admitted to the hospital for a
vaginal hysterectomy, and the nurse is collecting subjective data
prior to surgery. Which statement by the nurse could be
construed as judgmental?
A) "How often do your adult children typically visit you?"
B) "Your husband's death must have been very difficult for
you."
C) "You must quit smoking because it affects others, not only
you."
D) "How would you describe your feelings about getting older?"
Correct Answers "You must quit smoking because it affects
others, not only you."
A client comes to the health care provider's office for a visit.
The client has been seen in this office on occasion for the past 5
years and arrives today complaining of a fever and sore throat.
Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment Correct Answers Focused
assessment
,A client has a documented history of hepatomegaly (liver
enlargement), and the nurse recognizes the need to perform deep
palpation during the physical assessment. The nurse should
perform which of the following actions?
A) Use one hand and depress the skin 1 centimeter.
B) Use the dominant hand to depress the skin one-half to three-
quarters of an inch.
C) Use both hands to depress the skin one-half of an inch.
D) Use both hands to depress the skin 1 to 2 inches. Correct
Answers Use both hands to depress the skin 1 to 2 inches.
A client has been admitted following an unexplained weight loss
of 15 pounds over the past 3 months. How should the nurse best
assess the subjective component of the client's nutritional status?
A) Ask the client to explain MyPlate.
B) Obtain a 24-hour diet recall.
C) Ask about the contents of one typical meal.
D) Elicit the client's favorite foods. Correct Answers Obtain a
24-hour diet recall.
A client has just been admitted to the postsurgical unit from
postanesthetic recovery, and the nurse is in the introductory
phase of the client interview. Which of the following activities
should the nurse perform first?
A) Collaborate with the client to identify problems.
B) Explain the purpose of the interview.
C) Determine the client's vital signs.
D) Obtain family health history data. Correct Answers Explain
the purpose of the interview.
, A client has presented for care with complaints of persistent
lower back pain. When using the mnemonic COLDSPA, which
question should the nurse use to evaluate the "P"?
A) "What makes it worse?"
B) "When did it start?"
C) "How does it feel?"
D) "How would you rate your pain?" Correct Answers "What
makes it worse?"
A client has presented to the clinic for the treatment of an
ovarian cyst. Which of the following would be most important
for the nurse to do immediately before performing this woman's
physical exam?
A) Explain the purpose of the interview to the client.
B) Construct the client's family genogram.
C) Establish the client's reliability as historian.
D) Collect necessary equipment essential to the exam. Correct
Answers Collect necessary equipment essential to the exam.
A client has presented to the emergency department (ED) with
complaints of abdominal pain. Which member of the care team
would most likely be responsible for collecting the subjective
data on the client during the initial comprehensive assessment?
A) Gastroenterologist
B) ED nurse
C) Admissions clerk
D) Diagnostic technician Correct Answers ED nurse
A client has presented to the emergency department and is
having difficulty describing her vague sensation of physical
Subjective vs. Objective Data Questions With Complete
Solutions
A 20-year-old female client has presented to the clinic, and the
nurse is preparing to perform a comprehensive assessment. The
client states, I'd really like to have my mom in the room. That's
okay, isn't it? How should the nurse best respond to the client's
request?
A) Of course. There's a chair in the exam room where she can
sit.
B) That's no problem. I'll just have to get you to sign a privacy
waiver first.
C) That's fine, but be aware that some of the examinations might
be embarrassing for you or her.
D) It's best to undergo the examination alone in order to make
sure I get accurate data, but if you really want her present, we
can do that. Correct Answers Of course. There's a chair in the
exam room where she can sit.
A 60-year-old woman with a bunion will undergo surgery later
today. The client tells the nurse in the surgical daycare admitting
department, "I'm sure I've been asked these questions before.
Can't we just focus on my foot and not all these other topics?"
How should the nurse best explain the rationale for obtaining a
health history?
A) "In general, it's necessary for us to gather as much
information about each client as possible."
B) "We want to make sure your nursing care matches your needs
as closely as possible."
,C) "The care team needs to cross-reference your diagnostic
testing with the information that I'm asking you about."
D) "We don't want to make the mistake of focusing solely on the
medical problem that brought you here." Correct Answers
"We want to make sure your nursing care matches your needs as
closely as possible."
A 71-year-old woman has been admitted to the hospital for a
vaginal hysterectomy, and the nurse is collecting subjective data
prior to surgery. Which statement by the nurse could be
construed as judgmental?
A) "How often do your adult children typically visit you?"
B) "Your husband's death must have been very difficult for
you."
C) "You must quit smoking because it affects others, not only
you."
D) "How would you describe your feelings about getting older?"
Correct Answers "You must quit smoking because it affects
others, not only you."
A client comes to the health care provider's office for a visit.
The client has been seen in this office on occasion for the past 5
years and arrives today complaining of a fever and sore throat.
Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment Correct Answers Focused
assessment
,A client has a documented history of hepatomegaly (liver
enlargement), and the nurse recognizes the need to perform deep
palpation during the physical assessment. The nurse should
perform which of the following actions?
A) Use one hand and depress the skin 1 centimeter.
B) Use the dominant hand to depress the skin one-half to three-
quarters of an inch.
C) Use both hands to depress the skin one-half of an inch.
D) Use both hands to depress the skin 1 to 2 inches. Correct
Answers Use both hands to depress the skin 1 to 2 inches.
A client has been admitted following an unexplained weight loss
of 15 pounds over the past 3 months. How should the nurse best
assess the subjective component of the client's nutritional status?
A) Ask the client to explain MyPlate.
B) Obtain a 24-hour diet recall.
C) Ask about the contents of one typical meal.
D) Elicit the client's favorite foods. Correct Answers Obtain a
24-hour diet recall.
A client has just been admitted to the postsurgical unit from
postanesthetic recovery, and the nurse is in the introductory
phase of the client interview. Which of the following activities
should the nurse perform first?
A) Collaborate with the client to identify problems.
B) Explain the purpose of the interview.
C) Determine the client's vital signs.
D) Obtain family health history data. Correct Answers Explain
the purpose of the interview.
, A client has presented for care with complaints of persistent
lower back pain. When using the mnemonic COLDSPA, which
question should the nurse use to evaluate the "P"?
A) "What makes it worse?"
B) "When did it start?"
C) "How does it feel?"
D) "How would you rate your pain?" Correct Answers "What
makes it worse?"
A client has presented to the clinic for the treatment of an
ovarian cyst. Which of the following would be most important
for the nurse to do immediately before performing this woman's
physical exam?
A) Explain the purpose of the interview to the client.
B) Construct the client's family genogram.
C) Establish the client's reliability as historian.
D) Collect necessary equipment essential to the exam. Correct
Answers Collect necessary equipment essential to the exam.
A client has presented to the emergency department (ED) with
complaints of abdominal pain. Which member of the care team
would most likely be responsible for collecting the subjective
data on the client during the initial comprehensive assessment?
A) Gastroenterologist
B) ED nurse
C) Admissions clerk
D) Diagnostic technician Correct Answers ED nurse
A client has presented to the emergency department and is
having difficulty describing her vague sensation of physical
