Fundamentals: Chapter 16: Nursing
Assessment
se is using critical thinking skills during the first phase of the nursing process. Which action
indicates the nurse is in the first phase?
a. Completes a comprehensive database
b. Identifies pertinent nursing diagnoses
c. Intervenes based on priorities of patient care
d. Determines whether outcomes have been achieved - ANS ANS: A
The assessment phase of the nursing process involves data collection to complete a
thorough patient database and is the first phase. Identifying nursing diagnoses occurs
during the diagnosis phase or second phase. The nurse carries out interventions during the
implementation phase (fourth phase), and determining whether outcomes have been
achieved takes place during the evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to data collection. Which action will the
nurse take first?
a. Complete the questions in chronological order.
b. Focus on the patient's presenting situation.
c. Make accurate interpretations of the data.
d. Conduct an observational overview. - ANS ANS: B
A problem-oriented approach focuses on the patient's current problem or presenting
situation rather than on an observational overview. The database is not always completed
using a chronological approach if focusing on the current problem. Making interpretations of
the data is not data collection. Data interpretation occurs while appropriate nursing
diagnoses are assigned. The question is asking about data collection.
3. 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?
a. Administer scheduled medications assuming that the NAP would have reported abnormal
vital signs.
, b. Have the patient transported to the radiology department for a scheduled x-ray, and
review vital signs upon return.
c. Ask the NAP to record the patient's vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress. - ANS ANS: C
The nurse should ask the nursing assistive personnel to record the vital signs for review
before administering medicines or transporting the patient to another department. The nurse
should not make assumptions when providing high-quality patient care, and omitting the vital
signs is not an appropriate action.
4. The nurse is gathering data on a patient. Which data will the nurse report as objective
data?
a. States "doesn't feel good"
b. Reports a headache
c. Respirations 16
d. Nauseated - ANS ANS: C
Objective data are observations or measurements of a patient's health status, like
respirations. Inspecting the condition of a surgical incision or wound, describing an observed
behavior, and measuring blood pressure are examples of objective data. States "doesn't feel
good," reports a headache, and nausea are all subjective data. Subjective data include the
patient's feelings, perceptions, and reported symptoms. Only patients provide subjective
data relevant to their health condition.
5. 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?
a. The patient can now perform the dressing changes without help.
b. The patient can begin retaking all of the previous medications.
c. The patient is apprehensive about discharge.
d. The patient's surgery was not successful. - ANS ANS: C
Subjective data include expressions of fear of going home and being alone. These data
indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is
not an appropriate sign that a patient is able to perform dressing changes independently. An
order from a health care provider is required before a patient is taught to resume previous
medications. The nurse cannot infer that surgery was not successful if the incision is nearly
completely healed.
6. Which method of data collection will the nurse use to establish a patient's database?
a. Reviewing the current literature to determine evidence-based nursing actions
Assessment
se is using critical thinking skills during the first phase of the nursing process. Which action
indicates the nurse is in the first phase?
a. Completes a comprehensive database
b. Identifies pertinent nursing diagnoses
c. Intervenes based on priorities of patient care
d. Determines whether outcomes have been achieved - ANS ANS: A
The assessment phase of the nursing process involves data collection to complete a
thorough patient database and is the first phase. Identifying nursing diagnoses occurs
during the diagnosis phase or second phase. The nurse carries out interventions during the
implementation phase (fourth phase), and determining whether outcomes have been
achieved takes place during the evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to data collection. Which action will the
nurse take first?
a. Complete the questions in chronological order.
b. Focus on the patient's presenting situation.
c. Make accurate interpretations of the data.
d. Conduct an observational overview. - ANS ANS: B
A problem-oriented approach focuses on the patient's current problem or presenting
situation rather than on an observational overview. The database is not always completed
using a chronological approach if focusing on the current problem. Making interpretations of
the data is not data collection. Data interpretation occurs while appropriate nursing
diagnoses are assigned. The question is asking about data collection.
3. 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?
a. Administer scheduled medications assuming that the NAP would have reported abnormal
vital signs.
, b. Have the patient transported to the radiology department for a scheduled x-ray, and
review vital signs upon return.
c. Ask the NAP to record the patient's vital signs before administering medications.
d. Omit the vital signs because the patient is presently in no distress. - ANS ANS: C
The nurse should ask the nursing assistive personnel to record the vital signs for review
before administering medicines or transporting the patient to another department. The nurse
should not make assumptions when providing high-quality patient care, and omitting the vital
signs is not an appropriate action.
4. The nurse is gathering data on a patient. Which data will the nurse report as objective
data?
a. States "doesn't feel good"
b. Reports a headache
c. Respirations 16
d. Nauseated - ANS ANS: C
Objective data are observations or measurements of a patient's health status, like
respirations. Inspecting the condition of a surgical incision or wound, describing an observed
behavior, and measuring blood pressure are examples of objective data. States "doesn't feel
good," reports a headache, and nausea are all subjective data. Subjective data include the
patient's feelings, perceptions, and reported symptoms. Only patients provide subjective
data relevant to their health condition.
5. 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?
a. The patient can now perform the dressing changes without help.
b. The patient can begin retaking all of the previous medications.
c. The patient is apprehensive about discharge.
d. The patient's surgery was not successful. - ANS ANS: C
Subjective data include expressions of fear of going home and being alone. These data
indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is
not an appropriate sign that a patient is able to perform dressing changes independently. An
order from a health care provider is required before a patient is taught to resume previous
medications. The nurse cannot infer that surgery was not successful if the incision is nearly
completely healed.
6. Which method of data collection will the nurse use to establish a patient's database?
a. Reviewing the current literature to determine evidence-based nursing actions
