Deck 3: Assessment

Question 1

What makes a nursing history different from a medical history when collecting assessment data from the patient?

A) A nursing history focuses on the patient's responses to the health problem.
B) The same information is gathered; 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

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

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

Answer 2

Pain

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

What is the role of the Joint Commission in regard to patient assessment? The Joint Commission

A) States what assessments are collected by individuals with different credentials
B) Regulates the time frames for when assessments should be completed
C) Identifies how data are to be collected and documented
D) Sets standards for what and when to assess the patient

Question 5

Which 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 is 160/94 mm Hg; he states that that is typical for him.
D) The client states she eats a low-sodium diet and reports eating processed food.

Question 6

Of the following recommended interviewing techniques,which one is the most basic?

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

Question 7

Which 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 8

Which 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 9

A nursing instructor asked a group of nursing students to discuss 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 documenting assessments and interventions right after they are done."
D) "My patient was really quiet and didn't say much,so I documented that he acted depressed."

Question 10

The nurse is interviewing a patient who has a recent onset of migraine headaches.The patient is highly anxious and cannot seem to focus on what the nurse is saying.Which question would be best for the nurse to use 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 11

A patient comes to the urgent care clinic because he stepped on a rusty nail.Which type of assessment should the nurse perform when collecting data from this patient?

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

Question 12

A nursing instructor is guiding nursing students on best practices for interviewing patients.Which student comment 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 13

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

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

Question 14

For which purpose is a graphic flow sheet superior to other methods of recording data?

A) 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 vital signs were taken

Question 15

Which is an example of an active listening behavior?

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

Question 16

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 17

Which example includes both objective and subjective data?

A) The client's blood pressure is 132/68 and her heart rate is 88.
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 18

Which 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 with the first perception of pain
D) Asking the patient in detail how he will return to his normal exercise activities

Question 19

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 20

Which is the reason why nondirective interviewing is a useful technique?

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 21

The new nurse is struggling with identifying nursing diagnoses to guide a client's care.What should the preceptor encourage the nurse to do?

A) Look at assessment data.
B) Ask the client for her goals for care.
C) Analyze the results of care provided.
D) Identify actions to address specific problems.

Question 22

The nurse updates a client's database prior to attending an interdisciplinary care meeting.Which best explains why the nurse performed this action?

A) Minimizes repetition between the disciplines
B) Reduces the amount of work that another person needs to do
C) Assists when deciding the best course of treatment for the client
D) Ensures that the nurse remains as the leader of the care meeting

Question 23

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).To which sources should the nurse turn for the answer this question?

A) The nurse practice act of his state
B) The American Medical Association guidelines
C) The Code of Ethics for Nurses
D) The American Nurses Association's Scope and Standards of Practice
E) The staff nurse who was hired with you several months earlier

Question 24

A preceptor researches information to best explain the concept of assessment to a new graduate nurse.What should the preceptor include when defining assessment?

A) Recording data
B) Collecting data
C) Categorizing data
D) Identifying outcomes
E) Using a systematic process

Question 25

The nurse includes functional ability when assessing a client.What is the nurse's purpose in collecting this information?

A) Estimates the cost for healthcare
B) Evaluates the success of interventions
C) Identifies future rehabilitation and palliative care needs
D) Reduces the amount of repetition being provided by care providers

Question 26

Which questions would be effective for obtaining information from a patient during the nursing assessment?

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?"
E) "Are you hungry or thirsty?"

Question 27

Which is the most obvious reason for using a framework when assessing a patient?

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

Question 28

Which are cues rather than inferences?

A) Ate 50% of his meal
B) Patient feels better today
C) States,"I slept well"
D) White blood cell count 15,000/mm³
E) Blood pressure 120/80 mm Hg

Question 29

Which situation is the most conducive to conducting a successful interview of an older adult client (alert and oriented)whose spouse and two children are in the hospital room visiting and watching television?

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 questions.
C) After the family leaves,ask the client if she is comfortable and willing to answer a few questions.
D) Ask the client if you can talk with her while her family is watching the television.

Question 30

A client is admitted for total hip replacement surgery.What information is essential for the nurse to collect when planning for this client's discharge?

A) Number of steps to get into the home
B) Location of the bathroom in the home
C) Number of hours the client sleeps per night
D) Number of steps to walk inside of the home
E) Individuals available to transport the client for care