Chapter 16: Nursing Assessment
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MULTIPLE CHOICE ra
1. The nursing attendant is using critical thinking skills during thefirst phase of thenurs
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in g process. Which action indicates thenursing attendant is in thefirst phase? a.
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Completes a comprehensive database. ra ra ra
b. Identifies pertinent nursing diagnoses. ra ra ra
c. Intervenes based on priorities of hospital client care. ra ra ra ra ra ra ra
d. Determines whether outcomes have been achieved. ra ra ra ra ra
ACCURATE ra
ANSWER:-A
The assessment phase of thenursing process involves data collection to complete a thorough ho
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spital client database and is thefirst phase. Identifying nursing diagnoses occurs during thedi
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agnosis phase or second phase. thenursing attendant carries out interventions during theimpl
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ementation phase (fourth phase) and determining whether outcomes have been achieved tak
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es place during theevaluation phase (fifth phase) of thenursing process.
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DIF:Apply (application) ra
OBJ:Explain therelationship between assessment, clinical judgment and clinical decision making.
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TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
2. A nursing attendant is using theproblemspecific approach to data collection. Which a
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ction will thenursing attendant take first?
ar ra a. ra ra ra
Completing thequestions in chronological order ra ra ra ra
b. Focusing on thehospital client ’s presenting situation ra ra ra ra ra ra
c. Making accurate interpretations of thedata ra ra ra ra
d. Conducting an observational overview ra ra ra
ACCURATE ar
ANSWER:-B A problem- ra
specific approach focuses on thehospital client ’s current problem or presenting situation ra
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ther than on an observational overview. thedatabase is not always completed using a chrono
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logical approach if focusing on thecurrent problem. Making interpretations of thedata is not
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data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned.
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thequestion is asking about data collection.
a ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Differentiate thetypes of nursing assessments used in practice. ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
3. After reviewing thedatabase, thenursing attendant discovers that thehospital client ’s vit
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al signs have not been recorded by thenursing assistive personnel (NAP). Which clinical d
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ecision should thenursing attendant make?
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a. Administer scheduled medications assuming that theNAP would have reported ra ra ra ra ra ra ra ra ar
abnormal vital signs. ra ra
b. Have thehospital client transported to theradiology department for a schedule d x-
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ray and review vital signs upon return.
ra ra ra ra ra ra
, c. Ask theNAP to record thehospital client ’s vital signs before administering medications.
ra ra ra ra ra ra ra ra ra ra ra
d. Omit thevital signs because thehospital client is presently in no distress.
ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing attendant should ask thenursing assistive personnel to record thevital signs for r
ra ra ra ra ra ra ra ra ra ra ra ra ra
eview before administering medicines or transporting thehospital client to another departme
ra ra ra ra ra ra ra ra ra ra
nt. thenursing attendant should not make assumptions when providing highquality hospital clie
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nt care, and omitting thevital signs is not an appropriate action.
ra ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Explain therelationship between assessment, clinical judgment and clinical decision making.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Health Promotion and Maintenance ra ra ra
4. The nursing attendant is gathering data on a hospital client . Which data will thenursin
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g attendant report as objective data? a. States ―doesn’t feel good‖
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b. Reports a headache ra ra
c. Respirations 16 ra
d. Nauseated
ACCURATE ANSWER:-C ra
Objective data are observations or measurements of a hospital client ’s health status, like respirat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ions. Inspecting thecondition of a surgical incision or wound, describing an observed behavior, a
ra ra ra ra ra ra ra ra ra ra ra ra ra
nd measuring blood pressure are examples of objective data. States ―doesn’t feel good,‖ reports
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a ra
headache, and nausea are all subjective data. Subjective data include thehospital client ’s feelings,
ra ra ra ra ra ra ra ra ra ra ar ra ra
ra
perceptions, and reported symptoms. Only hospital client s provide subjective data relevant to th
ra ra ra ra ra ra ra ra ra ra ra ra ra
eir health condition.
ra ra
DIF:Apply (application) ra
OBJ:Differentiate thetypes of nursing assessments used in practice. ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
5. A hospital client expresses fear of going home and being alone. Vital signs are stable, and th
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eincision is nearly completely healed. What can thenursing attendant infer from thesubje
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ctive data? ra
a. The hospital client can now perform thedressing changes without help.
ra ra ra ra ra ra ra ra ra
b. The hospital client can begin retaking all of theprevious medications.
ra ra ra ra ra ra ra ra ra
c. The hospital client is fearful of being discharged.
ra ra ra ra ra ra ra
d. The hospital client ’s surgery was not successful.
ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
Subjective data include expressions of fear of going home and being alone. These data indicat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e (use inference) that thehospital client is apprehensive about discharge. Expressing fear is n
ra ra ra ra ra ra ra ra ra ra ra ra ra
ot an appropriate sign that a hospital client is able to perform dressing changes independentl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
y. An order from a health care provider is required before a hospital client is taught to resume
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
previous medications. thenursing attendant cannot infer that surgery was not successful if the
ra ra ra ra ra ra ra ra ra ar ra ra
incision is nearly completely healed. ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Analyze practice situations to determine thetype of nursing assessment to use.
ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Psychosocial Integrity ra ra
, 6. Which method of data collection will thenursing attendant use to establish a hospital client ’
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s database?
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a. Reviewing thecurrent literature to determine evidence-based nursing actions ra ra ra ra ra ra ra
b. Checking orders for diagnostic and laboratory tests ra ra ra ra ra ra
c. Performing a physical examination ra ra ra
d. Ordering medications ra
ACCURATE ANSWER:-C ra
You will learn to conduct different types of assessments: thehospital client centered interview du
ra ra ra ra ra ra ra ra ra ra ra ra ra
ring a nursing health history, a physical examination, and theperiodic a
ra ra ra ra ra ra ra ra ra ra
ssessments you make during rounding or administering care. A nursing database includes a p
ra ra ra ra ra ra ra ra ra ra ra ra ra
hysical examination. thenursing attendant reviews thecurrent literature in theimplementatio
ra ra ra ra ra ra ra ra
n phase of thenursing process to determine evidencebased actions, and thehealth care provider is
ar ra ra ra ra ra ra ra ra ra ra ra ar r
responsible for ordering medications. thenursing
a ra ra ra ra
attendant uses results from thediagnostic and laboratory tests to establish a hospital client d
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
atabase, not checking orders for tests. ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Analyze practice situations to determine thetype of nursing assessment to use.
ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
7. A nursing attendant is gathering information about a hospital client ’s habits and lifestyle p
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
atterns. Which method of data collection will thenursing attendant use that will best obtain
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
this information? ra
a. Carefully review lab results. ra ra ra
b. Conduct thephysical assessment. ra ra
c. Perform a thorough nursing health history. ra ra ra ra ra
d. Prolong thetermination phase of theinterview. ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing health history also includes a description of a hospital client ’s habits and lifest
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
yle patterns. Lab results and physical assessment will not reveal as much about thehospital c
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
lient ’s habits and lifestyle patterns as thenursing health history. Collecting data is part of the
ra ra ra ra ra ra ra ra ra ra ra ar ra ra ra
working phase of theinterview. ra ra ra
DIF:Analyze (analysis) ra
OBJ:Display professionalism during history taking. TOP:Assessment ra ra ra ra ar
MSC: Health Promotion and Maintenance ra ra ra ra
8. While interviewing an older female hospital client of Asian descent, thenursing attendan
ra ra ra ra ra ra ra ra ra ra ra
t notices that thehospital client looks at theground when answering questions. What shou
ar ra ra ra ra ra ra ra ra ra ra ra
ld thenursing attendant do?
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a. Consider cultural differences during this assessment. ra ra ra ra ra
b. Ask thehospital client to make eye contact to determine her affect.
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c. Continue with theinterview and document that thehospital client is depressed. ra ra ra ra ra ra ra ra ra
d. Notify thehealth care provider to recommend a psychological evaluation.
ar ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
To conduct an accurate and complete assessment, consider a hospital client ’s cultural backgr
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ound. This nursing attendant needs to practice culturally competent care and appreciate thec
ra ra ra ra ra ra ra ra ra ra ra ar
ra ra ra
MULTIPLE CHOICE ra
1. The nursing attendant is using critical thinking skills during thefirst phase of thenurs
ra ra ra ra ra ra ra ra ra ra ra ra
in g process. Which action indicates thenursing attendant is in thefirst phase? a.
ar ra ra ra ra ra ra ra ra ra
Completes a comprehensive database. ra ra ra
b. Identifies pertinent nursing diagnoses. ra ra ra
c. Intervenes based on priorities of hospital client care. ra ra ra ra ra ra ra
d. Determines whether outcomes have been achieved. ra ra ra ra ra
ACCURATE ra
ANSWER:-A
The assessment phase of thenursing process involves data collection to complete a thorough ho
ra ra ra ra ra ra ra ra ra ra ra ra ar
spital client database and is thefirst phase. Identifying nursing diagnoses occurs during thedi
ra ra ra ra ra ra ra ra ra ra ra ra
agnosis phase or second phase. thenursing attendant carries out interventions during theimpl
ra ra ra ra ra ra ra ra ra ra ra
ementation phase (fourth phase) and determining whether outcomes have been achieved tak
ra ra ra ra ra ra ra ra ra ra ra
es place during theevaluation phase (fifth phase) of thenursing process.
ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain therelationship between assessment, clinical judgment and clinical decision making.
ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
2. A nursing attendant is using theproblemspecific approach to data collection. Which a
ra ra ra ra ra ra ra ra ra ra ra
ction will thenursing attendant take first?
ar ra a. ra ra ra
Completing thequestions in chronological order ra ra ra ra
b. Focusing on thehospital client ’s presenting situation ra ra ra ra ra ra
c. Making accurate interpretations of thedata ra ra ra ra
d. Conducting an observational overview ra ra ra
ACCURATE ar
ANSWER:-B A problem- ra
specific approach focuses on thehospital client ’s current problem or presenting situation ra
ra ra ra ra ra ra ra ra ra ra ra ra
ther than on an observational overview. thedatabase is not always completed using a chrono
ra ra ra ra ra ra ra ra ra ra ra ra ra
logical approach if focusing on thecurrent problem. Making interpretations of thedata is not
ra ra ra ra ra ra ra ra ra ar ra ra ra
data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned.
ra ra ra ra ra ra ra ra ar ra r
thequestion is asking about data collection.
a ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Differentiate thetypes of nursing assessments used in practice. ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
3. After reviewing thedatabase, thenursing attendant discovers that thehospital client ’s vit
ra ra ra ra ra ra ra ra ra ra
al signs have not been recorded by thenursing assistive personnel (NAP). Which clinical d
ar ra ra ra ra ra ra ra ra ra ra ra ra
ecision should thenursing attendant make?
ra ra ra ra
a. Administer scheduled medications assuming that theNAP would have reported ra ra ra ra ra ra ra ra ar
abnormal vital signs. ra ra
b. Have thehospital client transported to theradiology department for a schedule d x-
ra ra ra ra ra ra ra ra ra ar
ray and review vital signs upon return.
ra ra ra ra ra ra
, c. Ask theNAP to record thehospital client ’s vital signs before administering medications.
ra ra ra ra ra ra ra ra ra ra ra
d. Omit thevital signs because thehospital client is presently in no distress.
ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing attendant should ask thenursing assistive personnel to record thevital signs for r
ra ra ra ra ra ra ra ra ra ra ra ra ra
eview before administering medicines or transporting thehospital client to another departme
ra ra ra ra ra ra ra ra ra ra
nt. thenursing attendant should not make assumptions when providing highquality hospital clie
ra ra ra ra ra ra ra ra ra ra ra
nt care, and omitting thevital signs is not an appropriate action.
ra ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Explain therelationship between assessment, clinical judgment and clinical decision making.
ra ra ra ra ra ra ra ra ra ar
TOP:Implementation MSC: Health Promotion and Maintenance ra ra ra
4. The nursing attendant is gathering data on a hospital client . Which data will thenursin
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
g attendant report as objective data? a. States ―doesn’t feel good‖
ar ra ra ra ra ra ra ra
b. Reports a headache ra ra
c. Respirations 16 ra
d. Nauseated
ACCURATE ANSWER:-C ra
Objective data are observations or measurements of a hospital client ’s health status, like respirat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ions. Inspecting thecondition of a surgical incision or wound, describing an observed behavior, a
ra ra ra ra ra ra ra ra ra ra ra ra ra
nd measuring blood pressure are examples of objective data. States ―doesn’t feel good,‖ reports
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
a ra
headache, and nausea are all subjective data. Subjective data include thehospital client ’s feelings,
ra ra ra ra ra ra ra ra ra ra ar ra ra
ra
perceptions, and reported symptoms. Only hospital client s provide subjective data relevant to th
ra ra ra ra ra ra ra ra ra ra ra ra ra
eir health condition.
ra ra
DIF:Apply (application) ra
OBJ:Differentiate thetypes of nursing assessments used in practice. ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
5. A hospital client expresses fear of going home and being alone. Vital signs are stable, and th
ra ra rara ra ra ra ra ra ra ra ra ra ra ra ra ar
eincision is nearly completely healed. What can thenursing attendant infer from thesubje
ra ra ra ra ra ra ra ra ra ra ra
ctive data? ra
a. The hospital client can now perform thedressing changes without help.
ra ra ra ra ra ra ra ra ra
b. The hospital client can begin retaking all of theprevious medications.
ra ra ra ra ra ra ra ra ra
c. The hospital client is fearful of being discharged.
ra ra ra ra ra ra ra
d. The hospital client ’s surgery was not successful.
ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
Subjective data include expressions of fear of going home and being alone. These data indicat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e (use inference) that thehospital client is apprehensive about discharge. Expressing fear is n
ra ra ra ra ra ra ra ra ra ra ra ra ra
ot an appropriate sign that a hospital client is able to perform dressing changes independentl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
y. An order from a health care provider is required before a hospital client is taught to resume
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
previous medications. thenursing attendant cannot infer that surgery was not successful if the
ra ra ra ra ra ra ra ra ra ar ra ra
incision is nearly completely healed. ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Analyze practice situations to determine thetype of nursing assessment to use.
ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Psychosocial Integrity ra ra
, 6. Which method of data collection will thenursing attendant use to establish a hospital client ’
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
s database?
ar
a. Reviewing thecurrent literature to determine evidence-based nursing actions ra ra ra ra ra ra ra
b. Checking orders for diagnostic and laboratory tests ra ra ra ra ra ra
c. Performing a physical examination ra ra ra
d. Ordering medications ra
ACCURATE ANSWER:-C ra
You will learn to conduct different types of assessments: thehospital client centered interview du
ra ra ra ra ra ra ra ra ra ra ra ra ra
ring a nursing health history, a physical examination, and theperiodic a
ra ra ra ra ra ra ra ra ra ra
ssessments you make during rounding or administering care. A nursing database includes a p
ra ra ra ra ra ra ra ra ra ra ra ra ra
hysical examination. thenursing attendant reviews thecurrent literature in theimplementatio
ra ra ra ra ra ra ra ra
n phase of thenursing process to determine evidencebased actions, and thehealth care provider is
ar ra ra ra ra ra ra ra ra ra ra ra ar r
responsible for ordering medications. thenursing
a ra ra ra ra
attendant uses results from thediagnostic and laboratory tests to establish a hospital client d
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
atabase, not checking orders for tests. ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Analyze practice situations to determine thetype of nursing assessment to use.
ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Health Promotion and Maintenance ra ra ra ra
7. A nursing attendant is gathering information about a hospital client ’s habits and lifestyle p
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
atterns. Which method of data collection will thenursing attendant use that will best obtain
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
this information? ra
a. Carefully review lab results. ra ra ra
b. Conduct thephysical assessment. ra ra
c. Perform a thorough nursing health history. ra ra ra ra ra
d. Prolong thetermination phase of theinterview. ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing health history also includes a description of a hospital client ’s habits and lifest
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
yle patterns. Lab results and physical assessment will not reveal as much about thehospital c
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
lient ’s habits and lifestyle patterns as thenursing health history. Collecting data is part of the
ra ra ra ra ra ra ra ra ra ra ra ar ra ra ra
working phase of theinterview. ra ra ra
DIF:Analyze (analysis) ra
OBJ:Display professionalism during history taking. TOP:Assessment ra ra ra ra ar
MSC: Health Promotion and Maintenance ra ra ra ra
8. While interviewing an older female hospital client of Asian descent, thenursing attendan
ra ra ra ra ra ra ra ra ra ra ra
t notices that thehospital client looks at theground when answering questions. What shou
ar ra ra ra ra ra ra ra ra ra ra ra
ld thenursing attendant do?
ar ra ra
a. Consider cultural differences during this assessment. ra ra ra ra ra
b. Ask thehospital client to make eye contact to determine her affect.
ra ra ra ra ra ra ra ra ra ra
c. Continue with theinterview and document that thehospital client is depressed. ra ra ra ra ra ra ra ra ra
d. Notify thehealth care provider to recommend a psychological evaluation.
ar ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
To conduct an accurate and complete assessment, consider a hospital client ’s cultural backgr
ra ra ra ra ra ra ra ra ra ra ra ra ra
ound. This nursing attendant needs to practice culturally competent care and appreciate thec
ra ra ra ra ra ra ra ra ra ra ra ar
