Deck 16: Nursing Assessment

Question 1

The nurse is assessing a patient with a hearing deficit.Where is the best place to conduct this interview?

A) The patient's room with the door closed
B) The waiting area with the television turned off
C) The patient's room before administration of pain medication
D) The patient's room while the occupational therapist is working on leg exercises

Answer 1

The patient's room with the door closed

Question 2

While interviewing an older female patient of Asian descent,the nurse notices that the patient looks at the ground when answering questions.This nurse should

A) Notify the physician to recommend a psychological evaluation.
B) Consider cultural differences during this assessment.
C) Ask the patient to make eye contact to determine her affect.
D) Continue with the interview and document that the patient is depressed.

Answer 2

Consider cultural differences during this assessment.

Question 3

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue.Which question should the nurse ask?

A) "Is there anything that you are stressed about right now?"
B) "What reasons do you think are contributing to your fatigue?"
C) "What are your normal work hours?"
D) "Are you sleeping 8 hours a night?"

Answer 3

"What reasons do you think are contributing to your fatigue?"

Question 4

Which of the following are examples of subjective data?

A) Patient describing excitement about discharge
B) Patient's wound appearance
C) Patient's expression of fear regarding upcoming surgery
D) Patient pacing the floor while awaiting test results
E) Patient's temperature

Question 5

While the patient's lower extremity,which is in a cast,is assessed,the patient tells the nurse about an inability to rest at night.The nurse disregards this complaint,thinking that no correlation has been noted between having a leg cast and developing restless sleep.A more theoretically sound approach would be to first

A) Document the sleep patterns and complaint in the patient's chart.
B) Tell the patient you are just focused on the leg right now.
C) Explain that a more thorough assessment will be needed next shift.
D) Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

Question 6

Subjective data include

A) A patient's feelings, perceptions, and reported symptoms.
B) A description of the patient's behavior.
C) Observations of a patient's health status.
D) Measurements of a patient's health status.

Question 7

Components of a nursing health history include

A) Current treatment orders.
B) Nurse's concerns.
C) Nurse's goals for the patient.
D) Patient expectations.

Question 8

To gather information about a patient's home and work surroundings,the nurse will need to utilize which method of data collection?

A) Carefully review lab results.
B) Conduct the physical assessment before collecting subjective information.
C) Perform a thorough nursing health history.
D) Prolong the termination phase of the interview.

Question 9

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

A) Completes a comprehensive database.
B) Identifies pertinent nursing diagnoses.
C) Intervenes based on patient goals and priorities of care.
D) Determines whether outcomes have been achieved.

Question 10

After setting the agenda during a patient-centered interview,what will the nurse do?

A) Begin by introducing himself.
B) Conduct a nursing health history.
C) Explain that the interview will be over in a few more minutes.
D) Tell the patient that he'll be back to administer medications in 1 hour.

Question 11

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed.What is the nurse's best action in response to her observation?

A) Proceed to the next patient's room while making rounds.
B) Offer a massage because the patient does not want any more pain medicine.
C) Administer the pain medication ordered for moderate to severe pain.
D) Ask the patient about the facial grimacing with movement.

Question 12

Which of the following methods of data collection is utilized to establish a patient's nursing database?

A) Reviewing the current literature to determine evidence-based nursing actions
B) Orders for diagnostic and laboratory tests
C) Physical examination
D) Anticipated medications to be ordered

Question 13

A patient expresses fear of going home and being alone.Her vital signs are stable and her incision is nearly completely healed.The nurse can infer from the subjective data that

A) The patient can now perform the dressing changes herself.
B) The patient can begin retaking all her previous medications.
C) The patient is apprehensive about discharge.
D) Surgery was not successful.

Question 14

A nurse comparing data validation and data interpretation correctly explains the difference with which statement?

A) "Validation involves looking for patterns in professional standards."
B) "Data interpretation involves discovering patterns in professional standards."
C) "Validation involves comparing data with other sources for accuracy."
D) "Data interpretation occurs before data validation."

Question 15

Which scenario best illustrates the use of data validation when making an independent nursing clinical decision?

A) The nurse determines that she needs to remove a wound dressing when the patient reveals the time of the last dressing change, and she notices that the present dressing is saturated with fresh and old blood.
B) The nurse administers pain medicine due at 1700 at 1600 because the patient complains of increased pain.
C) The nurse removes a leg cast when the patient complains of decreased mobility.
D) The nurse administers potassium when a patient complains of leg cramps.

Question 16

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented.The patient's daughter is present in the room.Which of the following actions made by the nursing student requires the nursing professor to intervene?

A) The nursing student is making eye contact with the patient.
B) The nursing student is speaking only to the patient's daughter.
C) The nursing student nods periodically while the patient is speaking.
D) The nursing student leans forward while talking with the patient.

Question 17

After reviewing the database,the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant.With this in mind,what clinical decision should the nurse make?

A) Administer scheduled medications assuming she would have been informed if the vital signs were abnormal.
B) Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return.
C) Ask the nursing assistant to record the patient's vital signs before administering medications.
D) Omit the vital signs because the patient is presently in no distress.

Question 18

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago).The nurse is performing what type of assessment approach in this situation?

A) Comprehensive assessment using Gordon's Functional Health Patterns
B) General to specific assessment
C) Activity-exercise pattern assessment
D) Problem-oriented assessment

Question 19

While completing an admission database,the nurse is interviewing a patient who states that he is allergic to latex.The most appropriate nursing action is to first

A) Leave the room and place the patient in isolation.
B) Ask the patient to describe the type of reaction.
C) Proceed to the termination phase of the interview.
D) Document the latex allergy on the medication administration record.

Question 20

A nurse using the problem-oriented approach to data collection will first

A) Complete an observational overview.
B) Disregard cues and complete the database questions in chronological order.
C) Focus on the patient's presenting situation.
D) Make accurate interpretations of the data.