Medical, Pharmaceutical & Health Sciences
NursingFundamentals NursingFundamentals of NursingPractice Set 9
NursingFundamentals NursingFundamentals of NursingPractice Set 9Nursing Assessment
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- Nursing TodayThe Health Care Delivery SystemCommunity-Based Nursing PracticeTheoretical Foundations of Nursing PracticeEvidence-Based PracticeHealth and WellnessCaring in Nursing PracticeCaring for the Cancer SurvivorCultural AwarenessCaring for FamiliesDevelopmental TheoriesConception Through AdolescenceYoung and Middle AdultsOlder AdultCritical Thinking in Nursing PracticeNursing AssessmentNursing DiagnosisPlanning Nursing CareImplementing Nursing CareEvaluationManaging Patient CareEthics and ValuesLegal Implications in Nursing PracticeCommunicationPatient EducationDocumentation and InformaticsPatient Safety and QualityImmobilityInfection Prevention and ControlVital SignsHealth Assessment and Physical ExaminationMedication AdministrationComplementary and Alternative TherapiesSelf-ConceptSexualitySpiritual HealthThe Experience of Loss, Death, and GriefStress and CopingActivity and ExerciseHygieneOxygenationFluid, Electrolyte, and Acid-Base BalanceSleepPain ManagementNutritionUrinary EliminationBowel EliminationSkin Integrity and Wound CareSensory AlterationsCare of Surgical Patients
Question 1
Free
Multiple Choice
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?
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Completes a comprehensive database
Identifies pertinent nursing diagnoses
Intervenes based on priorities of patient care
Determines whether outcomes have been achieved
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Question 2
Free
Multiple Choice
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
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Complete the questions in chronological order.
Focus on the patient's presenting situation.
Make accurate interpretations of the data.
Conduct an observational overview.
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Question 3
Free
Multiple Choice
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?
Choose correct answer/s
Administer scheduled medications assuming that the NAP would have reported abnormal vital signs.
Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return.
Ask the NAP to record the patient's vital signs before administering medications.
Omit the vital signs because the patient is presently in no distress.
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Question 4
Free
Multiple Choice
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
Choose correct answer/s
States "doesn't feel good"
Reports a headache
Respirations 16
Nauseated
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Question 5
Free
Multiple Choice
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?
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The patient can now perform the dressing changes without help.
The patient can begin retaking all of the previous medications.
The patient is apprehensive about discharge.
The patient's surgery was not successful.
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Question 6
Multiple Choice
Which method of data collection will the nurse use to establish a patient's database?
Choose correct answer/s
Reviewing the current literature to determine evidence-based nursing actions
Checking orders for diagnostic and laboratory tests
Performing a physical examination
Ordering medications
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Question 7
Multiple Choice
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?
Choose correct answer/s
Carefully review lab results.
Conduct the physical assessment.
Perform a thorough nursing health history.
Prolong the termination phase of the interview.
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Question 8
Multiple Choice
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?
Choose correct answer/s
Consider cultural differences during this assessment.
Ask the patient to make eye contact to determine her affect.
Continue with the interview and document that the patient is depressed.
Notify the health care provider to recommend a psychological evaluation.
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Question 9
Multiple Choice
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Choose correct answer/s
Begin with introductions.
Ask about the chief concerns or problems.
Explain that the interview will be over in a few minutes.
Tell the patient "I will be back to administer medications in 1 hour."
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Question 10
Multiple Choice
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
Choose correct answer/s
"Is there anything that you are stressed about right now that I should know?"
"What reasons do you think are contributing to your fatigue?"
"What are your normal work hours?"
"Are you sleeping 8 hours a night?"
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Question 11
Multiple Choice
A nurse is conducting a nursing health history. Which component will the nurse address?
Choose correct answer/s
Nurse's concerns
Patient expectations
Current treatment orders
Nurse's goals for the patient
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Question 12
Multiple Choice
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?
Choose correct answer/s
Tell the patient to just focus on the leg and cast right now.
Document the sleep patterns and information in the patient's chart.
Explain that a more thorough assessment will be needed next shift.
Ask the patient about usual sleep patterns and the onset of having difficulty resting.
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Question 13
Multiple Choice
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?
Choose correct answer/s
Gordon's Functional Health Patterns
Activity-exercise pattern assessment
General to specific assessment
Problem-oriented assessment
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Question 14
Multiple Choice
Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
Choose correct answer/s
"Data interpretation occurs before data validation."
"Validation involves looking for patterns in professional standards."
"Validation involves comparing data with other sources for accuracy."
"Data interpretation involves discovering patterns in professional standards."
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Question 15
Multiple Choice
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
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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.
The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done.
The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps.
The nurse elevates a leg cast when the patient reports decreased mobility.
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Question 16
Multiple Choice
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?
Choose correct answer/s
Immediately place the patient in isolation.
Ask the patient to describe the type of reaction.
Proceed to the termination phase of the interview.
Document the latex allergy on the medication administration record.
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Question 17
Multiple Choice
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?
Choose correct answer/s
Proceed to the next patient's room to make rounds.
Determine the patient does not want any pain medicine.
Ask the patient about the facial grimacing with movement.
Administer the pain medication ordered for moderate to severe pain.
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Question 18
Multiple Choice
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
Choose correct answer/s
The patient's room with the door closed
The waiting area with the television turned off
The patient's room before administration of pain medication
The waiting room while the occupational therapist is working on leg exercises
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Question 19
Multiple Choice
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
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The nurse makes eye contact with the patient.
The nurse speaks only to the patient's daughter.
The nurse leans forward while talking with the patient.
The nurse nods periodically while the patient is speaking.
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Question 20
Multiple Choice
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
Choose correct answer/s
Patient's temperature
Patient's wound appearance
Patient describing excitement about discharge
Patient pacing the floor while awaiting test results
Patient's expression of fear regarding upcoming surgery
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