ADPIE NCLEX
Read the following scenario and identify the term for the characteristics of
patient
that aredata
numbered
below.
The nurse is conducting an initial assessment of a 79 year old female patient
admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses
clinical reasoning to gather the appropriate patient data, (2) first ask the
patient about the most important details leading to her diagnosis, (3)
collects as much information as possible to understand the patient's health
problems, (4) collects the patient data in an organized manner, (5) verifies
that the data obtained is pertinent to the patient care plan, and (6) records
the data according to agency policy. correct answers 1. Purposeful - The
nurse identified the purpose of the nursing assessment (comprehensive) and
gathers the appropriate data.
2. Prioritized - The nurse gets the most important information first.
3.Complete - The nurse gathers as much data as possible to understand
the patient health problem and develop a plan of care.
4. Systematic - The nurse gathers the information in an organized manner.
5. Factual & Accurate - The nurse verifies that the information is reliable.
6.Recorded in a standard manner - The nurse records the data
according to agency policy so that all caregivers can easily access what is
learned.
The nurse practitioner is performing a short assessment of a newborn who is
displaying
signs of jaundice. The nurse observes the infant's skin color and orders
a test forlevels to report to the primary care provider. What type of
bilirubin
assessment has this
nurse
performed?
a.
comprehensive
b.
initial
c. time-
lapsed
d. quick priority correct
answers d
The nurse is admitting a 35 year old pregnant women to the hospital for
treatment of The patient asks the nurse: "Why are you doing a history
preeclampsia.
and physical
exam when the doctor just did one?" Which statement best explains
the primary
reasons a nursing assessment is performed? select all
that
a. apply
"The nursing assessment will allow us to plan and deliver
individualized,
nursing holistic
care that draws on your
strengths."
b. "It's hospital policy, I know it must be tiresome, but I will try to
make
c. "I'mitaquick."
student nurse and need to develop the skill of assessing your health
statusfor
need andnursing
care."
d. "We want to make sure your responses to the medical exam are
consistent
all you dataandis that
accurate."
, e. "We need to check your health status to see what kind of nursing
care you may
need.
"
f. "We need to see of you require a referral to a physician or other
health professio
When you receive the shift report, you learn that you patient has no
correct answers
special
aef skin care needs. You are surprised during the bath to observe
reddened areas over bony prominences. What action is appropriate?
a. correct the initial assessment form
b. redo the initial assessment and document current findings
c. conduct and document an emergency assessment
d. perform and document a focused assessment of skin integrity correct
answers d
A student nurse attempts to perform a nursing history for the first time.
The student
nurse asks the instructor how anyone ever lens all the questions a nurse
must
get a ask
good tobaseline of data. What would be the instructors
best reply?
a. "There's a lot to learn at first, but once it becomes part of you, you just
keepsame
the askingquestions over and over in each situation until you can do it in
b.
your sleep" make the basic questions part of you and then learn to
"You can
modify
each them situation,
unique for asking yourself how much you need to know to plan
good
c. "Nocare."
one ever really learns how to do this well because each history is
different!
feel like I'mI often
starting afresh each new
patient"
d. "Don't worry about learning all the questions to ask. Every agency
has its own form you must use." correct
assessment
answers b
The nurse collects objective and subjective data when conducting patient
assessments.
Which patient conditions are examples of subjective data? Select all
that apply tells the nurse that she feels
a. a patient
nauseous
b. a patients ankles are
swollen
c. a patient tells the nurse that she is nervous about her
test
d. a patient
results complains of having a rash on her arm
that
e. is itchy rates his pain as a 7 on a scale of
a patient
1a
f. topatient
10 vomits after eating dinner correct
answers acde
When the nurse enters the patients room to begin nursing history, the
patients
there. wifeshould
What is the nurse
a. introduce oneself and than the wife for being
do?
present
b. introduce oneself and asks the wife if she wants to
remain
c. introduce oneself and ask the wife to
leave
d. introduce the wife and ask the patient if he would like the wife to
stay correct
answers
d
A nurse is performing an initial comprehensive assessment of an 84
year oldadmitted
patient male to along term care facility from home. The nurse
begins the buy asking the patient How would you describe your health
assessment
status and well-
Read the following scenario and identify the term for the characteristics of
patient
that aredata
numbered
below.
The nurse is conducting an initial assessment of a 79 year old female patient
admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses
clinical reasoning to gather the appropriate patient data, (2) first ask the
patient about the most important details leading to her diagnosis, (3)
collects as much information as possible to understand the patient's health
problems, (4) collects the patient data in an organized manner, (5) verifies
that the data obtained is pertinent to the patient care plan, and (6) records
the data according to agency policy. correct answers 1. Purposeful - The
nurse identified the purpose of the nursing assessment (comprehensive) and
gathers the appropriate data.
2. Prioritized - The nurse gets the most important information first.
3.Complete - The nurse gathers as much data as possible to understand
the patient health problem and develop a plan of care.
4. Systematic - The nurse gathers the information in an organized manner.
5. Factual & Accurate - The nurse verifies that the information is reliable.
6.Recorded in a standard manner - The nurse records the data
according to agency policy so that all caregivers can easily access what is
learned.
The nurse practitioner is performing a short assessment of a newborn who is
displaying
signs of jaundice. The nurse observes the infant's skin color and orders
a test forlevels to report to the primary care provider. What type of
bilirubin
assessment has this
nurse
performed?
a.
comprehensive
b.
initial
c. time-
lapsed
d. quick priority correct
answers d
The nurse is admitting a 35 year old pregnant women to the hospital for
treatment of The patient asks the nurse: "Why are you doing a history
preeclampsia.
and physical
exam when the doctor just did one?" Which statement best explains
the primary
reasons a nursing assessment is performed? select all
that
a. apply
"The nursing assessment will allow us to plan and deliver
individualized,
nursing holistic
care that draws on your
strengths."
b. "It's hospital policy, I know it must be tiresome, but I will try to
make
c. "I'mitaquick."
student nurse and need to develop the skill of assessing your health
statusfor
need andnursing
care."
d. "We want to make sure your responses to the medical exam are
consistent
all you dataandis that
accurate."
, e. "We need to check your health status to see what kind of nursing
care you may
need.
"
f. "We need to see of you require a referral to a physician or other
health professio
When you receive the shift report, you learn that you patient has no
correct answers
special
aef skin care needs. You are surprised during the bath to observe
reddened areas over bony prominences. What action is appropriate?
a. correct the initial assessment form
b. redo the initial assessment and document current findings
c. conduct and document an emergency assessment
d. perform and document a focused assessment of skin integrity correct
answers d
A student nurse attempts to perform a nursing history for the first time.
The student
nurse asks the instructor how anyone ever lens all the questions a nurse
must
get a ask
good tobaseline of data. What would be the instructors
best reply?
a. "There's a lot to learn at first, but once it becomes part of you, you just
keepsame
the askingquestions over and over in each situation until you can do it in
b.
your sleep" make the basic questions part of you and then learn to
"You can
modify
each them situation,
unique for asking yourself how much you need to know to plan
good
c. "Nocare."
one ever really learns how to do this well because each history is
different!
feel like I'mI often
starting afresh each new
patient"
d. "Don't worry about learning all the questions to ask. Every agency
has its own form you must use." correct
assessment
answers b
The nurse collects objective and subjective data when conducting patient
assessments.
Which patient conditions are examples of subjective data? Select all
that apply tells the nurse that she feels
a. a patient
nauseous
b. a patients ankles are
swollen
c. a patient tells the nurse that she is nervous about her
test
d. a patient
results complains of having a rash on her arm
that
e. is itchy rates his pain as a 7 on a scale of
a patient
1a
f. topatient
10 vomits after eating dinner correct
answers acde
When the nurse enters the patients room to begin nursing history, the
patients
there. wifeshould
What is the nurse
a. introduce oneself and than the wife for being
do?
present
b. introduce oneself and asks the wife if she wants to
remain
c. introduce oneself and ask the wife to
leave
d. introduce the wife and ask the patient if he would like the wife to
stay correct
answers
d
A nurse is performing an initial comprehensive assessment of an 84
year oldadmitted
patient male to along term care facility from home. The nurse
begins the buy asking the patient How would you describe your health
assessment
status and well-
