(Fundamentals) Chapter 3: Assessment

A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should review and practice communication techniques.

A

After collecting data from a patient with respiratory distress, the nurse prioritizes the patient interventions to provide oxygen to the patient first. This is an example of which of the following models for organizing data? A) Hierarchy of Human Needs B) Functional Health Patterns C) Human Response Patterns D) Body Systems Model

A

Of the following data, what type would be collected during a physical assessment? A) color, moisture, and temperature of the skin B) type, amount, and duration of pain C) foods eaten that cause nausea D) specific allergies resulting in itching

A

Which of the following examples of patient data needs to be validated? Select all that apply. A) A patient has trouble reading an informed consent, but states he does not need glasses. B) An elderly patient explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a patient with a respiratory infection documents fever and chills. D) A patient in a nursing home states that she is unable to eat the food being served. E) A pregnant patient is experiencing contractions that are 2 minutes apart. F) Following a MVA, the teenage driver with alcohol on his breath states that he was not drinking.

A,B,F

Which of the following are examples of common factors that may influence assessment priorities? Select all that apply. A) a patient's diet and exercise program B) a patient's standing in the community C) a patient's ability to pay for services D) a patient's developmental stage E) a patient's need for nursing

A,D,E

What type of patient record data would the nurse find in the medical history and progress notes? A) findings of the physician's assessment and treatment B) results of laboratory and diagnostic studies C) nursing documentation and plan of care D) information from other members of the healthcare team

A. findings of the physician's assessment and treatment

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) to identify a life-threatening problem B) to establish a database for medical care C) to practice respiratory assessment skills D) to facilitate the resident's ability to breathe

A. to identify a life-threatening problem

A student takes an adult patient's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next? A) Record the pulse rate on the appropriate vital signs sheet in the chart. B) Ask the instructor or a staff nurse to take the pulse. C) Discuss this finding during postconference with other students. D) Wait 4 hours and take the patient's pulse again.

B

Which of the following entries would be an example of appropriate documentation? A) Patient appears depressed and tired. B) "I am so down today, and I just don't have any energy." C) Patient had a good bowel movement. D) Complains of abdominal pain. Probably constipated.

B

Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."

B

nurse is collecting data from a home care patient. In addition to information about the patient's health status, what is another observation the nurse should make? A) number of rooms in the house B) safety of the immediate environment C) frequency of home visits to be made D) friendliness of the patient and family

B

On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing? A) the pathology of the illness B) the response of the patient to the illness C) information from a nursing textbook D) knowledge from more experienced nurses

B) the response of the patient to the illness

Mrs. James comes to her healthcare provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) initial assessment B) focused assessment C) emergency assessment D) time-lapsed assessment

B. focused assessment

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

C

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

C

A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) carrying out a physician's order to intubate a patient B) teaching a novice nurse the principles of triage C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family F) teaching a diabetic patient about the importance of proper foot care

C,D,E C) using the nursing process to diagnose a blocked airway D) interviewing a patient suspected of being a victim of abuse privately E) checking the data supplied by a patient with dementia with the family

A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patient's daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patient's value as an individual? A) "Sarah, can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

C. "Mr. Koeppe, tell me what you do to take care of yourself."

Which of the following group of terms best defines assessing in the nursing process? A) problem focused, time lapsed, emergency based B) design a plan of care, implement nursing interventions C) collection, validation, communication of patient data D) nurse focused, establishing nursing goals

C. collection, validation, communication of patient data

Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

C. nausea, abdominal pain

Who or what is the primary source of information for a nursing history? A) previous medical records B) other healthcare personnel C) the patient D) family members

C. the patient

A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) comprehensive B) focused C) time-lapsed D) emergency

C. time-lapsed

A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself? A) standing at the end of the bed B) standing at the side of the bed C) sitting at least 6 feet from the beside D) sitting at a 45-degree angle to the bed

D

assessment? A) to identify data to be validated B) to establish an effective nurse-patient communication C) to maintain effective relationships with coworkers D) to plan appropriate nursing care

D

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

D. "Unable to palpate femoral pulse in left leg."

Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis? A) The nursing diagnosis confirms the medical diagnosis. B) The nursing diagnosis duplicates the medical diagnosis. C) There is no relationship between nursing and medical diagnoses. D) The nursing diagnosis is based on patient response to the medical diagnosis.

D. The nursing diagnosis is based on patient response to the medical diagnosis.

The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) to gather data about a specific and current health problem B) to identify life-threatening problems that require immediate attention C) to compare and contrast current health status to baseline data D) to establish a database to identify problems and strengths

D. to establish a database to identify problems and strengths