Deck 3: Assessment

Question 1

The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data?
1)Prioritizes collection of assessment data
2)Organizes and clusters data efficiently
3)Separates subjective and objective data
4)Identifies both primary and secondary data

Answer 1

2

Question 2

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client's admission to the unit. Which professional standard influences the nurse's decision about who will be assigned to perform the assessment of the second client?
1)The state board for nursing-assistant testing
2)The American Nurses Association (ANA)
3)The facility policy and procedure committee
4)The bargaining committee for facility nurses

Answer 2

2

Question 3

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches?
1)"When did your migraines begin?"
2)"Tell me about your family history of migraines."
3)"What are the things that trigger your headaches?"
4)"Describe for me what your headaches feel like."

Answer 3

1

Question 4

After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data?
1)The client's blood pressure reading is 132/68 mm Hg, and heart rate is 88 beats/min.
2)The client's cholesterol is elevated, and he admits to liking and eating fried food.
3)The client reports having trouble sleeping and admits drinking coffee in the evening.
4)The client verbally reports having frequent headaches and taking aspirin for the pain.

Question 5

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment?
1)Obtaining a patient's temperature 1 hour after giving acetaminophen
2)Examining a patient's throat after soreness with swallowing is reported
3)Requesting a patient to rate pain intensity level using a scale of 0 to 10
4)Asking a patient the details of a plan to return to normal exercise activities

Question 6

For which reason does the nurse use nondirective interviewing as an assessment technique?
1)Allows the nurse to have control of the interview
2)Is an efficient way to interview a patient
3)Facilitates open communication
4)Helps focus the attention of patients who are anxious

Question 7

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform?
1)Comprehensive
2)Ongoing
3)Initial focused
4)Special needs

Question 8

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate?
1)The client's weight is 185 lb (83.9 kg) at the clinic.
2)The client's liver function test results are elevated.
3)The client states that blood pressure (BP) of 160/94 mm Hg is typical.
4)The client reports eating processed foods on a low-sodium diet.

Question 9

The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history?
1)A nursing history focuses on the patient's responses and needs to the health problem.
2)The same information is gathered in both; the difference is in who obtains the information.
3)A nursing history is gathered by using a specific format.
4)A medical history collects more in-depth information.

Question 10

After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model?
1)To sort and cluster assessment data into specific categories
2)To organize assessment data according to body systems
3)To validate the use of the nursing process to collect data
4)To follow the American Nurses Association (ANA) Standards of Care

Question 11

During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information?
1)To determine what type of therapies are acceptable to the client
2)To identify whether the client has a nutrition deficiency
3)To help the nurse understand the client's cultural and spiritual beliefs
4)To be aware of potential interaction with prescribed medication

Question 12

The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit. While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission?
1)Nutritional status
2)Pain
3)Cultural
4)Wellness

Question 13

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?"?
1)Comprehensive assessment
2)Ongoing focused assessment
3)Special needs assessment
4)Initial focused assessment

Question 14

The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data?
1)Provides easy documentation of routine vital signs
2)Visually reflects the patterns of a patient's fever
3)Describes symptoms accompanying vital sign changes
4)Enables a quick check for patient tolerance of care

Question 15

The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question?
1)"Have you had surgery before?"
2)"When was your last menstrual period?"
3)"What happens when you have a headache?"
4)"Do you have a family history of heart disease?"

Question 16

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?
1)"I find it difficult to avoid using phrases like 'the patient tolerated the procedure well.'"
2)"It's confusing to have to remember which abbreviations this hospital allows."
3)"I need to work on charting assessments and interventions right after they are done."
4)"My patient was really quiet and didn't say much, so I charted that he acted depressed."

Question 17

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform?
1)Family
2)Functional
3)Community
4)Psychosocial

Question 18

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?
1)Time constraints support small portions of assessment at a time.
2)Validating an absence of change decreases the need to document.
3)Critical changes are less likely to occur with constant observation.
4)Repetition makes it less likely the nurse will miss an assessment area.

Question 19

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction?
1)"My patient is a young adult, so I plan to talk to her without her parents in the room."
2)"Because my patient is old enough to be my grandfather, I will address him with 'Mr.'"
3)"When reading my patient's health record, I thought of a few questions to ask."
4)"When I give my patient his pain medication, I will have time to ask questions."

Question 20

The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior?
1)Taking frequent notes
2)Asking for more details
3)Leaning toward the patient
4)Sitting comfortably with legs crossed

Question 21

The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, be married, have a history of heart disease. Obtaining this information is an example of which process?
1)Collecting data
2)Analyzing data
3)Categorizing data
4)Physical assessment

Question 22

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client's spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview?
1)Provide enough chairs for the family to sit facing the client.
2)Ask the client's preference for how to be addressed by the nurse.
3)Ask if the client is willing to answer questions after the family leaves.
4)Give the client the option of having the interview while the family watches television.

Question 23

The nurse manager is reviewing documentation performed by newly hired nurses. Which of the examples does the nurse manager recognize as high-quality nursing documentation? Select all that apply.
1)Patient states, "I feel dizzy in the morning."
2)Patient is alert and oriented to person, place, and time.
3)Drainage from midline abdominal incision appears normal.
4)Patient appears angry and is refusing to talk to the spouse.
5)Patient expresses no complaints of pain at this time.

Question 24

The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply.
1)"How did this happen to you?"
2)"What was your first symptom?"
3)"Why didn't you seek healthcare earlier?"
4)"When did you start having symptoms?"
5)"Why did you decide to seek help now?"

Question 25

The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain?
1)"When did your chest pain begin?"
2)"On a scale of 0 to 10, what is your pain level?"
3)"Can you give a description of the pain you are having?"
4)"Have you taken any medication for your pain?"

Question 26

A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient?
1)"Do you live alone?"
2)"Are you having any pain?"
3)"What is your past medical history?"
4)"Why did you come to the hospital today?"

Question 27

The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse?
1)"I don't go to church as much as I used to, but I watch services on TV."
2)"I have fallen twice at home in the past 6 months, but I have not injured myself."
3)"I don't eat much red meat anymore, but I get my protein from other foods."
4)"I had a toothache recently, so I made an appointment to see the dentist."

Question 28

The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate?
1)"Thank you. I am having a busy day, and I can use your help."
2)"I'm sorry, but nurses are responsible for all patient assessments."
3)"If you start an assessment on the last patient, I will continue it later."
4)"If you could obtain and record the vital signs, it would be a big help."

Question 29

Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation?
1)"Patient breathing is normal. No pain noted. Urine output is adequate at this time."
2)"Good strength in both lower extremities. Ambulating with walker in the hall."
3)"Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting."
4)"Patient seems upset with visiting spouse. Physical assessment planned at a later time."

Question 30

The nurse recognizes which examples of objective data? Select all that apply.
1)Blood pressure of 120/80 mm Hg
2)Pain rated as 6 on a pain scale of 0 to 10
3)Moderate amount of yellow drainage from right ear
4)Spouse stating the client is not sleeping well at night
5)Patient reporting the presence of stomach pain

Question 31

A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other members of the healthcare 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) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply.
1)Nurse practice act of the nurse's state
2)American Medical Association (AMA) guidelines
3)Code of Ethics for Nurses
4)American Nurses Association (ANA) Scope and Standards of Practice
5)Facility policy and procedure guidelines

Question 32

Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply.
1)Assessment is a professional nursing responsibility.
2)Assessment helps the nurse identify problems and priorities.
3)Assessment helps the nurse formulate the medical diagnosis.
4)Assessment of pain is focused on patients indicating the presence of pain.
5)Assessments can be delegated according to state practice acts and agency policies.

Question 33

During the assessment process, the patient tells the nurse, "I am having numbness and tingling in my right arm." Which type of data does the nurse recognize on the basis of the patient's statement?
1)Subjective data
2)Objective data
3)Secondary data
4)Comprehensive data

Question 34

Which of the following are cues rather than inferences? Select all that apply.
1)Patient ate 50% of the meal.
2)Patient feels better today.
3)Patient states, "I slept well."
4)Patient's white blood cell (WBC) count is 15,000/mm³.
5)Patient does not appear to be in pain.