Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

A. Matching Type:
Match the terms in the left column with the correct descriptions in the right
column:
Term Description

______1. Nursing assessment a. Developing a plan of nursing care and outcome

______ 2. Nursing diagnostic phase
______ 3. Planning
______ 4. Implementation
______ 5. Evaluation
______ 6. Nursing diagnosis
______ 7. Subjective data
______ 8. Objective data
______ 9. Collaborative problem
______10. Referral problem
Outcome criteria
b. Carrying the plan of care
c. Sensations or symptoms that can be
Verified only by the client (e.g., pain)
d. Problem the requires the attentions of assistance of
other health care professionals
e. Assessing whether outcome criteria have been met and
revising the plan
f. Collection of subjective and objective data
g. Clinical judgement about individual, family, or community
responses to actual or potential health problems and life
processes
h. Physiologic complications that nurses monitor to detect there
i. Analysis of subjective data to make a professional nursing
judgement
j. Findings directly observe or indirectly observe through
measurements (e.g., body temperature)
 MULTIPLE CHOICE: Choose the one best answer for each of the following multiple
choice questions.

_______ 1. A medical examination differs from a comprehensive nursing of examination in

that the medical examinatio9n focuses primarily on the client’s
a. physiologic status.
b. holistic wellness status.
c. developmental history.
d. level of functioning.

________2. The result of nursing assessment is the

a. prescription of treatment.
b. documentation of the need for a referral
c. client’s physiologic status
d. formulation of nursing diagnosis.

________3. Although the assessment phase of the nursing process precedes the other
phase, the assessment6 phase is.
a. continues.
b. completed on admission.
c. linear.
d. performed only by nurses

________4. When a client first enters the hospital for an elective surgical procedure, the
nurse should perform an assessment termed.
a. entry.
b. exploratory.
c. focused.
d. comprehensive.

________5. An assessment of a client who already has a complete recorded database in the
system and returns to the health care agency with a specific health concern is
referred to as a (n)
a. ongoing or partial assessment.
b. focused or problem-oriented assessment.
c. emergency assessment.
d. initial comprehensive assessment.

________6. To prepare for the assessment of a client visiting a neighborhood health care
clinic, the nurse should first.
a. discus the client’s symptoms with other team member.
b. plan for potential laboratory procedures.
c. reviewed the client’s health care record.
d. determined potential health care resources.
________7. The nurse is preparing to meet a client in the clinic for the first time. After
reviewing the client’s record, the nurse should.
a. analyze data that have already been collected.
b. reviewed any past collaborative problems.
c. avoided premature judgements about the client.
d. consult with the client’s family members.

________8. Before beginning a comprehensive health assessment of an adult client, the

nurse should explain to the client that the purpose of the assessment is to
a. arrived at conclusions about the client’s health.
b. document any physical symptoms the client’s health.
c. contributed to the medical diagnosis.
d. validate the data collected.

________9. To arrive at a nursing diagnosis or a collaborative problem, the nurse goes to

the steps of analysis of data. After proposing possible nursing diagnoses, the
nurse should next.
a. cluster the data collected.
b. draw inferences and identify problems.
c. documents conclusions.
d. check to the pre4sence of defining characteristics.

________10. The depth and scope of nursing assessment has expanded significantly over
the past several decades primarily because of
a. the growing elderly population with chronic illness.
b. rapid advances in biomedical knowledge and technology.
c. an increase in the number of baccalaureate programs in nursing.
d. an increase in the number of nurse practitioner.
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

B. MULTIPLE CHOICE: Choose the one best answer for each of the following multiple choice
questions.

________1. During an interview, the nurse collects both subjective data from an adult
client. Subjective ta would include the client’s.
a. perception of pain.
b. height.
c. weight.
d. temperature.
________2. During an interview with an adult client, the nurse can keep an interview from
going off course by
a. using open-ended questions.
b. rephrasing the client’s statements.
c. inferring information.
d. using closed-ended question.

________3. The nurse ha interviewed a Hispanic client with limited English skills for the first
time. The nurse observe that the client is reluctant to reveal personal
information and believed in a hot-cold syndrome of disease causation. The
nurse should.
a. indicated acceptance of the client’s cultural differences.
b. requested a family member to interpret for the client.
c. use slang terms to identify certain body parts.
d. remained in a standing position during the interview.

________4. For a nurse to be therapeutic with clients when dealing with sensitive issues
such as terminal illness or sexuality, the nurse should have.
a. advance preparation in this area.
b. experience in dealing with these types of clients.
c. knowledge of his or her own thoughts and feelings about these issue.
d. personal experiences with death, dying, and sexuality.

________5. The nurse interviewing a client in the clinic for the first time. The clients
appears to have a very limited vocabulary. The nurse should plan to.
a. used a very basic lay terminology.
b. having a family member present during the interview.
c. use standard medical terminology.
d. showed the clients pictures of different symptoms, such as the “faces pain
chart.”
________6. The nurse is interviewing a client in a clinic for the first time. when the client
tells the nurse that he smokes “about two packs of a cigarettes a day,” the
nurse should.
a. looked at the client with a frown.
b. telling the client that he is spending a lot of money foolishly.
c. provides the client with a list of dangers associated with smoking.
d. encouraged the client to quit smoking.

________7. During a client interview, the nurse uses nonverbal expressions appropriately
when the nurse.
a. avoided excessive eye contact with the client.
b. remains expressionless throughout the interview.
c. uses touch in a friendly in a friendly manner to establish rapport.
d. displayed mental distancing during the interview.

________8. During the interview of an adult client, the nurse should

a. use leading questions for valid responses.
b. provided the client with information as question arise.
c. read each question carefully from the history form.
d. completed the interview as quickly as possible.

_______9. While interviewing a client for the first time, the nurse is using a standardized
nursing history form. The nurse should
a. maintained eye contact while asking the questions from the form.
b. read the questions verbatim from the form.
c. asked the client to complete the form.
d. asked leading questions throughout the interview.

_______10. The nurse is interviewing a 78-years-old client for the first time. The nurse
should first.
a. assessed the client’s hearing faculty.
b. established rapport with the client.
c. obtaining biographic data.
d. use medical terminology.

MATCHING TYPE:
Match the terms in the left column with the correct description in the right column.
Term
_______1. Sim’s position
_______2. Sitting position
_______3. Supine position
_______4. Standing position
_______5. Prone position
_______6. Lithotomy position
_______7. Finger pads
_______8. Ulnar surface or palm of hand
assess
_______9. Dorsal surface of hand
_______10. Bell of stethoscope
_______11. Diaphragm of stethoscope
Description
a. Part of examiner’s hand use to feel for
Temperature.
b. Side-lying position during the rectal
Examination
c. position used during much of the
physical examination including
examination of the head, neck, lungs,
chest, back, breast, axilla, heart, vital
signs, and upper extremities.
d. Back-lying position used for
examination of the abdomen (with
one small pillow under the head and
another under knees):
e. Larger end of stethoscope used to
detect breath sounds, normal heart
sounds, and bowel sounds.
f. position used to examine male
genitalia and to assess gait, posture,
and balance
g. Part of examiner’s hand used to feel
for fine discriminations: pulse,
texture, size, consistency, shape, and
crepitus.
h. Client lies on abdomen with head
turned to side: may be used to
back and mobility of hip joint
i. Part of examiner’s hand used to feel
for vibration, thrills, or fremitus
j. Smaller end of stethoscope used to
detect low-pitched sounds (abnormal
heart sounds and bruits)
k. Back-lying position with hips at edge
of examining table and feet supported
in stirrups; used for examination of
female genitalia, reproductive tract,
and rectum
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

C. MULTIPLE CHOICE:

Choose the one best answer for each of the following multiple choice questions.

________1. Before beginning a physical assessment of the client, the nurse should first
a. wash both hands with soap and water.
b. determined whether the client is anxious.
c. asked the client to remove all clothing.
d. requested a family member to be present.

________2. To alleviate a client’s anxiety during a comprehensive assessment, the nurse

Should.
a. begins with intrusive procedures first to get them completed quickly.
b. explained each procedure being performed and the reason for the
procedure.
c. remained in the examination room while the client changes into a gown.
d. asked the client to sign a consent for the physical examination.

________3. While performing a physical examination on an older adult, the nurse should
plan to.
a. completed the examination as quickly as possible.
b. asked the client to change positions frequently.
c. provide only minimal teaching related to health care.
d. use minimal position changes.

_______4. During a comprehensive assessment, the primarily technique used by the nurse
throughout the examinations is.
a. palpation.
b. percussion.
c. auscultation.
d. inspection.

________5. While examining a client, the nurse plans to palpate temperature of the skin by
using the
a. fingertips of the hand.
b. ulnar surface of the hand.
c. dorsal surface of the hand.
d. palmar surface of the hand.
_______6. During palpation of a client’s the nurse palpates the spleen by applying
pressure between 2.5 and 5 cm. he nurse is performing
a. light palpation.
b. moderate palpation.
c. deep palpation.
d. bimanual palpation.

________7. While performing a physical examination on an adult client, the nurse can
detect the density of an underlying structure by using.
a. inspection.
b. palpation.
c. Doppler magnification.
d. percussion.

_______8. When the nurse places one hand flat on the body surface and uses the first of
the other hand to strike the back of the hand flat on the body surface, the nurse
is using.
a. firm percussion.
b. direct percussion.
c. indirect percussion.
d. blunt percussion.

_______9. An adult client visits a clinic and tells the nurse the she suspects has urinary tract
infection. To detect tenderness over the client’s kidney’s the nurse should
instruct the client that he or she will be performing.
a. moderate palpation.
b. deep palpation.
c. indirect percussion.
d. blunt percussion.

_______10. The most commonly used method of percussion is

a. direct percussion.
b. mild percussion.
c. indirect percussion.
d. blunt percussion.

_______11. During a comprehensive assessment of the lungs of an adult client with a

diagnosis of emphysema, the nurse anticipates that during percussion the
client will exhibit.
a. hyperresonsnce.
b. tympany.
c. dullness.
d. flatness.
_______12. While percussing an adult client during a physical examination, the nurse can
expect to her flatness over the client’s
a. lungs.
b. bone.
c. liver.
d. abdomen.

________13. During a comprehensive assessment of an adult client, the nurse can best
hear high-pitched sounds by using a stethoscope with a
a. 1-inch.
b. 1 ½ -inch diaphragm.
c. 15-inch.
d. 1-inch diaphragm.