Nursing Assessment
7. 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?
a. Carefully review lab results.
b. Conduct the physical assessment.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
ANS: C
The nursing health history also includes a description of a patient’s habits and lifestyle
patterns. Lab results and physical assessment will not reveal as much about the
patient’s habits and lifestyle patterns as the nursing health history. Collecting data is
part of the working phase of the interview.
8. 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?
a. Consider cultural differences during this assessment.
b. Ask the patient to make eye contact to determine her affect.
c. Continue with the interview and document that the patient is depressed.
Notify the health care provider to recommend a psychological
d. evaluation.
ANS: A
To conduct an accurate and complete assessment, consider a patient’s cultural
background. This nurse needs to practice culturally competent care and appreciate the
cultural differences. Assuming that the patient is depressed or in need of a
psychological evaluation or to force eye contact is inappropriate.
,11. 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 mutually established, not nurse’s goals, are part of the nursing care plan.
12. 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?
a
. Tell the patient to just focus 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
. difficulty 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 difficulty 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.
14. 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
Validation, by definition, involves comparing data with other sources for accuracy.
Data interpretation involves identifying abnormal findings, clarifying information, and
identifying patient problems. The nurse should validate data before interpreting the
data and making inferences. The nurse is interpreting and validating patient data, not
professional standards.
16. 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?
a. Immediately place the patient in isolation.
b. Ask the patient to describe the type of reaction.
c. Proceed to the termination phase of the interview.
d. Document the latex allergy on the medication administration record.
7. 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?
a. Carefully review lab results.
b. Conduct the physical assessment.
c. Perform a thorough nursing health history.
d. Prolong the termination phase of the interview.
ANS: C
The nursing health history also includes a description of a patient’s habits and lifestyle
patterns. Lab results and physical assessment will not reveal as much about the
patient’s habits and lifestyle patterns as the nursing health history. Collecting data is
part of the working phase of the interview.
8. 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?
a. Consider cultural differences during this assessment.
b. Ask the patient to make eye contact to determine her affect.
c. Continue with the interview and document that the patient is depressed.
Notify the health care provider to recommend a psychological
d. evaluation.
ANS: A
To conduct an accurate and complete assessment, consider a patient’s cultural
background. This nurse needs to practice culturally competent care and appreciate the
cultural differences. Assuming that the patient is depressed or in need of a
psychological evaluation or to force eye contact is inappropriate.
,11. 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 mutually established, not nurse’s goals, are part of the nursing care plan.
12. 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?
a
. Tell the patient to just focus 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
. difficulty 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 difficulty 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.
14. 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
Validation, by definition, involves comparing data with other sources for accuracy.
Data interpretation involves identifying abnormal findings, clarifying information, and
identifying patient problems. The nurse should validate data before interpreting the
data and making inferences. The nurse is interpreting and validating patient data, not
professional standards.
16. 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?
a. Immediately place the patient in isolation.
b. Ask the patient to describe the type of reaction.
c. Proceed to the termination phase of the interview.
d. Document the latex allergy on the medication administration record.
