Fundamentals I & II: Chapter 16: Nursing Assessment
1. 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
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.
ANS: A
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
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.
ANS: A
10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? a. "Is there anything that you are stressed about right now that I should know?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"
ANS: B
11. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse's concerns b. Patient expectations c. Current treatment orders d. Nurse's goals for the patient
ANS: B
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.
ANS: B
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.
ANS: B
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
9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the patient "I will be back to administer medications in 1 hour."
ANS: B
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."
ANS: C
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
3. 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
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. Respiration 16 d. Nauseated
ANS: C
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
6. 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
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
20. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient's temperature b. Patient's wound appearance c. Patient describing excitement about discharge d. Patient pacing the floor while awaiting test results e. Patient's expression of fear regarding upcoming surgery
ANS: C, E
12. While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a. Tell the patient to just focus on the leg and cast right now. b. Document the sleep patterns and information in the patient's chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
ANS: D
13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon's Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment
ANS: D
