C HAPTER 16: N URSING A SSESSMENT
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is conducting a nursing health history. Which component will the
nurse address?
a. Nurse’s concerns
b. Patient expectations
c. Current treatment orders
d. Nurse’s goals for the patient
ANS: B
Some components of a nursing health history include chief concern,
patient expectations, spiritual health, and review of systems. Current
treatment orders are located under the Orders section in the patient’s
chart and are not a part of the nursing health history. Patient concerns,
not nurse’s concerns, are included in the database. Goals that are
mutuall y established, not nurse’s goals, are part of the nursing care
plan.
DIF: Understand (comprehension) OBJ: Explain the
assessment process. TOP: Assessment MSC: Health
Promotion and Maintenance
2. While the patient’s lower extremit y, which is in a cast, is assessed, the
, patient tells the nurse about an inabilit y 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?
a. Tell the patient to just foc us on the leg and cast right now.
b. Document the sleep patterns and information in the patient’s chart.
c. Explain that a more thorough assessment will be needed next shift.
d. Ask the patient about usual sleep patterns and the onset of having
difficult y resting.
ANS: D
The nurse must use critical thinking skills in this situation to assess
first in this situation. The best response is to gather more assessment
data by asking the patient about usual sleep patterns and the onset of
having difficult y resting. The nurse should assess before documenting
and should not ignore the patient’s report of a problem or postpone it
till the next shift.
DIF: Anal yze (anal ysis) OBJ: Examine how the use of critical
thinking attitudes and professional standards yield a
comprehen sive assessment data base. TOP: Assessment
MSC: Health Promotion and Maintenance
3. 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 t ype of assessment
approach is the nurse using?
a. Gordon’s Functional Health Patterns
b. Activit y-exercise pattern assessment
c. General to specific assessment
, d. Problem-specific assessment
ANS: D
The nurse is not doing a complete, general ass essment and then
focusing on specific problem areas. Instead, the nurse focuses
immediatel y on the problem at hand (dressing and drainage from
surgery) and performs a problem -oriented assessment. Utilizing
Gordon’s Functional Health Patterns is an example of a structured
database-t ype assessment technique that includes 11 patterns to assess.
The nurse in this question is performing a specific problem -oriented
assessment approach, not a general approach. The nurse is not
performing an activity-exercise pattern assessment in this question.
DIF: Appl y (application) OBJ: Differentiate the t ypes of
nursing assessments used in practice. TOP: Assessment MSC:
Health Promotion and Maintenance
4. Which statement by a nurse indicates a good understanding about the
differences between data validation and data interpretation?
a. “Data interpretation occurs before data validation. ”
b. “Validation involves looking for patterns in professional standards. ”
c. “Validation involves comparing data with other sources for
accuracy.”
d. “Data interpretation involves discovering patterns in professional
standards.”
ANS: C
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. A nurse is conducting a nursing health history. Which component will the
nurse address?
a. Nurse’s concerns
b. Patient expectations
c. Current treatment orders
d. Nurse’s goals for the patient
ANS: B
Some components of a nursing health history include chief concern,
patient expectations, spiritual health, and review of systems. Current
treatment orders are located under the Orders section in the patient’s
chart and are not a part of the nursing health history. Patient concerns,
not nurse’s concerns, are included in the database. Goals that are
mutuall y established, not nurse’s goals, are part of the nursing care
plan.
DIF: Understand (comprehension) OBJ: Explain the
assessment process. TOP: Assessment MSC: Health
Promotion and Maintenance
2. While the patient’s lower extremit y, which is in a cast, is assessed, the
, patient tells the nurse about an inabilit y 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?
a. Tell the patient to just foc us on the leg and cast right now.
b. Document the sleep patterns and information in the patient’s chart.
c. Explain that a more thorough assessment will be needed next shift.
d. Ask the patient about usual sleep patterns and the onset of having
difficult y resting.
ANS: D
The nurse must use critical thinking skills in this situation to assess
first in this situation. The best response is to gather more assessment
data by asking the patient about usual sleep patterns and the onset of
having difficult y resting. The nurse should assess before documenting
and should not ignore the patient’s report of a problem or postpone it
till the next shift.
DIF: Anal yze (anal ysis) OBJ: Examine how the use of critical
thinking attitudes and professional standards yield a
comprehen sive assessment data base. TOP: Assessment
MSC: Health Promotion and Maintenance
3. 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 t ype of assessment
approach is the nurse using?
a. Gordon’s Functional Health Patterns
b. Activit y-exercise pattern assessment
c. General to specific assessment
, d. Problem-specific assessment
ANS: D
The nurse is not doing a complete, general ass essment and then
focusing on specific problem areas. Instead, the nurse focuses
immediatel y on the problem at hand (dressing and drainage from
surgery) and performs a problem -oriented assessment. Utilizing
Gordon’s Functional Health Patterns is an example of a structured
database-t ype assessment technique that includes 11 patterns to assess.
The nurse in this question is performing a specific problem -oriented
assessment approach, not a general approach. The nurse is not
performing an activity-exercise pattern assessment in this question.
DIF: Appl y (application) OBJ: Differentiate the t ypes of
nursing assessments used in practice. TOP: Assessment MSC:
Health Promotion and Maintenance
4. Which statement by a nurse indicates a good understanding about the
differences between data validation and data interpretation?
a. “Data interpretation occurs before data validation. ”
b. “Validation involves looking for patterns in professional standards. ”
c. “Validation involves comparing data with other sources for
accuracy.”
d. “Data interpretation involves discovering patterns in professional
standards.”
ANS: C
