Nursing Assessment

1. 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.

ANS: A

The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

DIF: Understand REF: 207

OBJ: Discuss the relationship between critical thinking and nursing assessment.

TOP: Assessment MSC: Health Promotion and Maintenance

2. 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.

ANS: C

A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

DIF: Understand REF: 210 OBJ: Explain the process of data collection.

TOP: Assessment MSC: Health Promotion and Maintenance

3. 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.

ANS: C

The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

DIF: Apply REF: 210 OBJ: Explain the process of data collection.

TOP: Evaluation MSC: Health Promotion and Maintenance

4. 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.

ANS: A

Subjective data include the patient’s feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patient’s behavior, observations made, and measurements of a patient’s health status are all examples of objective data.

DIF: Remember REF: 210

OBJ: Differentiate between subjective and objective data. TOP: Evaluation

MSC: Health Promotion and Maintenance

5. 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.

ANS: C

Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

DIF: Apply REF: 210

OBJ: Differentiate between subjective and objective data. TOP: Assessment

MSC: Health Promotion and Maintenance

6. 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

ANS: C

A nursing database includes a physical examination. Orders are included in the order section of the patient’s chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

DIF: Remember REF: 211-212 OBJ: Describe the methods of data collection.

TOP: Assessment MSC: Health Promotion and Maintenance

7. 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.

ANS: C

A thorough nursing history includes information about the patient’s home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

DIF: Understand REF: 211-212 OBJ: Describe the methods of data collection.

TOP: Assessment MSC: Health Promotion and Maintenance

8. 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.

ANS: B

Older women of Asian descent consider it rude to look an authority figure, such as a health care professional, in the eye. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation is inappropriate.

DIF: Apply REF: 214 OBJ: Describe the methods of data collection.

TOP: Assessment MSC: Health Promotion and Maintenance

9. 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.

ANS: B

After setting the agenda, the nurse should conduct the actual interview and proceed with data collection. Setting the stage begins with introductions and takes place before an agenda is set. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

DIF: Understand REF: 212

OBJ: Discuss the process of conducting a patient-centered interview.

TOP: Assessment MSC: Health Promotion and Maintenance

10. 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?”

ANS: B

The question asking the patient what factors might be contributing to her fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal works hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on her complaints of daytime fatigue nor ask about the contributing reasons.

DIF: Apply REF: 213

OBJ: Discuss the process of conducting a patient-centered interview.

TOP: Assessment MSC: Health Promotion and Maintenance

11. 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.

ANS: D

Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patient’s chart and are not a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database. Goals that are mutually established, not nurse’s goals, are part of the nursing care plan.

DIF: Remember REF: 214-216 OBJ: Describe the components of a nursing history.

TOP: Assessment MSC: Health Promotion and Maintenance

12. 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.

ANS: D

The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient’s complaints.

DIF: Apply REF: 217

OBJ: Explain the differences among comprehensive, problem-oriented, and focused assessments.

TOP: Assessment MSC: Health Promotion and Maintenance

13. 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

ANS: D

The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique. The nurse in this question is performing a specific problem-oriented assessment approach. The nurse is not performing an activity-exercise pattern assessment in this question.

DIF: Apply REF: 208-209

OBJ: Explain the differences among comprehensive, problem-oriented, and focused assessments.

TOP: Assessment MSC: Health Promotion and Maintenance

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.”

ANS: C

Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

DIF: Understand REF: 217

OBJ: Explain the relationship between data interpretation and validation.

TOP: Assessment MSC: Health Promotion and Maintenance

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.

ANS: A

Changing the wound dressing is the only independent nursing action given. The nurse validates what the patient says with her own observation of the dressing. This option is the only assessment option as well that involves data validation. Administering pain medicine or potassium and removing a leg cast are examples of nursing interventions.

DIF: Apply REF: 217

OBJ: Explain the relationship between data interpretation and validation.

TOP: Assessment MSC: Health Promotion and Maintenance

16. 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.

ANS: B

The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

DIF: Apply REF: 217 OBJ: Conduct a nursing assessment.

TOP: Assessment MSC: Health Promotion and Maintenance

17. 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.

ANS: D

The nurse needs to clarify what she observes with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he rates his pain level at 2 out of 10. The nurse should not administer medication for moderate to severe pain if it is not necessary.

DIF: Apply REF: 217 OBJ: Conduct a nursing assessment.

TOP: Assessment MSC: Health Promotion and Maintenance

18. 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

ANS: A

Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient’s room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone’s ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for assessment to take place.

DIF: Apply REF: 213

OBJ: Discuss the process of conducting a patient-centered interview.

TOP: Assessment MSC: Health Promotion and Maintenance

19. 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.

ANS: B

When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment.

DIF: Evaluate REF: 211 OBJ: Conduct a nursing assessment.

TOP: Assessment MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Which of the following are examples of subjective data? (Select all that apply.)

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

ANS: A, C

Subjective data include patient’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient’s health status. In this question, the appearance of the wound and the patient’s temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

DIF: Understand REF: 210

OBJ: Differentiate between subjective and objective data. TOP: Assessment

MSC: Health Promotion and Maintenance