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A nurse is preparing to perform a comprehensive health assessment on
a new adult client. Which action should the nurse perform first?
A. Establish rapport and explain the purpose of the assessment
B. Begin palpating the abdomen
C. Obtain the client's complete medication list
D. Perform a focused neurological examination
Answer: A
Rationale: Establishing rapport and explaining the assessment
promotes trust, encourages cooperation, and helps the client
understand what will occur. Although medication history and physical
examination are important, the assessment should begin by
establishing a therapeutic relationship and explaining the process.
What is the best definition of assessment in nursing?
A. The systematic gathering of information about a person's physical,
mental, spiritual, socioeconomic, and cultural status
B. The process of prescribing treatment for an identified disease
C. The process of determining only a patient's physical condition
D. The documentation of medications administered to a patient
,Answer: A
Rationale: Nursing assessment is a systematic process of gathering
information about the patient's physical, psychological, spiritual,
socioeconomic, cultural, and functional status. The information
becomes the foundation for clinical decision-making and nursing care.
Which activity is an essential component of the nursing assessment
process?
A. Prescribing medications
B. Collecting, categorizing, recording, and interpreting data
C. Establishing a medical diagnosis
D. Performing surgery
Answer: B
Rationale: Assessment includes collecting data through observation,
interviews, and physical examination; organizing or categorizing the
information; interpreting its significance; and documenting the
findings.
Information collected specifically for the purpose at hand is referred to
as what type of data?
A. Secondary data
B. Historical data
C. Primary data
D. Archived data
,Answer: C
Rationale: Primary data are information collected directly for the
specific purpose of the current assessment. This may include
information obtained directly from the patient through an interview or
examination.
Data that were previously collected for a purpose other than the
current assessment are called:
A. Primary data
B. Secondary data
C. Objective data
D. Diagnostic data
Answer: B
Rationale: Secondary data have already been collected for another
purpose. Examples include information found in previous medical
records, laboratory reports, or reports from other healthcare
professionals.
Which nursing process step uses assessment data to identify actual or
potential health problems and patient strengths?
A. Diagnosis
B. Planning
C. Implementation
D. Evaluation
, Answer: A
Rationale: Nursing diagnosis involves analyzing assessment data to
identify actual or potential health problems, risks, and strengths that
can guide nursing care.
Which nursing process step uses assessment findings to formulate
realistic goals and select appropriate interventions?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: C
Rationale: During planning, the nurse establishes measurable
outcomes and selects interventions that are appropriate, acceptable,
and likely to be effective for the patient.
A nurse gathers information about a patient's response while carrying
out prescribed nursing interventions. Which phase of the nursing
process is being demonstrated?
A. Diagnosis
B. Implementation
C. Planning
D. Assessment