Deck 6: Assessment

Question 1

During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which of the following frameworks would the nurse most likely choose to document this data?

A) Head-to-toe model
B) Gordon's Functional Health Patterns
C) Body systems model
D) Cephalic-caudal model

Answer 1

Body systems model

Question 2

An in-depth health history: (Select all that apply.)

A) includes demographic data.
B) lists the patient's allergies.
C) contains the family history of diseases.
D) explains the patient's health promotion practices.
E) is completed only once and can be recalled electronically.

Answer 2

includes demographic data.
lists the patient's allergies.
contains the family history of diseases.
explains the patient's health promotion practices.

Question 3

A patient with moderate lower back pain tells the nurse, "My urine smells awful and is as dark as my glass of tea." Which action will assist in validating the patient's concern?

A) Ask the patient to describe the back pain.
B) Review the lab results of the most recent urinalysis.
C) Request the nursing assistant to obtain a set of vital signs.
D) Check the patient's history for urinary tract infections.

Answer 3

Review the lab results of the most recent urinalysis.

Question 4

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which of the following techniques would the nurse use to collect this data?

A) Inspection
B) Percussion
C) Palpation
D) Auscultation

Question 5

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which of the following would the nurse consider as having the highest priority?

A) A 68-year-old patient suffering from dehydration and disorientation
B) A 14-year-old patient having respiratory distress and increasing anxiety
C) A 46-year-old patient with multiple cuts and abrasions to the upper extremities
D) A 38-year-old patient with a broken right hip and in severe pain

Question 6

The nurse is using a stethoscope to assess a patient's cardiac status. This assessment technique is known as:

A) inspection.
B) percussion.
C) palpation.
D) auscultation.

Question 7

The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using Gordon's Functional Health Pattern of:

A) nutrition and metabolism.
B) activity and exercise.
C) sleep and rest.
D) elimination.

Question 8

A patient is transported to the emergency room from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient's son for additional health history information. Information provided by the son would be considered:

A) primary, objective data.
B) primary, subjective data .
C) secondary, objective data.
D) secondary, subjective data.

Question 9

The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should:

A) obtain demographic data using open-ended questions.
B) establish the name by which the patient prefers to be addressed.
C) gather general information using closed-ended questions.
D) stand by the bedside to ask the needed questions.

Question 10

The nurse is documenting data collected during a health assessment interview. Which statement indicates subjective data?

A) "My last bowel movement was 4 days ago."
B) Abdomen distended; firm and tender.
C) Dark colored; hard pellet-shaped stool.
D) Color pink. Skin warm and dry. No sign of discomfort.

Question 11

The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, "I have never had sugar problems before. My doctor says it is because I am getting this sugar water." These types of data are considered:

A) primary, objective data.
B) primary, subjective data.
C) secondary, objective data.
D) secondary, subjective data.

Question 12

The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, "I just don't feel good. I'm so hot and I feel sick to my stomach. Can you ask me those questions later?" The best response by the nurse is:

A) "It will not take too long. I can hurry."
B) "We need the information to complete your admission paperwork."
C) "I will come back in a few minutes and we can start over."
D) "Let me see if you can have something for the nausea and then talk later."

Question 13

The nurse is performing an assessment of a patient's right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient's reaction. The physical assessment technique being used is:

A) inspection.
B) percussion.
C) palpation.
D) auscultation.

Question 14

The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient's face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient's heart and lungs. Which category of physical assessment is the basis for the nurse's response?

A) Emergency
B) Focused
C) Complete
D) Initial comprehensive

Question 15

The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that he did not have yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurological status of the patient. This type of assessment is known as:

A) an emergency assessment.
B) a focused assessment.
C) a complete physical examination.
D) a comprehensive assessment.

Question 16

After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient's condition is:

A) the head-to-toe pattern
B) Marjory Gordon's Functional Health Patterns.
C) the cephalic-caudal pattern.
D) the body systems model.

Question 17

A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse:

A) avoids eye contact to appear less threatening.
B) demonstrates professionalism by not smiling.
C) sits close and leans in slightly toward the patient.
D) speaks in a slow rate of speech and low tone.

Question 18

The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. The nurse's best response should be:

A) "Maybe the patient doesn't think the show is funny."
B) "Don't worry about it. Her daughter says this is normal."
C) "I will go visit her right away and see what is going on."
D) "Just document what you observe in your notes."

Question 19

The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." The nurse should:

A) develop a comprehensive teaching plan related to the surgical procedure.
B) ask the patient what information the doctor has explained about the surgery.
C) contact the surgeon and ask for further clarification of information given to patient.
D) focus on postoperative exercises and home-care following surgery.

Question 20

The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in World War II. In light of this, the nurse should:

A) shake the patient's hand and allow the patient time to "warm up."
B) expect the patient to be optimistic and question everything.
C) allow the patient to multitask and talk in short "sound bites."
D) understand that the patient is probably technologically literate.

Question 21

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.)

A) determines the patient's cognitive ability and potential language barriers.
B) gathers information about what the patient already knows about diabetes.
C) Attempts to determine the need for referrals and education.
D) Formulates the patient's plan of care using a standard protocol.
E) Prepares to teach the patient using materials written at a third-grade level.

Question 22

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.)

A) A 28-year old patient scheduled to be discharged home today
B) A 49-year-old patient with stable chronic lung disease
C) A 78-year-old patient with recent onset of rectal bleeding
D) A 35-year-old patient waiting for transfer to a rehabilitation center
E) A 40-year-old patient being admitted from the emergency department

Question 23

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

A) understand patient preferences
B) be aware of family values
C) recognize the patient's expectations
D) base conclusions on the nurse's personal experiences
E) provide care in a standardized manner

Question 24

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

A) Respirations - 24 breaths per minute
B) Platelet count - 350,000 mm³
C) Wound size - 3 cm X 2 cm
D) Temperature - 98.4° F (36.8° C)
E) Complaints of severe abdominal pain.

Question 25

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.)

A) Blood test results
B) X-ray results
C) Recent vital signs
D) Patient's health history
E) Subjective data