CHAPTER 16: NURSING ASSESSMENT QUESTIONS WITH
DETAILED VERIFIED AND 100% ACCURATE ANSWERS
The nurse is using critical thinking skills during the first phase of the
nursing process. Which action indicates the nurse is in the first phase?
Correct Answers Completes a comprehensive database
A nurse is using the problem-oriented approach to data collection.
Which action will the nurse take first? Correct Answers Focus on the
patient's presenting situation.
After reviewing the database, the nurse discovers that the patient's vital
signs have not been recorded by the nursing assistive personnel (NAP).
Which clinical decision should the nurse make? Correct Answers Ask
the NAP to record the patient's vital signs before administering
medications.
The nurse is gathering data on a patient. Which data will the nurse report
as objective data? Correct Answers Respirations 16
A patient expresses fear of going home and being alone. Vital signs are
stable and the incision is nearly completely healed. What can the nurse
infer from the subjective data? Correct Answers The patient is
apprehensive about discharge.
Which method of data collection will the nurse use to establish a
patient's database? Correct Answers Performing a physical examination
,A nurse is gathering information about a patient's habits and lifestyle
patterns. Which method of data collection will the nurse use that will
best obtain this information? Correct Answers Perform a thorough
nursing health history.
While interviewing an older female patient of Asian descent, the nurse
notices that the patient looks at the ground when answering questions.
What should the nurse do? Correct Answers Consider cultural
differences during this assessment.
A nurse has already set the agenda during a patient-centered interview.
What will the nurse do next? Correct Answers Ask about the chief
concerns or problems.
The nurse is attempting to prompt the patient to elaborate on the reports
of daytime fatigue. Which question should the nurse ask? Correct
Answers "What reasons do you think are contributing to your fatigue?"
A nurse is conducting a nursing health history. Which component will
the nurse address? Correct Answers Patient expectations
While the patient's lower extremity, which is in a cast, is assessed, the
patient tells the nurse about an inability to rest at night. The nurse
disregards this information, thinking that no correlation has been noted
between having a leg cast and developing restless sleep. Which action
would have been best for the nurse to take? Correct Answers Ask the
patient about usual sleep patterns and the onset of having difficulty
resting.
, The nurse begins a shift assessment by examining a surgical dressing
that is saturated with serosanguineous drainage on a patient who had
open abdominal surgery yesterday (or 1 day ago). Which type of
assessment approach is the nurse using? Correct Answers Problem-
oriented assessment
Which statement by a nurse indicates a good understanding about the
differences between data validation and data interpretation? Correct
Answers "Validation involves comparing data with other sources for
accuracy."
Which scenario best illustrates the nurse using data validation when
making a nursing clinical decision for a patient? Correct Answers The
nurse determines to remove a wound dressing when the patient reveals
the time of the last dressing change and notices old and new drainage.
While completing an admission database, the nurse is interviewing a
patient who states "I am allergic to latex." Which action will the nurse
take first? Correct Answers Ask the patient to describe the type of
reaction.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme
facial grimacing while moving around in bed. What is the nurse's initial
action in response to these observations? Correct Answers Ask the
patient about the facial grimacing with movement.
DETAILED VERIFIED AND 100% ACCURATE ANSWERS
The nurse is using critical thinking skills during the first phase of the
nursing process. Which action indicates the nurse is in the first phase?
Correct Answers Completes a comprehensive database
A nurse is using the problem-oriented approach to data collection.
Which action will the nurse take first? Correct Answers Focus on the
patient's presenting situation.
After reviewing the database, the nurse discovers that the patient's vital
signs have not been recorded by the nursing assistive personnel (NAP).
Which clinical decision should the nurse make? Correct Answers Ask
the NAP to record the patient's vital signs before administering
medications.
The nurse is gathering data on a patient. Which data will the nurse report
as objective data? Correct Answers Respirations 16
A patient expresses fear of going home and being alone. Vital signs are
stable and the incision is nearly completely healed. What can the nurse
infer from the subjective data? Correct Answers The patient is
apprehensive about discharge.
Which method of data collection will the nurse use to establish a
patient's database? Correct Answers Performing a physical examination
,A nurse is gathering information about a patient's habits and lifestyle
patterns. Which method of data collection will the nurse use that will
best obtain this information? Correct Answers Perform a thorough
nursing health history.
While interviewing an older female patient of Asian descent, the nurse
notices that the patient looks at the ground when answering questions.
What should the nurse do? Correct Answers Consider cultural
differences during this assessment.
A nurse has already set the agenda during a patient-centered interview.
What will the nurse do next? Correct Answers Ask about the chief
concerns or problems.
The nurse is attempting to prompt the patient to elaborate on the reports
of daytime fatigue. Which question should the nurse ask? Correct
Answers "What reasons do you think are contributing to your fatigue?"
A nurse is conducting a nursing health history. Which component will
the nurse address? Correct Answers Patient expectations
While the patient's lower extremity, which is in a cast, is assessed, the
patient tells the nurse about an inability to rest at night. The nurse
disregards this information, thinking that no correlation has been noted
between having a leg cast and developing restless sleep. Which action
would have been best for the nurse to take? Correct Answers Ask the
patient about usual sleep patterns and the onset of having difficulty
resting.
, The nurse begins a shift assessment by examining a surgical dressing
that is saturated with serosanguineous drainage on a patient who had
open abdominal surgery yesterday (or 1 day ago). Which type of
assessment approach is the nurse using? Correct Answers Problem-
oriented assessment
Which statement by a nurse indicates a good understanding about the
differences between data validation and data interpretation? Correct
Answers "Validation involves comparing data with other sources for
accuracy."
Which scenario best illustrates the nurse using data validation when
making a nursing clinical decision for a patient? Correct Answers The
nurse determines to remove a wound dressing when the patient reveals
the time of the last dressing change and notices old and new drainage.
While completing an admission database, the nurse is interviewing a
patient who states "I am allergic to latex." Which action will the nurse
take first? Correct Answers Ask the patient to describe the type of
reaction.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme
facial grimacing while moving around in bed. What is the nurse's initial
action in response to these observations? Correct Answers Ask the
patient about the facial grimacing with movement.
