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MULTIPLE CHOICE : T L T L
1. A patient comes to the emergency department and tells the L
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L
T triage nurse that heis “having a heart attack.” What is the nurse’s top
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T T L T L T L
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T priority at this time? T L T L T L
a. Determine the patient’s personal data and L
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insurance coverage.
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b. Ask the patient to take a seat in the waiting L
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room until his name is called.
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c. Request that a nurse collect data for a L
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comprehensive history.
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d. Ask a nurse to start a focused assessment L
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of this patient now.
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ANS: D L
T
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
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cardiovascular system. The type of health assessment performed by the nurse is also driven
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by patient need. Personal data and insurance information will be obtained, but in this
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situation, these data can wait until after the patient is assessed. Based also on Maslow’s
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T
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
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T T L
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
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the patient’s health status. Complications can be prevented if an immediate assessment is
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T
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
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situation at this time. Some subjective data will be collected, such as allergies and medical
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T T L T L T L T L T L L
T T L T L T L T L T L
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
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T T L T L L
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mental health assessment is not a priority at this time.
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DIF: Cognitive Level: Apply T REF: Box 1-3 | p. 3
L T L T L T L L
T T L L T L
T
TOP: Nursing Process: Assessment
L
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L
T T L T L L
T T L L
T L
T L
T T L L
T L
T
Establishing Priorities
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T T L
2. Which situation illustrates a screening assessment? L
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a. A patient visits an obstetric clinic for the T L T L T L T L L
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T
first time and the nurse conducts a detailed L
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history and physical examination. L
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b. A hospital sponsors a health fair at a local L
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T
mall and provides cholesterol and blood L
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T T L T L
pressure checks to mall patrons. L
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T
c. The nurse in an urgent care center checks L
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the vital signs of a patient who is L
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complaining of leg pain. L
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, d. A patient newly diagnosed with diabetes
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mellitus comes to test his fasting blood
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glucose level.
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ANS: B L
T
A health fair at a local mall that provides cholesterol and blood pressure checks is an
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T T L T L T L T L L
T T L T L L
T L
T
example of a screening assessment focused on disease detection. A detailed history and
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T T L T L T L T L T L L
T T L T L L
T
physical examination conducted during a first-time visit to an obstetric clinic is an example
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T T L L
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T
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
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T T L T L T L T L L
T T L T L
area of an urgent care center is an example of a problem-based/focused assessment. A
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T T L L
T
patient’s return appointment 1 month after today’s office visit to report fasting blood
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glucose levels is an example of an episodic or follow-up assessment.
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T L
T T L T L T L T L
DIF: Cognitive Level: UnderstandT REF: Box 1-3 | p. 3
L T L T L T L L
T L L
T T T L
TOP: Nursing Process: Assessment
L
T T L T L T L
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
L
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T L
T L
T L
T L
T L
T T L L
T
3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery L
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T
yesterday L
T
b. The person who is unaware of his high L
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T
serum glucose levels L
T T L T L
c. The person who is being admitted to a L
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T
long-term care facility L
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d. The person who is beginning rehabilitation L
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after a knee replacement L
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T T L L
T
ANS: B L
T
A screening assessment is performed for the purpose of disease detection. In this case this
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T T L T L L
T T L L
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T T L T L
person may have diabetes mellitus. A shift assessment is most appropriate for the person
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T T L T L T L T L L
T
who is recovering in the hospital from surgery. A comprehensive assessment is performed
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T L
T T L L
T L
T L
T L
T L
T L
T T L T L L
T
during admission to a facility to obtain a detailed history and complete physical
L
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T T L L
T T L T L L
T L
T T L T L L
T T L T L
examination. An episodic or follow-up assessment is performed after knee replacement to
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T
evaluate the outcome of the procedure.
L
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DIF: Cognitive Level: UnderstandT REF: Box 1-3 | p. 3
L T L T L T L L
T L L
T T T L
TOP: Nursing Process: Assessment
L
T T L T L T L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L
T T L L
T L
T L
T T L L
T T L L
T L
T L
T
Establishing Priorities
L
T T L
4. For which person is a shift assessment indicated?
L
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T L
T L
T L
T T L
a. The person who had abdominal surgery L
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T
yesterday L
T
b. The person who is unaware of his high L
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T L
T L
T L
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T L
T
serum glucose levels L
T T L T L
c. The person who is being admitted to a L
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T L
T
long-term care facility L
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T L
T
d. The person who is beginning rehabilitation L
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T T L L
T
after a knee replacement L
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T T L L
T
ANS: A L
T
A shift assessment is most appropriate for the person who is recovering in the hospital from
L
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T T L L
T L
T T L L
T L
T L
T T L L
T T L L
T T L T L
surgery. A screening assessment is performed for the purpose of disease detection, in this
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T T L L
T T L T L T L
case diabetes mellitus. A comprehensive assessment is performed during admission to a
L
T T L T L T L L
T T L T L L
T T L L
T T L T L
, facility to obtain a detailed history and complete physical examination. An episodic or
T L L
T L
T T L T L T L L
T L
T T L T L T L T L
L
Tfollow-up assessment is performed after knee replacement to evaluate the outcome of the
L
T T L L
T L
T T L L
T L
T L
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T T L L
T L
T
L
Tprocedure.
DIF: Cognitive Level: Understand T REF: Box 1-3 | p. 4
L T L T L T L L
T L L
T T T L
TOP: Nursing Process: Assessment
L
T T L T L T L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L
Establishing Priorities
L
T T L
5. For which person is a comprehensive assessment indicated?
T L L
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T L
T
a. The person who had abdominal surgery L
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T L
T
yesterday L
T
b. The person who is unaware of his high L
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T T L T L L
T
serum glucose levels L
T L
T T L
c. The person who is being admitted to a L
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T
long-term care facility L
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T
d. The person who is beginning rehabilitation L
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T
after a knee replacement L
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T
ANS: C L
T
A comprehensive assessment is performed during admission to a facility to obtain a
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T T L T L L
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T T L L
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T L
T
detailed history and complete physical examination. A shift assessment is most appropriate
L
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T T L L
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T L
T
for the person who is recovering in the hospital from surgery. A screening assessment is
L
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T T L T L T L T L T L L
T T L T L T L T L L
T T L L
T
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
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T T L T L L
T L
T
or follow-up assessment is performed after knee replacement to evaluate the outcome of
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T T L T L T L L
T L
T T L L
T T L T L T L
the procedure.
L
T T L
DIF: Cognitive Level: Understand T REF: Box 1-3 | p. 3
L T L T L T L L
T L L
T T T L
TOP: Nursing Process: Assessment
L
T T L T L T L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L
Establishing Priorities
L
T T L
6. For which person is an episodic or follow-up assessment indicated?
L
T T L T L T L L
T T L L
T L
T L
T
a. The person who had abdominal surgery L
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T T L L
T L
T
yesterday L
T
b. The person who is unaware of his high L
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T L
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T L
T L
T L
T
serum glucose levels L
T L
T T L
c. The person who is being admitted to a L
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T L
T
long-term care facility L
T L
T L
T
d. The person who is beginning rehabilitation L
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T L
T L
T L
T
after a knee replacement L
T T L T L L
T
ANS: D L
T
An episodic or follow-up assessment is performed after the knee replacement to evaluate
T L T L T L T L T L L
T T L T L L
T T L L
T T L
the outcome of the procedure. A shift assessment is most appropriate for the person who is
L
T T L L
T L
T L
T L
T L
T L
T T L L
T L
T T L T L L
T L
T T L
recovering in the hospital from surgery. A screening assessment is performed for the
L
T L
T T L L
T T L T L T L L
T L
T T L T L T L T L
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
L
T L
T L
T L
T T L L
T L
T L
T T L L
T L
T L
T L
T
performed during admission to a facility to obtain a detailed history and complete physical
L
T T L L
T L
T L
T L
T L
T L
T L
T L
T T L L
T L
T L
T
examination.
L
T
DIF: Cognitive Level: Understand T L T L T L REF: Box 1-3 | p. 3 T L L
T L L
T T T L
L
T TOP: Nursing Process: Assessment T L T L T L
, MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L
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T L
T L
T L
T L
T L
T T L T L L
T
Establishing Priorities
L
T T L
7. Which is an example of data a nurse collects during a physical L
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T T L L
T L
T L
T L
T L
T T L T L
L
T examination?
a. The patient’s lack of hair and shiny skin L
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T
over both shins L
T T L T L
b. The patient’s stated concern about lack of
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T
money for prescriptions
L
T T L T L
c. The patient’s complaints of tinglingL
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T L
T
sensations in the feet
L
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T T L T L
d. The patient’s mother’s statements that the
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T L
T L
T
patient is very nervous lately
L
T T L T L T L T L
ANS: A L
T
The lack of hair and shiny skin over both shins are objective data or signs that are part of
T L T L T L T L T L T L T L L
T T L T L L
T T L T L T L T L T L T L L
T
the physical examination. A patient’s concerns about lack of money are subjective data and
L
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T L
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T T L L
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T T L T L L
T L
T
are part of the health history. A patient’s complaints of tingling sensations in the feet are
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T T L L
T T L T L T L T L
subjective data and are part of the health history. A patient’s family statements are
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T T L L
T T L T L T L T L T L T L
considered secondary data, are subjective data, and are part of the health history.
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T L
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T T L L
T
DIF: Cognitive Level: Apply T REF: Box 1-3 | p. 3
L T L T L T L L
T L L
T T T L
TOP: Nursing Process: Assessment
L
T T L T L T L
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
L
T L
T L
T T L L
T L
T L
T L
T L
T L
T
Specific Assessments
L
T T L
8. The nurse documents which information in the patient’s history? L
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T T L L
T L
T
a. The patient’s skin feels warm to the touch. T L L
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T T L L
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T
b. The patient is scratching his arm. L
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T
c. The patient’s temperature is 100° F.L
T T L L
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T L
T
d. The patient complains of itching. T L L
T T L L
T
ANS: D L
T
A patient’s complaint of itching is subjective information, which means it is a symptom
T L T L T L T L T L L
T T L T L T L T L L
T T L T L
and is documented in the history. The patient’s warm skin is objective information
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T T L L
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T T L T L T L
gathered by the nurse through palpation, is also a sign, and is documented in the physical
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T T L T L L
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T
examination. The patient’s scratching is objective information gathered by the nurse
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T
through observation, is also a sign, and is documented in the physical examination. The
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patient’s elevated temperature is objective information gathered by the nurse through
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T
measurement, is also a sign, and is documented in the physical examination.
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T T L T L L
T L
T T L L
T L
T L
T
DIF: Cognitive Level: Apply TREF: p. 1 | p. 2 and Box 1-2
L T L T L T L L
T T L L T T L L
T L
T L
T
TOP: Nursing Process: Assessment
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T T L T L T L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
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T L
T L
T L
T L
T L
T T L T L L
T
Establishing Priorities
L
T T L
9. Which patient information does the nurse document in the patient’s physical L
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T
L
T assessment?
a. Slurred speech L
T
b. Immunizations
c. Smoking habit L
T
d. Allergies