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1. Read the following scenario and identify the adjective used to describe the
characteristics of patient data that are numbered below. Place your answers on the lines provided. 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 identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (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 facility’s policy. (1) ___________________ (2) ___________________ (3) ___________________ (4) ___________________ (5) ___________________ (6) ___________________
2. 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 for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. Comprehensive b. Initial c. Time-lapsed d. Quick priority
3. The nurse is admitting a 35-year-old pregnant woman to the hospital for
treatment of preeclampsia. The patient asks the nurse: “Why are you doing a history and physical exam when the doctor just did one?” Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a. “The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths.” b. “It’s hospital policy. I know it must be tiresome, but I will try to make this quick!” c. “I’m a student nurse and need to develop the skill of assessing your health status and need for nursing care.” d. “We want to make sure that your responses to the medical exam are consistent and that all our data are accurate.” e. “We need to check your health status and see what kind of nursing care you may need.” f. “We need to see if you require a referral to a physician or other health care professional.”
4. A nurse notes that a shift report states that a patient has no special skin care
needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing 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.
5. A student nurse attempts to perform a nursing history for the first time. The
student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor’s best reply? a. “There’s a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!” b. “You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.” c. “No one ever really learns how to do this well because each history is different! I often feel like I’m starting afresh with each new patient.” d. “Don’t worry about learning all of the questions to ask. Every facility has its own assessment form you must use.”
6. The nurse collects objective and subjective data when conducting patient
assessments. Which patient situations are examples of subjective data? Select all that apply. a. A patient tells the nurse that she is feeling nauseous. b. A patient’s ankles are swollen. c. A patient tells the nurse that she is nervous about her test results. d. A patient complains that the skin on her arms is tingling. e. A patient rates his pain as a 7 on a scale of 1 to 10. f. A patient vomits after eating supper.
7. When a nurse enters the patient’s room to begin a nursing history, the patient’s
wife is there. After introducing herself to the patient and his wife, what should the nurse do? a. Thank the wife for being present. b. Ask the wife if she wants to remain. c. Ask the wife to leave. d. Ask the patient if he would like the wife to stay.
8. A nurse is performing an initial comprehensive assessment of a patient admitted
to a long-term care facility from home. The nurse begins the assessment by asking the patient, “How would you describe your health status and well- being?” The nurse also asks the patient, “What do you do to keep yourself healthy?” Which model for organizing data is this nurse following? a. Maslow’s human needs b. Gordon’s functional health patterns c. Human response patterns d. Body system model
9. The nurse is surprised to detect an elevated temperature (102°F) in a patient
scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a. Inform the charge nurse. b. Inform the surgeon.
redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.
5. b. Once a nurse learns what constitutes the minimum data set, it can be
adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.
6. a, c, d, e. Subjective data are information perceived only by the affected
person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
7. d. The patient has the right to indicate whom he would like to be present for the
nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.
8. b. Gordon’s functional health patterns begin with the patient’s perception of
health and well-being and progress to data about nutritional–metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow’s model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.
9. c. The nurse should first validate the finding if it is unusual, deviates from
normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.
10. a. The instructor is most likely to challenge the inference that the patient is
“fine” simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.
