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