Chapter 16 Nursing Assessment Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. What is the primary purpose of the nursing assessment? A) To diagnose medical conditions B) To collect comprehensive and accurate patient data for care planning C) To document nurse’s personal opinions D) To complete paperwork quickly Answer: B) To collect comprehensive and accurate patient data for care planning Rationale: The main goal of nursing assessment is to gather thorough, accurate data to support clinical decision-making and develop an individualized care plan. ________________________________________ 2. During the nursing assessment, subjective data refers to: A) Observable and measurable information B) Information reported by the patient about their feelings or symptoms C) Data collected by laboratory tests D) Vital signs Answer: B) Information reported by the patient about their feelings or symptoms Rationale: Subjective data are the patient's verbal descriptions of their health condition, such as pain, nausea, or fatigue. ________________________________________ 3. Which of the following is the best example of objective data? A) Patient reports feeling nauseous B) Skin is warm and dry to touch C) Patient states, “I feel dizzy” D) Patient feels anxious Answer: B) Skin is warm and dry to touch Rationale: Objective data are observable and measurable. The nurse can physically assess the skin’s temperature and moisture level. ________________________________________ 4. What is the first step in the assessment process? A) Validation of data B) Collection of data C) Interpretation of data D) Documentation of findings Answer: B) Collection of data Rationale: The assessment process begins with systematically gathering information about the patient’s health status. ________________________________________ 5. A focused assessment is: A) A detailed and comprehensive examination of all body systems B) Performed to collect data about a specific problem or complaint C) Conducted only once during hospitalization D) A summary of patient’s past medical history Answer: B) Performed to collect data about a specific problem or complaint Rationale: Focused assessments target particular health issues or concerns rather than the entire body. ________________________________________ 6. What type of assessment is usually conducted during admission? A) Ongoing assessment B) Comprehensive assessment C) Focused assessment D) Emergency assessment Answer: B) Comprehensive assessment Rationale: Upon admission, a complete and detailed assessment is performed to establish a baseline for future care. ________________________________________ 7. When validating assessment data, a nurse should: A) Assume all patient statements are accurate B) Verify data by repeating measurements or clarifying with the patient or other sources C) Ignore conflicting information D) Document data immediately without verification Answer: B) Verify data by repeating measurements or clarifying with the patient or other sources Rationale: Data validation ensures accuracy by confirming findings through additional assessment or corroboration. ________________________________________ 8. Which method of data collection involves using the senses of sight, hearing, touch, and smell? A) Interview B) Observation C) Palpation D) Auscultation Answer: B) Observation Rationale: Observation uses sensory input to detect patient conditions and behavior. ________________________________________ 9. Which part of the health history includes information about the patient’s family health problems? A) Biographical data B) Present illness C) Family history D) Review of systems Answer: C) Family history Rationale: The family history identifies hereditary conditions or risks that may impact the patient’s health. ________________________________________ 10. A nurse performing an assessment notes the patient’s blood pressure is 180/110 mm Hg. What should the nurse do next? A) Ignore the finding since it was taken only once B) Notify the healthcare provider immediately C) Reassess the blood pressure to validate the reading D) Document the finding and continue with the assessment Answer: C) Reassess the blood pressure to validate the reading Rationale: Validation helps rule out measurement error before taking further action like notifying the provider. ________________________________________ 11. During an interview, what technique helps to encourage the patient to provide more information? A) Closed-ended questions B) Reflective statements C) Ignoring patient cues D) Rapid questioning Answer: B) Reflective statements Rationale: Reflective techniques encourage elaboration and convey empathy, facilitating communication. ________________________________________ 12. Which of the following best describes the purpose of a review of systems (ROS)? A) To identify the patient’s chief complaint B) To assess each body system for abnormalities or symptoms C) To determine the patient’s social history D) To complete a physical examination Answer: B) To assess each body system for abnormalities or symptoms Rationale: The ROS screens for health problems across all body systems and supports holistic assessment. ________________________________________ 13. What is an example of cultural consideration during nursing assessment? A) Ignoring patient’s cultural beliefs during data collection B) Asking about health practices important to the patient’s culture C) Assuming all patients have the same health beliefs D) Avoiding questions about ethnicity Answer: B) Asking about health practices important to the patient’s culture Rationale: Cultural competence involves actively inquiring about beliefs that affect health behaviors. ________________________________________ 14. A nurse uses a pain scale to assess a patient’s pain. This is an example of: A) Subjective data collection B) Objective data collection C) Validation of data D) Focused assessment Answer: A) Subjective data collection Rationale: Pain is a subjective experience; the patient's report is the most reliable source. ________________________________________ 15. What is the primary goal of the physical examination component of the nursing assessment? A) To perform diagnostic tests B) To collect objective data through inspection, palpation, percussion, and auscultation C) To provide treatment D) To prescribe medication Answer: B) To collect objective data through inspection, palpation, percussion, and auscultation Rationale: Physical exams provide measurable and observable findings about a patient’s current condition.