Chapter 11- Nursing Assessment Nursing School Test Banks

 

1.

During data collection the nurse may validate data by which method? (Select all that apply)

A)

Comparing cues to normal function

B)

Referring to textbooks, journals, and research reports

C)

Checking consistency of cues

D)

Clarifying the patients statements

E)

Seeking consensus with colleagues about inferences

Ans:

A, B, C, D, E

Feedback:

These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses.

2.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

A)

Validate inferences with the patient

B)

Do not share inferences with the patient

C)

Document all inferences

D)

Avoid making any inferences

Ans:

A

Feedback:

The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and patient plans of care.

3.

While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history?

A)

Preparatory

B)

Introductory

C)

Maintenance

D)

Concluding

Ans:

C

Feedback:

Watching the patient to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview.

4.

The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate?

A)

When I perform the nursing history I will need to ask your family to leave the room.

B)

I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes.

C)

I will perform a physical assessment while I am obtaining the nursing history.

D)

I will leave a form with you to complete the nursing history information I need.

Ans:

B

Feedback:

Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical is performed separately. Family members can offer valuable information as long as the patient gives permission for them to remain present during the history taking.

5.

The RN is admitting a patient to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process, the patient complains of a severe headache so the nurse reassesses the vital signs to find the patients blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

A)

The company that made the blood pressure equipment

B)

The nurse

C)

The UAP

D)

The charge nurse

Ans:

B

Feedback:

While the nurse may delegate duties to UAP, the professional RN is ultimately responsible for the completeness and accuracy of the information. Since this was part of the admission assessment it would be advisable for the nurse to have measured the vital signs herself.

6.

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

A)

Size of the liver

B)

Presence of peristalsis

C)

Pupil reaction

D)

Skin temperature

Ans:

B

Feedback:

Peristalsis (bowel sounds) are assessed by auscultation with a stethoscope. The size of the liver is determined with percussion, inspection yields pupil size, and skin temperature is assessed through palpation.

7.

Which of the following are examples of objective data?

A)

Patient describing his pain

B)

Laboratory results

C)

Breath sounds

D)

Mother describing her childs asthma attack

E)

a patients temperature

Ans:

B, C, E

Feedback:

Objective data from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory results, reports from other healthcare team members), physical assessment (e.g., breath sounds, strength of extremities), and measurement devices (e.g., blood pressure, temperature) are collected to judge the patients behavioral responses to nursing interventions.

8.

Which of the following would be considered examples of subjective data? Select all that apply.

A)

Comments made by the patients family.

B)

Description of a symptom by a patient.

C)

A mother telling a nurse what the baby looked like when he was very ill.

D)

A nursing assessment of the patients vital signs.

E)

The physical exam notes made by the physician.

Ans:

A, B, C

Feedback:

Subjective data are collected from many sources: the patient, family members or significant others, nursing staff, and other healthcare team members.

9.

The nurse has identified a priority problem on her unit. Which of the following statements is true regarding addressing a priority problem?

A)

Setting priorities involves skipping interventions.

B)

Priorities are set at predetermined intervals throughout the shift.

C)

A priority problem requires a nursing intervention before another problem is addressed.

D)

Priority of problems is established and continued according to the nursing plan of care.

E)

The physician is responsible for determining priority of patient needs.

Ans:

C

Feedback:

A priority problem requires a nursing intervention before another problem is addressed, but setting priorities does not entail skipping any interventions. Setting priorities affects only the order in which nursing interventions are performed.

10.

During the interview component of the health assessment, the nurse conveys to the patient that the information is important by

A)

Nodding frequently during the interview

B)

Sitting at eye level with the patient

C)

Standing next to the patient while interviewing

D)

Limiting questions to those with yes or no answers

Ans:

B

Feedback:

When the patient responds to a question, convey interest by maintaining eye contact, occasionally nodding or verbally responding to his or her remarks.

11.

Before conducting a health assessment on a patient, the nurse should first

A)

Ask a family member to be present for the assessment

B)

Tell the patient the amount of time for the assessment

C)

Inform the patient of the procedure done in the assessment

D)

Introduce herself or himself to the patient

Ans:

D

Feedback:

Introduce yourself to the patient, and explain the nature and purpose of the health assessment.

12.

A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a priority?

A)

Assess the patients diet

B)

Assess the patients activity level

C)

Assess the patients blood pressure

D)

Assess the patients medication regimen

Ans:

C

Feedback:

While the diet, activity level, and medication regimen should be assessed, the priority intervention for the patient with an unstable blood pressure is to first measure the blood pressure.

13.

After assessment of a patient in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?

A)

Auscultation of the lungs

B)

Complaint of nausea

C)

Sensation of burning in her epigastric area

D)

Belief that demons are in her stomach

Ans:

A

Feedback:

Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.

14.

When assessing the patients pulse, the nurse is using the following assessment technique:

A)

Inspection

B)

Palpation

C)

Percussion

D)

Auscultation

Ans:

B

Feedback:

The pulsations of blood vessels; the outlines of organs such as the thyroid, spleen, or liver; the size, shape and mobility of masses; the temperature of the skin; vibration or movement of blood in a blood vessel; and tenderness or sensitivity of a body part are detected by palpation.

15.

During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should

A)

Review literature pertinent to the patients attributes

B)

Assess his or her own feelings regarding similar clinical situations

C)

Inform the patient of the maintenance of confidentiality

D)

Implement supportive nursing interventions

Ans:

C

Feedback:

During the introductory phase, the nurse should inform the patient how the information will be used and that confidentiality will be maintained.

16.

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should

A)

Clarify the patients health status

B)

Review as much information as possible

C)

Identify actual and potential nursing diagnoses

D)

Develop the nursing plan of care

Ans:

B

Feedback:

The preparatory or preinteraction phase occurs when the nurse meets the patient. The nurse should review as much information as possible about the patient.

17.

The purpose of obtaining a nursing history is to

A)

Assist the physician to establish a medical diagnosis

B)

Minimize the time required to establish a nursing diagnosis

C)

Focus on objective physical data specific to the patient

D)

Identify actual and potential nursing diagnoses

Ans:

D

Feedback:

The nursing history focuses on the patients account of the actual or potential health problems and their impact on his or her health status.

18.

Which of the following cultural groups may interpret touch by another as an invasion of privacy?

A)

Chinese American

B)

Spanish American

C)

European American

D)

African American

Ans:

A

Feedback:

Patients of Chinese heritage are very modest about having their bodies touched and may find it difficult to perform self-examinations for their own health promotion.

19.

A patient is a poor historian of his past medical history. Whom should the nurse consult about the patients past history?

A)

Physician

B)

Old chart

C)

Social worker

D)

Family

Ans:

D

Feedback:

Family members or significant others, if available, can provide information for a patient who is confused or incapacitated.

20.

The nurse observes the patient as he walks into the room. What information will this provide the nurse?

A)

Information regarding the patients gait

B)

Information regarding the patients personality

C)

Information regarding the patients psychosocial status

D)

Information on the rate of recovery from surgery

Ans:

A

Feedback:

Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and appraising.

21.

What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5 3 tall?

A)

Assess the HDL/LDL levels

B)

Obtain an electrocardiogram daily

C)

Assess blood pressure with a large cuff

D)

Begin patient teaching regarding a low fat diet

Ans:

C

Feedback:

When assessing an obese patient, a larger blood pressure cuff will likely be needed in order to prevent false high readings. It is not in the nurses scope of practice to determine when and if cholesterol levels and an ECG are ordered. Diet teaching may or may not be warranted depending on the cause of the obesity.

22.

When assessing an infant, it is important to involve the

A)

Parents

B)

Siblings

C)

Physician

D)

Infant

Ans:

A

Feedback:

The assessment of a child often involves parental assistance.

23.

A patient describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a patients description of pain in the right leg?

A)

Explanatory

B)

Subjective

C)

Objective

D)

Severe

Ans:

B

Feedback:

Cues may be signs (objective) or symptoms (subjective). Pain is subjectively described by the patient.

24.

When collecting subjective and objective data for a database in a patients home, it is important to

A)

Ask the patient to turn off the television

B)

Ask the social worker to verify the collected data

C)

Collect a 24-hour diet recall

D)

Evaluate the care provided by the physician

Ans:

A

Feedback:

Distractions such as a television should be minimized.

25.

A nurse is asking questions about a patients sexual history. It is important for the nurse to

A)

Evaluate the patients past history of sexual dysfunction

B)

Provide a time that enhances openness

C)

Collect data in a quiet, private environment

D)

Pull the curtains in a semiprivate room

Ans:

C

Feedback:

An assessment is best performed in a quiet, private setting that lends itself to the discussion of sensitive, personal, and confidential information.

26.

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?

A)

The patients airway should be assessed.

B)

The nurse should determine the reason for admission.

C)

The nurse should review the patients medications.

D)

The patients past medical history is assessed.

Ans:

A

Feedback:

Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Often, the patients difficulty involves airway, breathing, and circulatory problems.

27.

A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, she stated that she was planning to leave her husband. On the next visit in 2 weeks, the nurse practitioner will assess her patients commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

A)

Complete

B)

Focus

C)

Time-lapsed

D)

Emergency

Ans:

C

Feedback:

Like the focus assessment, the time-lapsed reassessment determines the status of problems already identified. Because of varying time intervals between reassessments, a complete review of all functional health patterns is carried out.

28.

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

A)

Complete

B)

Focus

C)

General

D)

Time-lapse

Ans:

B

Feedback:

In focus assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed.

29.

In order for a hospital to meet criteria regarding nursing care established by the Joint Commission on Accreditation of Healthcare Organizations, the nurse must conduct which of the following types of assessment?

A)

Focus

B)

Psychosocial

C)

Physical

D)

Initial

Ans:

D

Feedback:

The Joint Commission on the Accreditation of Healthcare Organizations has mandated that each patient have a documented nursing admission assessment that follows institutional policies.

30.

A patient has been discharged from an acute care facility. The first task a home health nurse must accomplish is

A)

Care of the patients physical pain

B)

Establish the patients database

C)

Evaluate the care provided previously

D)

Receive a report from the nursing staff

Ans:

B

Feedback:

An initial assessment is performed when the patient enters a healthcare facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic.

31.

The phase of the nursing process when the nurse gathers data about the patient to establish a plan of care is the

A)

Assessment

B)

Goals

C)

Interventions

D)

Evaluation

Ans:

A

Feedback:

The purpose of the nursing assessment is to gather data about the patient that can be used in diagnosing, identifying outcomes, planning, and implementing care.

32.

What must the nurse do to identify actual or potential health problems?

A)

Evaluate care implemented

B)

Meet with significant others

C)

Call the physician

D)

Gather data from sources

Ans:

D

Feedback:

The first phase of the nursing process, called assessment, is the collection of data for nursing purposes.

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