Fundamentals: Chapter 16: Nursing Assessment UPDATED
ACTUAL Questions and CORRECT Answers
1. The nurse is using critical thinking skills during the first ANS: A
phase of the nursing process. Which action indicates the The assessment phase of the nursing process involves data collection to
nurse is in the first phase? complete a thorough patient database and is the first phase. Identifying nursing
a. Completes a comprehensive database diagnoses occurs during the diagnosis phase or second phase. The nurse carries
b. Identifies pertinent nursing diagnoses out interventions during the implementation phase (fourth phase), and
c. Intervenes based on priorities of patient care determining whether outcomes have been achieved takes place during the
d. Determines whether outcomes have been achieved evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to ANS: B
data collection. Which action will the nurse take first? A problem-oriented approach focuses on the patient's current problem or
a. Complete the questions in chronological order. presenting situation rather than on an observational overview. The database is not
b. Focus on the patient's presenting situation. always completed using a chronological approach if focusing on the current
c. Make accurate interpretations of the data. problem. Making interpretations of the data is not data collection. Data
d. Conduct an observational overview. interpretation occurs while appropriate nursing diagnoses are assigned. The
question is asking about data collection.
3. After reviewing the database, the nurse discovers that ANS: C
the patient's vital signs have not been recorded by the The nurse should ask the nursing assistive personnel to record the vital signs for
nursing assistive personnel (NAP). Which clinical decision review before administering medicines or transporting the patient to another
should the nurse make? department. The nurse should not make assumptions when providing high-quality
a. Administer scheduled medications assuming that the patient care, and omitting the vital signs is not an appropriate action.
NAP would have reported abnormal vital signs.
b. Have the patient transported to the radiology
department for a scheduled x-ray, and review vital signs
upon return.
c. Ask the NAP to record the patient's vital signs before
administering medications.
d. Omit the vital signs because the patient is presently in
no distress.
4. The nurse is gathering data on a patient. Which data ANS: C
will the nurse report as objective data? Objective data are observations or measurements of a patient's health status, like
a. States "doesn't feel good" respirations. Inspecting the condition of a surgical incision or wound, describing
b. Reports a headache an observed behavior, and measuring blood pressure are examples of objective
c. Respirations 16 data. States "doesn't feel good," reports a headache, and nausea are all subjective
d. Nauseated data. Subjective data include the patient's feelings, perceptions, and reported
symptoms. Only patients provide subjective data relevant to their health
condition.
, 5. A patient expresses fear of going home and being ANS: C
alone. Vital signs are stable and the incision is nearly Subjective data include expressions of fear of going home and being alone. These
completely healed. What can the nurse infer from the data indicate (use inference) that the patient is apprehensive about discharge.
subjective data? Expressing fear is not an appropriate sign that a patient is able to perform
a. The patient can now perform the dressing changes dressing changes independently. An order from a health care provider is required
without help. before a patient is taught to resume previous medications. The nurse cannot infer
b. The patient can begin retaking all of the previous that surgery was not successful if the incision is nearly completely healed.
medications.
c. The patient is apprehensive about discharge.
d. The patient's surgery was not successful.
6. Which method of data collection will the nurse use to ANS: C
establish a patient's database? You will learn to conduct different types of assessments: the patient-centered
a. Reviewing the current literature to determine interview during a nursing health history, a physical examination, and the periodic
evidence-based nursing actions assessments you make during rounding or administering care. A nursing database
b. Checking orders for diagnostic and laboratory tests includes a physical examination. The nurse reviews the current literature in the
c. Performing a physical examination implementation phase of the nursing process to determine evidence-based
d. Ordering medications actions, and the health care provider is responsible for ordering medications. The
nurse uses results from the diagnostic and laboratory tests to establish a patient
database, not checking orders for tests.
7. A nurse is gathering information about a patient's habits ANS: C
and lifestyle patterns. Which method of data collection The nursing health history also includes a description of a patient's habits and
will the nurse use that will best obtain this information? lifestyle patterns. Lab results and physical assessment will not reveal as much
a. Carefully review lab results. about the patient's habits and lifestyle patterns as the nursing health history.
b. Conduct the physical assessment. Collecting data is part of the working phase of the interview.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
8. While interviewing an older female patient of Asian ANS: A
descent, the nurse notices that the patient looks at the To conduct an accurate and complete assessment, consider a patient's cultural
ground when answering questions. What should the background. This nurse needs to practice culturally competent care and
nurse do? appreciate the cultural differences. Assuming that the patient is depressed or in
a. Consider cultural differences during this assessment. need of a psychological evaluation or to force eye contact is inappropriate.
b. Ask the patient to make eye contact to determine her
affect.
c. Continue with the interview and document that the
patient is depressed.
d. Notify the health care provider to recommend a
psychological evaluation.
9. A nurse has already set the agenda during a patient- ANS: B
centered interview. What will the nurse do next? After setting the agenda, the nurse should conduct the actual interview and
a. Begin with introductions. proceed with data collection, such as asking about the patient's current chief
b. Ask about the chief concerns or problems. concerns or problems. Introductions occur before setting the agenda. Begin an
c. Explain that the interview will be over in a few minutes. interview by introducing yourself and your position and explaining the purpose of
d. Tell the patient "I will be back to administer the interview. Your aim is to set an agenda for how you will gather information
medications in 1 hour." about a patient's current chief concerns or problems. The termination phase
includes telling the patient when the interview is nearing an end. Telling the
patient that medications will be given later when the nurse returns would typically
take place during the termination phase of the interview.
ACTUAL Questions and CORRECT Answers
1. The nurse is using critical thinking skills during the first ANS: A
phase of the nursing process. Which action indicates the The assessment phase of the nursing process involves data collection to
nurse is in the first phase? complete a thorough patient database and is the first phase. Identifying nursing
a. Completes a comprehensive database diagnoses occurs during the diagnosis phase or second phase. The nurse carries
b. Identifies pertinent nursing diagnoses out interventions during the implementation phase (fourth phase), and
c. Intervenes based on priorities of patient care determining whether outcomes have been achieved takes place during the
d. Determines whether outcomes have been achieved evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to ANS: B
data collection. Which action will the nurse take first? A problem-oriented approach focuses on the patient's current problem or
a. Complete the questions in chronological order. presenting situation rather than on an observational overview. The database is not
b. Focus on the patient's presenting situation. always completed using a chronological approach if focusing on the current
c. Make accurate interpretations of the data. problem. Making interpretations of the data is not data collection. Data
d. Conduct an observational overview. interpretation occurs while appropriate nursing diagnoses are assigned. The
question is asking about data collection.
3. After reviewing the database, the nurse discovers that ANS: C
the patient's vital signs have not been recorded by the The nurse should ask the nursing assistive personnel to record the vital signs for
nursing assistive personnel (NAP). Which clinical decision review before administering medicines or transporting the patient to another
should the nurse make? department. The nurse should not make assumptions when providing high-quality
a. Administer scheduled medications assuming that the patient care, and omitting the vital signs is not an appropriate action.
NAP would have reported abnormal vital signs.
b. Have the patient transported to the radiology
department for a scheduled x-ray, and review vital signs
upon return.
c. Ask the NAP to record the patient's vital signs before
administering medications.
d. Omit the vital signs because the patient is presently in
no distress.
4. The nurse is gathering data on a patient. Which data ANS: C
will the nurse report as objective data? Objective data are observations or measurements of a patient's health status, like
a. States "doesn't feel good" respirations. Inspecting the condition of a surgical incision or wound, describing
b. Reports a headache an observed behavior, and measuring blood pressure are examples of objective
c. Respirations 16 data. States "doesn't feel good," reports a headache, and nausea are all subjective
d. Nauseated data. Subjective data include the patient's feelings, perceptions, and reported
symptoms. Only patients provide subjective data relevant to their health
condition.
, 5. A patient expresses fear of going home and being ANS: C
alone. Vital signs are stable and the incision is nearly Subjective data include expressions of fear of going home and being alone. These
completely healed. What can the nurse infer from the data indicate (use inference) that the patient is apprehensive about discharge.
subjective data? Expressing fear is not an appropriate sign that a patient is able to perform
a. The patient can now perform the dressing changes dressing changes independently. An order from a health care provider is required
without help. before a patient is taught to resume previous medications. The nurse cannot infer
b. The patient can begin retaking all of the previous that surgery was not successful if the incision is nearly completely healed.
medications.
c. The patient is apprehensive about discharge.
d. The patient's surgery was not successful.
6. Which method of data collection will the nurse use to ANS: C
establish a patient's database? You will learn to conduct different types of assessments: the patient-centered
a. Reviewing the current literature to determine interview during a nursing health history, a physical examination, and the periodic
evidence-based nursing actions assessments you make during rounding or administering care. A nursing database
b. Checking orders for diagnostic and laboratory tests includes a physical examination. The nurse reviews the current literature in the
c. Performing a physical examination implementation phase of the nursing process to determine evidence-based
d. Ordering medications actions, and the health care provider is responsible for ordering medications. The
nurse uses results from the diagnostic and laboratory tests to establish a patient
database, not checking orders for tests.
7. A nurse is gathering information about a patient's habits ANS: C
and lifestyle patterns. Which method of data collection The nursing health history also includes a description of a patient's habits and
will the nurse use that will best obtain this information? lifestyle patterns. Lab results and physical assessment will not reveal as much
a. Carefully review lab results. about the patient's habits and lifestyle patterns as the nursing health history.
b. Conduct the physical assessment. Collecting data is part of the working phase of the interview.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
8. While interviewing an older female patient of Asian ANS: A
descent, the nurse notices that the patient looks at the To conduct an accurate and complete assessment, consider a patient's cultural
ground when answering questions. What should the background. This nurse needs to practice culturally competent care and
nurse do? appreciate the cultural differences. Assuming that the patient is depressed or in
a. Consider cultural differences during this assessment. need of a psychological evaluation or to force eye contact is inappropriate.
b. Ask the patient to make eye contact to determine her
affect.
c. Continue with the interview and document that the
patient is depressed.
d. Notify the health care provider to recommend a
psychological evaluation.
9. A nurse has already set the agenda during a patient- ANS: B
centered interview. What will the nurse do next? After setting the agenda, the nurse should conduct the actual interview and
a. Begin with introductions. proceed with data collection, such as asking about the patient's current chief
b. Ask about the chief concerns or problems. concerns or problems. Introductions occur before setting the agenda. Begin an
c. Explain that the interview will be over in a few minutes. interview by introducing yourself and your position and explaining the purpose of
d. Tell the patient "I will be back to administer the interview. Your aim is to set an agenda for how you will gather information
medications in 1 hour." about a patient's current chief concerns or problems. The termination phase
includes telling the patient when the interview is nearing an end. Telling the
patient that medications will be given later when the nurse returns would typically
take place during the termination phase of the interview.
