NURS 316 200 Study Guide 1
Chapter 16: Nursing Assessment
1. 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?
a. Completes a comprehensive database
The assessment phase of the nursing process involves data collection to complete a thorough
patient database and is the first phase. Identifying nursing diagnoses occurs during the
diagnosis phase or second phase. The nurse carries out interventions during the
implementation phase (fourth phase), and determining whether outcomes have been achieved
takes place during the evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to data collection. Which action will
the nurse take first?
b. Focus on the patient’s presenting situation.
A problem-oriented approach focuses on the patient’s current problem or presenting situation
rather than on an observational overview. The database is not always completed using a
chronological approach if focusing on the current problem. Making interpretations of the data
is not data collection. Data interpretation occurs while appropriate nursing diagnoses are
assigned. The question is asking about data collection.
3. 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?
c. Ask the NAP to record the patient’s vital signs before administering medications.
The nurse should ask the nursing assistive personnel to record the vital signs for review
before administering medicines or transporting the patient to another department. The
nurse should not make assumptions when providing high-quality patient care, and omitting
the vital signs is not an appropriate action.
4. The nurse is gathering data on a patient. Which data will the nurse report as objective data?
c. Respirations 16
,Objective data are observations or measurements of a patient’s health status, like respirations.
Inspecting the condition of a surgical incision or wound, describing an observed behavior, and
measuring blood pressure are examples of objective data. States “doesn’t feel good,” reports a
headache, and nausea are all subjective data. Subjective data include the patient’s feelings,
perceptions, and reported symptoms. Only patients provide subjective data relevant to their
health condition.
5. 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?
c. The patient is apprehensive about discharge.
Subjective data include expressions of fear of going home and being alone. These data indicate
(use inference) that the patient is apprehensive about discharge. Expressing fear is not an
appropriate sign that a patient is able to perform dressing changes independently. An order
from a health care provider is required before a patient is taught to resume previous
medications. The nurse cannot infer that surgery was not successful if the incision is nearly
completely healed.
6. Which method of data collection will the nurse use to establish a patient’s database?
c. Performing a physical examination
You will learn to conduct different types of assessments: the patient-centered interview during
a nursing health history, a physical examination, and the periodic assessments you make during
rounding or administering care. A nursing database includes a physical examination. The nurse
reviews the current literature in the implementation phase of the nursing process to determine
evidence-based actions, and the health care provider is responsible for ordering medications.
The nurse uses results from the diagnostic and laboratory tests to establish a patient database,
not checking orders for tests.
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?
c. Perform a thorough nursing health history.
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.
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.
9. A nurse has already set the agenda during a patient-centered interview. What will the
nurse do next?
b. Ask about the chief concerns or problems.
After setting the agenda, the nurse should conduct the actual interview and proceed with data
collection, such as asking about the patient’s current chief concerns or problems. Introductions
occur before setting the agenda. Begin an interview by introducing yourself and your position
and explaining the purpose of the interview. Your aim is to set an agenda for how you will
gather information about a patient’s current chief concerns or problems. The termination
phase includes telling the patient when the interview is nearing an end. Telling the patient that
medications will be given later when the nurse returns would typically take place during the
termination phase of the interview.
10. The nurse is attempting to prompt the patient to elaborate on the reports of
daytime fatigue. Which question should the nurse ask?
b. “What reasons do you think are contributing to your fatigue?”
The question asking the patient what factors might be contributing to the fatigue will elicit the
best open-ended response. Asking whether the patient is stressed and asking if the patient is
sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking
about normal work hours will elicit a matter-of-fact response and does not prompt the patient
to elaborate on the daytime fatigue or ask about the contributing reasons.
11. A nurse is conducting a nursing health history. Which component will the nurse address?
b. Patient expectations
, 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?
d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
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.
13. 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?
d. Problem-oriented assessment
The nurse is not doing a complete, general assessment and then focusing on specific problem
areas. Instead, the nurse focuses immediately 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-type 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.
14. Which statement by a nurse indicates a good understanding about the differences
between data validation and data interpretation?
c. “Validation involves comparing data with other sources for accuracy.”
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.
Chapter 16: Nursing Assessment
1. 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?
a. Completes a comprehensive database
The assessment phase of the nursing process involves data collection to complete a thorough
patient database and is the first phase. Identifying nursing diagnoses occurs during the
diagnosis phase or second phase. The nurse carries out interventions during the
implementation phase (fourth phase), and determining whether outcomes have been achieved
takes place during the evaluation phase (fifth phase) of the nursing process.
2. A nurse is using the problem-oriented approach to data collection. Which action will
the nurse take first?
b. Focus on the patient’s presenting situation.
A problem-oriented approach focuses on the patient’s current problem or presenting situation
rather than on an observational overview. The database is not always completed using a
chronological approach if focusing on the current problem. Making interpretations of the data
is not data collection. Data interpretation occurs while appropriate nursing diagnoses are
assigned. The question is asking about data collection.
3. 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?
c. Ask the NAP to record the patient’s vital signs before administering medications.
The nurse should ask the nursing assistive personnel to record the vital signs for review
before administering medicines or transporting the patient to another department. The
nurse should not make assumptions when providing high-quality patient care, and omitting
the vital signs is not an appropriate action.
4. The nurse is gathering data on a patient. Which data will the nurse report as objective data?
c. Respirations 16
,Objective data are observations or measurements of a patient’s health status, like respirations.
Inspecting the condition of a surgical incision or wound, describing an observed behavior, and
measuring blood pressure are examples of objective data. States “doesn’t feel good,” reports a
headache, and nausea are all subjective data. Subjective data include the patient’s feelings,
perceptions, and reported symptoms. Only patients provide subjective data relevant to their
health condition.
5. 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?
c. The patient is apprehensive about discharge.
Subjective data include expressions of fear of going home and being alone. These data indicate
(use inference) that the patient is apprehensive about discharge. Expressing fear is not an
appropriate sign that a patient is able to perform dressing changes independently. An order
from a health care provider is required before a patient is taught to resume previous
medications. The nurse cannot infer that surgery was not successful if the incision is nearly
completely healed.
6. Which method of data collection will the nurse use to establish a patient’s database?
c. Performing a physical examination
You will learn to conduct different types of assessments: the patient-centered interview during
a nursing health history, a physical examination, and the periodic assessments you make during
rounding or administering care. A nursing database includes a physical examination. The nurse
reviews the current literature in the implementation phase of the nursing process to determine
evidence-based actions, and the health care provider is responsible for ordering medications.
The nurse uses results from the diagnostic and laboratory tests to establish a patient database,
not checking orders for tests.
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?
c. Perform a thorough nursing health history.
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.
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.
9. A nurse has already set the agenda during a patient-centered interview. What will the
nurse do next?
b. Ask about the chief concerns or problems.
After setting the agenda, the nurse should conduct the actual interview and proceed with data
collection, such as asking about the patient’s current chief concerns or problems. Introductions
occur before setting the agenda. Begin an interview by introducing yourself and your position
and explaining the purpose of the interview. Your aim is to set an agenda for how you will
gather information about a patient’s current chief concerns or problems. The termination
phase includes telling the patient when the interview is nearing an end. Telling the patient that
medications will be given later when the nurse returns would typically take place during the
termination phase of the interview.
10. The nurse is attempting to prompt the patient to elaborate on the reports of
daytime fatigue. Which question should the nurse ask?
b. “What reasons do you think are contributing to your fatigue?”
The question asking the patient what factors might be contributing to the fatigue will elicit the
best open-ended response. Asking whether the patient is stressed and asking if the patient is
sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking
about normal work hours will elicit a matter-of-fact response and does not prompt the patient
to elaborate on the daytime fatigue or ask about the contributing reasons.
11. A nurse is conducting a nursing health history. Which component will the nurse address?
b. Patient expectations
, 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?
d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
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.
13. 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?
d. Problem-oriented assessment
The nurse is not doing a complete, general assessment and then focusing on specific problem
areas. Instead, the nurse focuses immediately 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-type 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.
14. Which statement by a nurse indicates a good understanding about the differences
between data validation and data interpretation?
c. “Validation involves comparing data with other sources for accuracy.”
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.
