QUESTIONS AND VERIFIED ANSWERS (COMPLETE
SOLUTIONS) GRADE A+!!
1. A nurse is performing a comprehensive assessment on a newly
admitted patient. What is the primary purpose of this type of
assessment?
A) To address a specific, urgent health crisis.
B) To focus on one or two body systems for a detailed examination.
C) To establish baseline data for problem identification and care
planning.
D) To evaluate the effectiveness of a previous nursing intervention.
Answer: C
Rationale: A comprehensive (initial) assessment is performed to gather
complete baseline data on a patient's health status, which is essential
for identifying problems and developing an individualized care plan.
While other assessments focus on specific issues, the comprehensive
assessment is holistic and time-consuming.
2. A patient comes to the clinic with a chief complaint of severe
headache and blurred vision. The nurse assesses the patient's
neurological status and vision. Which type of assessment is the nurse
performing?
,A) Emergency assessment
B) Comprehensive assessment
C) Episodic/Problem-focused assessment
D) Functional assessment
Answer: C
Rationale: An episodic or problem-focused assessment is based on the
patient's specific health issues and involves a smaller scope,
concentrating on one or two body systems (in this case, neurological
and visual) but in more depth than a comprehensive assessment. It is
not an emergency unless the symptoms are life-threatening.
3. The acronym ABCDE in emergency assessment stands for:
A) Airway, Breathing, Circulation, Disability, Exposure
B) Ability, Breathing, Coordination, Disability, Evaluation
C) Airway, Blood pressure, Circulation, Defibrillation, Environment
D) Assessment, Breathing, Circulation, Diagnosis, Embolism
Answer: A
Rationale: ABCDE is a systematic approach used in emergency situations
to assess and manage a patient in a life-threatening situation. It stands
for Airway, Breathing, Circulation, Disability (neurological status), and
Exposure (to identify other injuries or environmental factors).
4. In the ADPIE nursing process, what is the first step a nurse must
perform?
A) Planning
B) Nursing Diagnosis
,C) Implementation
D) Assessment
Answer: D
Rationale: ADPIE stands for Assessment, Diagnosis, Planning,
Implementation, and Evaluation. Assessment is the first and most
critical step, as it establishes the baseline and gathers all necessary data
before any diagnosis or interventions can be planned.
5. A patient is brought to the ER following a traumatic car accident.
The patient is unconscious and bleeding profusely. Which type of
assessment should the nurse perform first?
A) Comprehensive assessment
B) Episodic assessment
C) Emergency assessment
D) Focused health history
Answer: C
Rationale: An emergency assessment is indicated for life-threatening or
unstable situations, such as traumatic injury. It uses the ABCDE
approach to quickly identify and treat threats to life (airway, breathing,
circulation) before performing a more thorough head-to-toe
examination.
6. The "E" in the ABCDE emergency framework directs the nurse to:
A) Evaluate the patient's response to treatment
B) Expose the patient for a full-body examination
, C) Ensure the patient is emotionally stable
D) Explain the procedure to the family
Answer: B
Rationale: The "E" in ABCDE stands for Exposure. This involves
undressing the patient to perform a thorough physical examination to
identify other injuries, rashes, or signs of illness that might not be
immediately obvious. It should be balanced with preventing
hypothermia.
7. Which statement best differentiates a nursing diagnosis from a
medical diagnosis?
A) A medical diagnosis identifies disease, while a nursing diagnosis
identifies human responses to health problems.
B) A nursing diagnosis is always made before a medical diagnosis.
C) A medical diagnosis is used for planning, while a nursing diagnosis is
used for treatment.
D) A nursing diagnosis focuses only on physical symptoms, while a
medical diagnosis is holistic.
Answer: A
Rationale: The key difference is focus. A medical diagnosis identifies and
treats the disease or pathology. A nursing diagnosis, according to
NANDA, is a clinical judgment about individual, family, or community
responses to actual or potential health problems/life processes.
8. During the implementation phase of the nursing process, which
action is most appropriate?