Question 1

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

Accepted Answer

A) Patient ate 50% of the meal. 
B) Patient feels better today. 
C) Patient states, "I slept well." 
D) Patient's white blood cell (WB
C)  count is 15,000/mm3. 
E) Patient does not appear to be in pain.

Question 2

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches?

Accepted Answer

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

Question 3

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate?

Accepted Answer

A) The client's weight is 185 lb (83.9 kg) at the clinic. 
B) The client's liver function test results are elevated. 
C) The client states that blood pressure (BP) of 160/94 mm Hg is typical. 
D) The client reports eating processed foods on a low-sodium diet.

Question 4

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform?

Accepted Answer

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

Question 5

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client's admission to the unit. Which professional standard influences the nurse's decision about who will be assigned to perform the assessment of the second client?

Accepted Answer

A) The state board for nursing-assistant testing 
B) The American Nurses Association (AN
A)  
C) The facility policy and procedure committee 
D) The bargaining committee for facility nurses

Question 6

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

A) Nurse practice act of the nurse's state 
B) American Medical Association (AM
A)  guidelines 
C) Code of Ethics for Nurses 
D) American Nurses Association (AN
A)  Scope and Standards of Practice 
E) Facility policy and procedure guidelines

Question 7

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

A) Provide enough chairs for the family to sit facing the client. 
B) Ask the client's preference for how to be addressed by the nurse. 
C) Ask if the client is willing to answer questions after the family leaves. 
D) Give the client the option of having the interview while the family watches television.

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

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 assessments." 
C) "If you start an assessment on the last patient, I will continue it later." 
D) "If you could obtain and record the vital signs, it would be a big help."

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?

Accepted Answer

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

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform?

Accepted Answer

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

Question 11

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?

Accepted Answer

A) Time constraints support small portions of assessment at a time. 
B) Validating an absence of change decreases the need to document. 
C) Critical changes are less likely to occur with constant observation. 
D) Repetition makes it less likely the nurse will miss an assessment area.

Question 12

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment?

Accepted Answer

A) Obtaining a patient's temperature 1 hour after giving acetaminophen 
B) Examining a patient's throat after soreness with swallowing is reported 
C) Requesting a patient to rate pain intensity level using a scale of 0 to 10 
D) Asking a patient the details of a plan to return to normal exercise activities

Question 13

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

A) "When did your chest pain begin?" 
B) "On a scale of 0 to 10, what is your pain level?" 
C) "Can you give a description of the pain you are having?" 
D) "Have you taken any medication for your pain?"

Question 14

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?"?

Accepted Answer

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

Exam 3: Assessment