Question 1

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

Accepted Answer

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 
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 A

Question 2

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

Accepted Answer

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 
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 C

Question 3

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

Accepted Answer

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. 
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. A

Question 4

Components of a nursing health history include

Accepted Answer

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

Question 5

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

Accepted Answer

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. 
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 6

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

Accepted Answer

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. 
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 7

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

Accepted Answer

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. 
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 8

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

Accepted Answer

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. 
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 9

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

Accepted Answer

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. 
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.

Question 10

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?

Accepted Answer

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. 
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 11

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

Accepted Answer

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. 
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.

Question 12

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?

Accepted Answer

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

Question 13

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

Accepted Answer

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. 
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 14

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

Accepted Answer

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. 
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 15

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?

Accepted Answer

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. 
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 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?

Accepted Answer

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. 
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

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

Accepted Answer

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?" 
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?"

Question 18

Subjective data include

Accepted Answer

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. 
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 19

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

Accepted Answer

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." 
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 20

Which of the following are examples of subjective data?

Accepted Answer

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 
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

Exam 16: Nursing Assessment

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

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

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

Components of a nursing health history include

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

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

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

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

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

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?

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

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 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?

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

Subjective data include

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

Which of the following are examples of subjective data?

Nursing Today

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Activity and Exercise

Hygiene

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