Deck 3: Nursing Process: Assessment

Question 1

What makes a nursing history different from a medical history?

A) A nursing history focuses on the patient's responses to the health problem.
B) The same information is gathered in both; the difference is in who obtains the information.
C) A nursing history is gathered using a specific format.
D) A medical history collects more in-depth information.

Answer 1

A nursing history focuses on the patient's responses to the health problem.

Question 2

For which of the following purposes is a graphic flowsheet superior to other methods of recording data?

A) Providing easy documentation of routine vital signs
B) Seeing the patterns of a patient's fever
C) Describing the symptoms accompanying a rising temperature
D) Checking to make sure vitals signs were taken

Answer 2

Seeing the patterns of a patient's fever

Question 3

When should the nurse make systematic observations about a patient?

A) When the patient has specific complaints
B) With the first assessment of the shift
C) Each time the nurse gives medications to the patient
D) Each time the nurse interacts with the patient

Answer 3

Each time the nurse interacts with the patient

Question 4

The most obvious reason for using a framework when assessing a patient is to:

A) Prioritize assessment data
B) Organize and cluster data
C) Separate subjective data from objective data
D) Identify both primary and secondary data

Question 5

Which of the following is an example of data that should be validated?

A) The client's weight measures 185 lb at the clinic.
B) The client's liver function test results are elevated.
C) The client's blood pressure reading is 160/94 mm Hg; he states that is typical for him.
D) The client states she eats a low-sodium diet; she reports eating processed food.

Question 6

Which of the following is an example of an active listening behavior?

A) Taking frequent notes
B) Asking for more details
C) Leaning toward the patient
D) Sitting comfortably with legs crossed

Question 7

A nursing instructor is guiding nursing students on best practices for interviewing patients.Which of the following comments by a student would indicate the need for further instruction?

A) "My patient is a young adult, so I plan to talk to her without her parents in the room."
B) "Because my patient is old enough to be my grandfather, I will call him Mr."
C) "When reading my patient's health record, I thought of a few questions to ask."
D) "When I give my patient his pain medication, I will have time to ask questions."

Question 8

A patient comes to the urgent care clinic because he stepped on a rusty nail.What type of assessment would the nurse perform?

A) Comprehensive
B) Ongoing
C) Initial focused
D) Special needs

Question 9

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?

A) "I find it difficult to avoid using phrases like 'the patient tolerated the procedure well.'"
B) "It's confusing to have to remember which abbreviations this hospital allows."
C) "I need to work on charting assessments and interventions right after they are done."
D) "My patient was really quiet and didn't say much, so I charted that he acted depressed."

Question 10

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

A) To determine what type of therapies are acceptable to the client
B) To identify whether the client has a nutrition deficiency
C) To help you to understand cultural and spiritual beliefs
D) To identify potential interaction with prescribed medication and therapies

Question 11

Nondirective interviewing is a useful technique because it:

A) Allows the nurse to have control of the interview
B) Is an efficient way to interview a patient
C) Facilitates open communication
D) Helps focus patients who are anxious

Question 12

The Joint Commission requires which type of assessment to be performed on all patients?

A) Functional ability
B) Pain
C) Cultural
D) Wellness

Question 13

Which of the following is an example of an ongoing assessment?

A) Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol)
B) Examining the patient's mouth at the time she complains of a sore throat
C) Requesting the patient to rate intensity on a pain scale at the first perception of pain
D) Asking the patient in detail how he will return to his normal exercise activities

Question 14

A patient has left-sided weakness because of a recent stroke.Which type of special needs assessment would be most important to perform?

A) Family
B) Functional
C) Community
D) Psychosocial

Question 15

Which of the following examples includes both objective and subjective data?

A) The client's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min.
B) The client's cholesterol is elevated, and he states he likes fried food.
C) The client states she has trouble sleeping and that she drinks coffee in the evening.
D) The client states he gets frequent headaches and that he takes aspirin for the pain.

Question 16

Which of the following is an example of an open-ended question?

A) Have you had surgery before?
B) When was your last menstrual period?
C) What happens when you have a headache?
D) Do you have a family history of heart disease?

Question 17

The nurse is interviewing a patient who has a recent onset of migraine headaches.The patient is very anxious and cannot seem to focus on what the nurse is saying.Which of the following would be best for the nurse to say to begin gathering data about the headaches?

A) "When did your migraines begin?"
B) "Tell me about your family history of migraines."
C) "What are the types of things that trigger your headaches?"
D) "Describe what your headaches feel like."

Question 18

Which of the following is an example of the most basic motivation in Maslow's Hierarchy of Needs?

A) Experiencing loving relationships
B) Having adequate housing
C) Receiving education
D) Living in a crime-free neighborhood

Question 19

What do the nursing assessment models have in common?

A) They assess and cluster data into model categories.
B) They organize assessment data according to body systems.
C) They specify use of the nursing process to collect data.
D) They are based on the ANA Standards of Care.

Question 20

Of the following recommended interviewing techniques,which one is the most basic? (That is,without the intervention,the others will all be less effective.)

A) Beginning with neutral topics
B) Individualizing your approach
C) Minimizing note taking
D) Using active listening

Question 21

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

A) Assessment is a professional nursing responsibility.
B) Assessment helps the nurse identify problems and assign priorities for patient care.
C) Assessment helps the nurse formulate the medical diagnosis.
D) Only patients complaining of pain need to be assessed for pain.
E) Parts of nursing assessments can be delegated according to state practice acts and agency policies.

Question 22

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

A) Patient states, "When I get up in the morning, I feel dizzy."
B) Patient is alert and oriented to person, place, time, and surroundings.
C) Drainage from midline abdominal incision appears normal.
D) Patient is angry with wife over arriving late for Dr. appointment.
E) Patent has no complaints of pain at this time.

Question 23

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?

A) "When did your chest pain begin?"
B) "On a scale of 0 to 10, what is your pain level?"
C) "Would you please tell me more about the pain you are having?"
D) "Have you taken any medication for your pain?"

Question 24

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:

A) Collecting data
B) Analyzing data
C) Categorizing data
D) Making a comprehensive physical assessment

Question 25

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?

A) "Do you live alone?"
B) "Are you having any pain?"
C) "What is your past medical history?"
D) "Why did you come to the hospital today?"

Question 26

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

A) "Thank you. I am having a busy day and I can use your help."
B) "I'm sorry, but nurses are responsible for all patient assessment."
C) "How long have you been a CNA?"
D) "If you will obtain the vital signs and place them in the chart then that would be a big help."

Question 27

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.

A) Provide enough chairs so the family and you are able to sit facing the client.
B) Introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking any further questions.
C) After the family leaves, ask the client whether she is comfortable and willing to answer a few questions.
D) Ask the client whether you can talk with her while her family is watching the television.

Question 28

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

A) "You shouldn't be smoking cigarettes; you have already had one heart attack."
B) "Why don't you take your blood pressure medications? You need them to keep your blood pressure normal."
C) "I can see that you are in pain right now. Would you like your pain medication and then I can complete the interview a little later?"
D) "I am going to be completing your interview now. Is this a good time for you?"
E) "Have you noticed any changes in your pattern of sleeping?"

Question 29

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?

A) Subjective data
B) Objective data
C) Secondary data
D) Focused assessment

Question 30

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

A) Ate 50% of his meal.
B) Patient feels better today.
C) States, "I slept well."
D) White blood cell count is 15,000/mm³.

Question 31

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?

A) "I don't go to church as much as I used to but I watch the services on TV."
B) "I have fallen twice at home in the past 6 months, so my wife thinks I need a walker."
C) "I don't eat much red meat anymore but I get my protein from other foods."
D) "I had a toothache but I already saw the dentist."

Question 32

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

A) Patient breathing is normal, no pain noted, urine output is adequate at this time.
B) Good strength in both lower extremities. Ambulating with walker down hall.
C) Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.
D) Patient seems upset with wife visiting in room; will perform physical assessment at a later time.

Question 33

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

A) Blood pressure reading 120/80 mm Hg
B) Pain rated as 6 on a pain scale of 0 to 10
C) Moderate amount of yellow drainage from right ear
D) Wife states, "He has not been sleeping well at night."
E) Patient states, "I have a stomach ache."

Question 34

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.

A) Nurse practice act of his state
B) American Medical Association guidelines
C) Code of Ethics for Nurses
D) ANA Scope and Standards of Practice

Question 35

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

A) How did this happen to you?
B) What was your first symptom?
C) Why didn't you seek healthcare earlier?
D) When did you start having symptoms?