Chapter 16 Practice Test: Nursing assessment

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a.Complete the questions in chronological order. b.Focus on the patient's presenting situation. c.Make accurate interpretations of the data. d.Conduct an observational overview.

ANS: B A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation.

a

18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"

ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools; therefore, asking about the number of bowel movements is most appropriate. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help nurses focus on the scope of medical practice

ANS: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. A diagnosis is a clinical judgment based on information.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c. Reports of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake

ANS: B There are defining characteristics (observable assessment cues such as patient behavior, physical signs) that support each problem-focused diagnostic judgment. The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity. Decreased oral intake and productive cough do not define activity intolerance.

8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a. Risk b. Problem focused c. Health promotion d. Collaborative problem

ANS: C A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status.

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.

16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database

ANS: C Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling

ANS: C Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient's data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis.

12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache

ANS: C Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that may lead a nurse to select Acute pain as a nursing diagnosis.

17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations? a. Proceed to the next patient's room to make rounds. b. Determine the patient does not want any pain medicine. c. Ask the patient about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain.

ANS: C First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary.

14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection

ANS: C Impaired skin integrity is the only nursing diagnosis listed that will correlate to the patient information. While risk for infection is a nursing diagnosis, the patient is not at risk; the patient has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis.

4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States "doesn't feel good" b. Reports a headache c. Respirations 16 d. Nauseated

ANS: C Objective data are observations or measurements of a patient's health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States "doesn't feel good," reports a headache, and nausea are all subjective data. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition.

5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can now perform the dressing changes without help. b. The patient can begin retaking all of the previous medications. c. The patient is apprehensive about discharge. d. The patient's surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? a. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the NAP to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

7. A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C The nursing health history also includes a description of a patient's habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the patient's habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea

ANS: C The signs the patient is exhibiting are consistent with deficient fluid volume (dehydration). Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

Which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications

ANS: C You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests.

19. A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? a. The nurse makes eye contact with the patient. b. The nurse speaks only to the patient's daughter. c. The nurse leans forward while talking with the patient. d. The nurse nods periodically while the patient is speaking.

Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment. Therefore, the charge nurse must correct this misconception. When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Thus, the charge nurse does not need to intervene or follow up.

16. While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first? a. Immediately place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

b The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. "Data interpretation occurs before data validation." b. "Validation involves looking for patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation involves discovering patterns in professional standards."

c Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when the patient reports decreased mobility.

A The only scenario that validates a patient's report with a nurse's observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse's assessment.

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met and interventions were effective.

15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a. Decreased cardiac output related to altered myocardial contractility. b. Patient needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort.

ANS: A Decreased cardiac output related to altered myocardial contractility is a correctly written nursing diagnosis. Patient needs a low-fat diet related to inadequate heart perfusion is a goal phrased statement, not a nursing diagnosis. Offer a low-fat diet is an intervention, not a diagnosis. Acute pain related to discomfort is a circular diagnosis and gives no direction to nursing care.

18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The waiting room while the occupational therapist is working on leg exercises

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for an interview to take place.

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a.Completes a comprehensive database b.Identifies pertinent nursing diagnoses c.Intervenes based on priorities of patient care d.Determines whether outcomes have been achieved

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.

9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation

ANS: A The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.