Question 1

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?

Accepted Answer

Collecting data is the process of gathering information about the patient's health status, including their mental orientation, marital status, and medical history, which is what the nurse is doing in this scenario.

Question 2

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?

Accepted Answer

The answer of The nurse is preparing to conduct an...

Question 3

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.

Accepted Answer

High-quality nursing documentation should be clear, objective, and specific. A) is a direct patient quote, B) is an objective assessment, and E) is a clear statement of the patient's current status. C) and D) are subjective and vague.

Question 4

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.

Accepted Answer

The answer of The nurse is conducting an interview with...

Question 5

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?

Accepted Answer

Option C, "Can you give a description of the pain you are having?" is an open-ended question that encourages the patient to provide a detailed description of their experience, allowing for a more comprehensive understanding of their condition.

Question 6

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?

Accepted Answer

The first question in an initial nursing interview is often aimed at understanding the immediate concern or reason for the patient's visit, which is why "Why did you come to the hospital today?" is the most appropriate initial question. It helps prioritize care based on the patient's current needs or symptoms.

Question 7

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?

Accepted Answer

Falling twice at home in the past 6 months indicates a potential risk for injury and may suggest mobility or balance issues, necessitating a special needs assessment to ensure safety and prevent future falls.

Question 8

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?

Accepted Answer

CNAs are trained to assist with basic care and can obtain and record vital signs, which is within their scope of practice. This allows the nurse to delegate appropriately while maintaining responsibility for the overall assessment.

Question 9

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?

Accepted Answer

Option C is the best example of high-quality nursing documentation because it provides specific, measurable information about the patient's intake and condition, including the percentage of food consumed and the absence of nausea or vomiting, which are important details for patient care and monitoring.

Question 10

The nurse recognizes which examples of objective data? Select all that apply.

Accepted Answer

Objective data are observable and measurable signs that can be seen, heard, felt, or measured by someone other than the person experiencing them. Blood pressure of 120/80 mm Hg (A) is measured using a sphygmomanometer, making it objective. A moderate amount of yellow drainage from the right ear (C) can be seen and assessed by the nurse, making it objective as well.

Question 11

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.

Accepted Answer

The answer of A nurse, with a large caseload of...

Question 12

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.

Accepted Answer

Assessment is a core nursing responsibility that enables the identification of patient problems and priorities, guiding care planning. While medical diagnosis is the physician's role, nurses focus on nursing diagnoses based on their assessments. Pain assessment, a part of the nursing assessment, is not limited to self-reports but includes observational and other methods. Some assessment tasks can be delegated within the scope of nursing practice as defined by state laws and institutional policies.

Question 13

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?

Accepted Answer

The patient's statement about experiencing numbness and tingling in their right arm is considered subjective data because it is information reported by the patient that cannot be directly observed or measured by the nurse.

Question 14

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

Accepted Answer

Cues are observable or measurable facts or data points. A) is a cue because it is a measurable fact about how much the patient ate. C) is a cue because it is a direct statement from the patient about their sleep, which is observable through communication. D) is a cue because it is a measurable lab value. B and E are inferences because they interpret or conclude something about the patient's condition (feeling better, not in pain) based on observations or data.

Quiz 3: Assessment