Question 1

Which of the following statements are true regarding professional standards of nursing assessment? Select all that apply.

Accepted Answer

Assessment is a professional responsibility and assists the nurse to identify problems and prioritize care.Parts of the assessment may be delegated depending on state boards of nursing and agency policies.Assessment helps the nurse formulate a nursing diagnosis; a medical diagnosis is not within the nurse's scope of practice.All patients are assessed for pain.

Question 2

Which of the following are examples of high-quality nursing documentation? Select all that apply.

Accepted Answer

Patient statements using the patient's own words,documentation of patient level of consciousness,and documentation of patient denial of pain are all examples of high-quality documentation.These statements are not subjective or vague.The statement regarding the patient's incision is vague as what is considered normal cannot be measured.Noting that the patient is angry is subjective and unclear.

Question 3

The patient comes to the emergency department complaining of chest pain.What question by the nurse will encourage the patient to provide the most details about the pain?

Accepted Answer

The most information is gained by asking the patient to tell the nurse more about the pain.This is an open-ended question and will give the nurse more information about pain.All other questions are closed questions and will only elicit short answers specific to that question.Each question is asked in pain assessment; however,the question that will elicit the most information the one that asks the patient to tell the nurse more.

Question 4

The nurse obtains the following information from the patient: Alert and oriented,is married,and has a history of heart disease.This is an example of:

Accepted Answer

The nurse is collecting data on this patient.Once the complete data are collected,they can then be categorized and analyzed to formulate nursing diagnoses and plan for care.Using the information given in the question,a comprehensive physical assessment has not been completed.

Question 5

A patient is not feeling well at home and comes to the emergency department to be evaluated.In the initial nursing interview,what is the first question the nurse would ask?

Accepted Answer

The nurse should first ask in the initial interview why the patient is seeking nursing or medical assistance.This broad question will elicit the most information because it is open ended.It is important to ask the patient about pain,medical history,and home situation; however,these questions can all be addressed later on when taking the health history and physical assessment,as the nurse follows the patient's leads.

Question 6

The certified nursing assistant (CNA)tells the nurse: "I can help you with your assessment." What is the most appropriate response by the nurse?

Accepted Answer

In making decisions about which parts of an assessment can be delegated to the CNA,the nurse must consider agency policies and the regulations of the state board of nursing.The length of time one has been a CNA does not determine scope of practice or which parts of assessment can be delegated,but the nurse must consider the CNA's competence and the patient's conditions.In most states,the CNA can obtain vital signs and record them in the patient's chart; however,these must first be validated by the nurse.

Question 7

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented.

Accepted Answer

The interview should be done when the client is comfortable and there are no distractions.Endearing terms are inappropriate unless the client prefers them.Family members may offer information that may or may not be pertinent,and may distract from the interview.The presence of family members may also inhibit full disclosure of information by the client.

Question 8

When conducting the patient interview,which of the following statements by the nurse are appropriate? Select all that apply.

Accepted Answer

Observing that the patient is in pain,offering pain medication,postponing the interview,and asking about sleeping patterns are all appropriate actions when performing the nursing interview.Patients should be comfortable and pain free during the process.Asking the patient about time of interview is appropriate and accommodating.Statements in which nurses give advice or use "why" questions may often offend patients. Nursing Process: Assessment Client Need: PHSI Cognitive

Question 9

During the assessment process the patient states,"I am having numbness and tingling in my right arm." Which of the following best describes the patient's statement?

Accepted Answer

The patient statement of experiencing numbness and tingling down the right arm is an example of subjective data,as the statement is in the patient's own words.Objective data are overt and gathered by the nurse,either through physical assessment,laboratory findings,or diagnostic testing results.Secondary data are obtained through a source other than the patient,such as a family member.There is not enough information in the patient statement's to categorize it as comprehensive data,as the nurse would have to complete a physical assessment and obtain all data.

Question 10

Which of the following are cues rather than inferences? Select all that apply.

Accepted Answer

Cues are what the client says and what you observe: "just the facts." The only inference in the list is "feels better." What did the nurse observe to tell her the client feels better? Those would be cues.States,"I slept well" is a cue because it is a fact-that is what the client stated.

Question 11

The nurse is performing an initial interview on a 75-year-old male.Which of the following statements by this patient indicates the need to perform a special needs assessment?

Accepted Answer

An older adult who has fallen twice in 6 months has a safety risk.Although the wife thinks the patient needs a walker,there is no indication that a walker has been obtained.Falling and risk for falls requires the nurse to perform a special needs assessment most likely related to functional status.The patient verbalizes he misses church but follows by saying how he is able to view services on TV.He also verbalizes eating less red meat but adds that he obtains protein from other sources.The client verbalizes a physiological concern in his toothache but he has addressed this by seeing his dentist.

Question 12

Which statement below is the best example of high-quality nursing documentation?

Accepted Answer

"Started on solid foods.Ate 75% of dinner.No complaints of nausea or vomiting" is clear,concrete,and specific.Noting that patient breathing is normal and urine output is adequate does not give enough information about breathing or urine output.These statements contain vague and subjective words."Good strength in both lower extremities" is vague as the word good is subjective."Patient seems upset" does not give enough information nor is it specific.

Question 13

Which of the following are examples of objective data? Select all that apply.

Accepted Answer

Blood pressure and yellow ear drainage are examples of objective data.These data are obtained by the nurse through assessment.Patient statements are subjective data.The wife's statement constitutes secondary data and is vague and subjective.

Question 14

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team.The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP)and which are appropriate for a licensed practical nurse (LPN)or a registered nurse (RN).To which sources should the nurse turn find out to whom to delegate which tasks? Select all that apply.

Accepted Answer

State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials.The ANA Scope and Standards of Practice provides a guide for determining who is ultimately responsible and qualified to collect assessment data.The American Medical Association provides guidelines and standards for physicians,not nurses.The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel.

Question 15

Which of the following questions would be effective for obtaining information from a patient? Select all that apply.

Accepted Answer

How,what,and when are acceptable lines of questioning.Asking "why" can put the patient on the defensive and may suggest disapproval,limiting the amount of information the patient is willing give.

Quiz 3: Nursing Process: Assessment