Assessing Fundamentals of Nursing

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?

ask the instructor or a staff nurse to take the pulse

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?

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?

collection, validation, communication of patient data

Of the following data, what type would be collected during a physical assessment?

color, moisture, and temperature of the skin

Of the following information collected during a nursing assessment, which are subjective data?

nausea, abdominal pain

Which of the following entries would be an example of appropriate documentation?

I am so down today, and I just don't have any energy

Which of the following examples of patient data needs to be validated? Select all that apply.

a patient has trouble reading an informed consent but states he does not need glasses an elderly patient explains that the black and blue marks on his arms and legs are due to a fall following a mva, the teenage driver with alcohol on his breath states that he was not drinking

Which of the following are examples of common factors that may influence assessment priorities? Select all that apply.

a patient's diet and exercise program a patient's developmental stage a patient's need for nursing

Which of the following questions or statements would be an appropriate termination of the health history interview?

can you think of anything else you would like to tell me

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?

do you take anything to help your constipation

What type of patient record data would the nurse find in the medical history and progress notes?

findings of the physician's assessment and treatment

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?

focused assessment

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?

hierarchy of human needs

A 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?

safety of the immediate environment

A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?

sitting at a 45 degree angle to the bed

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?

tell me more about what caused your pain

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?

the nurse should practice interviewing strategies

Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?

the nursing diagnosis is based on patient response to the medical diagnosis

Who or what is the primary source of information for a nursing history?

the patient

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?

the response of the patient to the illness

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?

time lapsed

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?

to establish a database to identify problems and strengths

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?

to identify a life threatening problem

What is the primary purpose of validation as a part of assessment?

to plan appropriate nursing care

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?

unable to palpate femoral pulse in left leg

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.

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