Question 1

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. To corroborate her suspicion, during the patient interview the nurse: (Select all that apply.)

Accepted Answer

Educational needs are assessed during the patient interview. The nurse should document gaps in patient knowledge and areas in which clarification of disease processes or treatment would be beneficial. Prior to initiating patient education, the nurse needs to assess a patient's cognitive ability, reading level, and potential language barriers. Assessment should include collecting information about what the patient already knows about her/his current condition and what additional knowledge is needed. Assessment information about the patient's educational needs should be documented and should guide aspects of the patient's individualized plan of care. Thorough assessment of the patient's knowledge should be used to determine the need for referrals and educational interventions.

Question 2

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)

Accepted Answer

Routine assessment of vital signs of a patient who is stable may be delegated to Licensed Practical or Licensed Vocational Nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care cannot be delegated to UAPs. Initial patient assessment of unstable patients cannot be delegated to LPNs/LVNs. LPNs/LVNs may contribute to the ongoing assessment of patients and document their observations and care. The patient with rectal bleeding needs critical care, and a new admission needs to be assessed by an RN. Stable patients such as the patient with stable lung disease, or awaiting discharge or transfer can be delegated to UAP.

Question 3

Patient-centered care requires the nurse to: (Select all that apply.)

Accepted Answer

Patient-centered care requires the nurse to understand patient and family preferences and values. Nurses must recognize patients' expectations for care and provide care with respect for the diversity of human experience. While interpreting data, the nurse must be careful to avoid inaccurate inferences (i.e., conclusions) based on the nurse's personal preferences, past experiences, generalizations, or outdated and inaccurate health care information.

Question 4

Which of the following examples given indicate objective data? (Select all that apply.)

Accepted Answer

Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms.

Question 5

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (Select all that apply.)

Accepted Answer

On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical examination.

Quiz 6: Assessment

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. To corroborate her suspicion, during the patient interview the nurse: (Select all that apply.)

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)

Patient-centered care requires the nurse to: (Select all that apply.)

Which of the following examples given indicate objective data? (Select all that apply.)

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (Select all that apply.)