Chapter 11: Assessing

1. 1Identify the term for the characteristic of patient data.
   
   The nurse is conducting an initial assessment of a 79 year old female patient admitted to the hospital w/a diagnosis of dehydration.
   
   The nurse ([blank_start]purposeful[blank_end]) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data, ([blank_start]prioritized[blank_end]) first asks the partner about the most important details leading up to her diagnosis, ([blank_start]complete[blank_end]) collects as much information as possible to understand the patient's health problems, ([blank_start]systematic[blank_end]) collects the patient data in an organized manner, ([blank_start]factual[blank_end] and [blank_start]accurate[blank_end]) verifies that the data obtained is pertinent to the patient care plan, and ([blank_start]recorded[blank_end] in a standard manner) records the data according to agency policy.
   
   
   
   

   1. Apurposeful
   2. Bprioritized
   3. Ccomplete
   4. Dsystematic
   5. Efactual
   6. Faccurate
   7. Grecorded
2. 2The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed?

   1. Acomprehensive
   2. Binitial
   3. Ctime-lapsed
   4. Dquick priority
3. 3The nurse is admitting a 35-year old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statement best explain the primary reasons a nursing assessment is performed?

   1. AThe nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths
   2. BIt's hospital policy. I know it must be tiresome, but I will try to make it quick
   3. CI'm a student nurse and need to develop the skill of assessing your health status and need for nursing care
   4. DWe want to make sure that your responses to the medical exam are consistent and that all our data are accurate
   5. EWe need to check your health status and see what kind of nursing care you may need
   6. FWe need to see if you require a referral to a physician or other health care professional
4. 4When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

   1. ACorrect the initial assessment forms
   2. BRedo the initial assessment and document current findings
   3. CConduct and document an emergency assessment
   4. DPerform and document a focused assessment of skin integrity
5. 5A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply?

   1. AThere's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep
   2. BYou make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care
   3. CNo one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh w/each new patient
   4. DDon't worry about learning all of the questions to ask. Every agency has its own assessment form you must use.
6. 6The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data?

   1. AA patient tells the nurse that she is feeling nauseous
   2. BA patient ankles are swollen
   3. CA patient tells the nurse that she is nervous about her feet results
   4. DA patient complains of having a rash on her arm that is itchy
   5. EA patient rates his pain as a 7 on a scale of 1-10
   6. FA patient vomits after eating supper
7. 7When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do?

   1. AIntroduce oneself and thank the wife for being present
   2. BIntroduce oneself and ask the wife if she wants to remain
   3. CIntroduce oneself and ask the wife to leave
   4. DIntroduce oneself and ask the patient if he would like the wife to stay
8. 8A nurse is performing an initial comprehensive assessment of an 84 year old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following?

   1. AMaslow's human needs
   2. BGordon's functional health patterns
   3. CHuman response pattern
   4. DBody system model
9. 9[blank_start]Gordon's functional health patterns[blank_end]: begins w/the patient's perception of health and well-being and progress to data bout nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping and values/beliefs
   
   [blank_start]Maslow's[blank_end] : is based on the human needs hierarchy.
   
   [blank_start]Human responses[blank_end]: include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling.
   
   [blank_start]Body system[blank_end]: based on the functioning of the major body systems
   
   

   1. AGordon's functional health patterns
   2. BMaslow's
   3. CHuman responses
   4. DBody system
10. 10The nurse is surprised to detect and elevated temperature (102F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signals of being febrile. What is the first thing the nurse should do?

    1. AInform the charge nurse
    2. BInform the surgeon
    3. CValidate the finding
    4. DDocument the finding

11. 11A student nurse tells the instructor that a patient is fine and has "no complains". What would be the instructor's best response.

    1. AYou made an inference that he is fine because she has no complaints. How did you validate this?
    2. BShe probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship
    3. CSometimes everyone gets lucky. Why don't you try to help another patient?
    4. DMaybe you should reassess the patient. She has to have a problem - why else would she be here?
12. 12The [blank_start]patient[blank_end] is the primary and usually the best source of information.

    1. Apatient
13. 13Unless specified otherwise, the data recorded in the nursing history are assumed to have been collected from the patient.

    1. AVerdadeiro
    2. BFalso
14. 14The [blank_start]physical[blank_end] [blank_start]assessment[blank_end] normally follows the nursing history and interview and may verify data gathered during the history or yield new data.

    1. Aphysical
    2. Bassessment
15. 15Unlike the physical assessment performed by the physician to identify [blank_start]pathologic[blank_end] conditions and their causes, the nursing physical assessment focuses primarily on the patient's [blank_start]functional[blank_end] [blank_start]abilities[blank_end].

    1. Apathologic
    2. Bfunctional
    3. Cabilities
16. 16Subjective data should be recorded using the [blank_start]patient's[blank_end] [blank_start]own[blank_end] [blank_start]words[blank_end] within [blank_start]quotation[blank_end] [blank_start]marks[blank_end].

    1. Apatient's
    2. Bown
    3. Cwords
    4. Dquotation
    5. Emarks
17. 17The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

    1. AThe physician's physical assessment will focus on the patient's functional abilities
    2. BThe physician's physical assessment will focus focus on pathologic conditions and their causes
    3. CThe nurses's physical assessment will focus on pathologic conditions and their causes
    4. DThe nurses's physical assessment will focus on the patient's functional abilities
18. 18Which of the following group of terms best defines assessing in the nursing process?

    1. ACollection, validation, communication of client data
    2. BProblem focused, time-lapsed, emergency based
    3. CDesign a plan of care, implement nursing interventions
    4. DNursed focus, establishing nursing goals
19. 19During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

    1. ALimiting questions to those with yes or no answers
    2. BNodding frequently throughout the interview
    3. CStanding next to the client during the interview
    4. DSitting at eye level with the client
20. 20While performing an assessment, the nurse recognizes that his own personal bias may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate?

    1. AThe nurse should verify the information w/one or two members w/out informing the client
    2. BThe nurse should document on the client's chart that the assessment may be biased
    3. CThe nurse should inform the client of these potential biases and obtain the client's opinion
    4. DThe nurse should consult w/another nurse for that colleague's description of the assessment or observations
21. 21The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment?

    1. APerform the assessment in several short episodes rather than at one sitting
    2. BSupplement's the client information by speaking with family or friends
    3. CLimit the assessment to objective data
    4. DObtain the clients records from admissions to other institutions
22. 22The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication technique?

    1. AWhen did you first notice the rash on your leg
    2. BWhy do you feel that way about your cancer diagnosis
    3. CDo you have any additional questions for me
    4. DHave you ever hear the saying "no pain, no gain"
23. 23The nurse is reviewing information about a client and notes the following assessment data. Which of the following data cues does the nurse recognize as subjective data?

    1. ABilateral pedal edema 2+
    2. BPupils equal, accomodate and react to light
    3. CPain rating is 7
    4. DWheezing throughout lung fields
24. 24Which activities does the nurse perform during assessment, according to the ANA Standards of Practice 1?

    1. AInvolves the client, family and other health care providers in holistic data collection
    2. BSynthesizes available data to identify patterns and variances
    3. CProvides health teaching to the client and family
    4. DCollects data to monitor quality and effectiveness of nursing practice
    5. EValidates the diagnoses with the client, family, and other health care provider
    6. FEstablishes plan priorities w/the client and family
25. 25A nurse who provides care on a postsurgical unit is experiencing 3 patients to be admitted to the unit from postanesthetic recovery w/in a short time span. The admission assessment document that is used on the unit is extensive and requires a significant time to complete. Which of the following principles should guide the nurse's assessments?

    1. AEnlist another nurse to do the documentation while the nurse performs the assessemnts
    2. BCollect data that are helpful when planning and delivery care
    3. CCollect as much patient information as possible w/in the time available
    4. DDelegate some assessments to nursing assistive personnel
26. 26A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which of the following?

    1. AMedical records
    2. BPrimary Care Physician
    3. CClient's spouse
    4. DClient
27. 27After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?

    1. AWhat practices have you found especially helpful in other settings?
    2. BWhat do you envision for your care while you are here at this facility?
    3. CWhat are your expectations from us and yourself in your care?
    4. DIs there anything else we should know in order to care for you better?
28. 28Who or what is the primary source of information for a nursing history?

    1. APrevious medical records
    2. BFamily members
    3. CThe client
    4. DOther health care personnel
29. 29The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of what?

    1. AObjective data
    2. BAn inference
    3. CA judgement
    4. DSubjective data
30. 30Which type of assessment would the nurse be expected to perform on the client who is one day post-op following a cholecystectomy?

    1. AFocused
    2. BInitial
    3. CEmergency
    4. DTime-lapsed
31. 31Before conducting a health assessment on a client, what should the nurse do first?

    1. ATell the client the amount of time for the assessment
    2. BInform the client of the procedure done in the assessment
    3. CAsk a family member to be present for the assessment
    4. DIntroduce himself/herself to the client
32. 32A 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 client's commitment to change her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

    1. AFocused
    2. BComplete
    3. CEmergency
    4. DTime-lapsed
33. 33After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment?

    1. AThe results of the client's bone scan indicate decreased bone density
    2. BThe client claims her mobility and independence have declined in recent years
    3. CThe client demonstrates an unsteady gait and spinal kyphosis
    4. DThe client's serum calcium levels are below the reference age
34. 34How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

    1. AClient states "I don't see the point in trying anymore"
    2. BClient is demonstrating signs and symptoms of depression
    3. CClient state that his rehabilitation will be unsuccesfull
    4. DClient makes statements indicating a loss of hope
35. 35The nurse is summarizing the key points of the interview. This nursing activity occurs during what phase?

    1. AWorking
    2. BPreparatory
    3. CTermination
    4. DIntroductory
36. 36During the initial assessment of a newly admitted client, the nurse has clustered the client's ROM w/his gait, his bowel sounds w/his elimination pattern, and his chest sounds w/his respiratory rate. The nurse is most likely organizing data according to which of the following?

    1. Ahuman needs
    2. Bhuman response matters
    3. Cbody systems
    4. Dfunctional health patterns
37. 37A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history?

    1. ASocial worker
    2. BPhysician
    3. CFamily
    4. DOld chart

Descrição

UNIT III: Person-Centered Care and the Nursing Process Chapter 11: Assessing

Autor

Alexandra Bozan

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assessingperson-centered carenursing processnursing 101: fundamentals of nursingexam 2

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