1
Nursing Process (Review Questions
from Fundamentals of Nursing)
If a nurse focuses on a patient's presenting situation and begins with problematic areas
such as incisional pain or limited understanding of postoperative recovery, what
approach to assessment is she/he using? - Correct Answer Problem-oriented approach
Before a patient-centered interview, how should the nurse prepare? - Correct Answer 1.
Review the patient's medical record
2. Review the previous nurse's notes
3. Consider the length of the interview
4. Consider the setting of the interview
How should you begin a patient-centered interview? - Correct Answer Introduce yourself
and your position and explain 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
Which of the following examples are steps of nursing assessment? (Select all that
apply.)
1. Collection of information from patient's family members
2. Recognition that further observations are needed to clarify information
3. Comparison of data with another source to determine data accuracy
4. Complete documentation of observational information
5. Determining which medications to administer based on a patient's assessment data -
Correct Answer 1. 2. 3.
Rationale: Assessment includes collection of data from secondary sources such as the
patient's family. Recognizing that more observation is needed is an example of
validation of data. Comparing data to determine accuracy is a feature of interpretation.
Although complete documentation is an important step in communicating assessment
data, it is not an assessment step.
When a nurse conducts an assessment, data about a patient often comes from which of
the following sources? (Select all that apply.)
1. An observation of how a patient turns and moves in bed
2. The unit policy and procedure manual
3. The care recommendations of a physical therapist
4. The results of a diagnostic x-ray film
5. Your experiences in caring for other patients with similar problems - Correct Answer
1. 3. 4.
, 2
Rationale: There are many sources of data for an assessment, including the patient
through interview, observations, and physical examination; family members or
significant others, health care team members such as a physical therapist, the medical
record (which includes x-ray film results, and the scientific and medical literature.
The nurse observes a patient walking down the hall with a shuffling gait. When the
patient returns to bed, the nurse checks the strength in both of the patient's legs. The
nurse applies the information gained to suspect that the patient has a mobility problem.
This conclusion is an example of:
1. Cue.
2. Reflection.
3. Clinical inference.
4. Probing. - Correct Answer 3.
Rationale: An inference is your judgment or interpretation of cues such as the shuffling
gait and reduced leg strength. Any information gathered through your senses is a cue.
Probing is a technique used in interviewing. Reflection is an internal process of thinking
back about a situation.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse
enters the patient's room and notices him to be diaphoretic, holding his chest and
breathing with difficulty. The nurse immediately checks the patient's heart rate and
blood pressure and asks him, "Tell me where your pain is." Which of the following
assessment approaches does this scenario describe?
1. Review of systems approach
2. Use of a structured database format
3. Back channeling
4. A problem-oriented approach - Correct Answer 4.
Rationale: This is an example of a problem-focused approach. The nurse focuses on
assessing one body system (cardiovascular) to determine the nature of the patient's
pain and other presenting symptoms.
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall
asleep? Do you have difficulty falling or staying asleep? This series of questions would
likely occur during which phase of a patient-centered interview?
1. Orientation
2. Working phase
3. Data validation
4. Termination - Correct Answer 3. Data validation
Rationale: The gathering of information is the working phase of a patient-centered
interview.
, 3
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has
diabetes, and works part time in the kitchen of a restaurant. The patient is facing
surgery for gallbladder disease. Which of the following approaches demonstrates the
nurse's cultural competence in assessing the patient's health care problems?
1. "I can tell that your eating habits have led to your diabetes. Is that right?"
2. "It's been difficult for people to find jobs. Is that why you work part time?"
3. "You have four children; do you have any concerns about going home and caring for
them?"
4. "I wish patients understood how overeating affects their health." - Correct Answer 3.
Rationale: This is the only assessment approach that is not biased or does not show
judgment about the patient's weight or occupational status. With the other options, the
nurse is reacting to the patient on the basis of personal stereotypes and biases.
Which type of interview question does the nurse first use when assessing the reason for
a patient seeking health care?
1. Probing
2. Open-ended
3. Problem-oriented
4. Confirmation - Correct Answer 2.
Rationale: The best interview question for initially determining why a patient is seeking
health care is by asking an open-ended question that allows the patient to tell his or her
story. This is also a more patient-centered approach. Probing questions are asked after
data are gathered to seek more in-depth information. Problem-oriented and confirmation
are not types of interview questions.
A nurse gathers the following assessment data. Which of the following cues together
form(s) a pattern suggesting a problem? (Select all that apply.)
1. The skin around the wound is tender to touch.
2. Fluid intake for 8 hours is 800 mL.
3. Patient has a heart rate of 78 beats/min and regular.
4. Patient has drainage from surgical wound.
5. Body temperature is 38.3° C (101° F).
6. Patient states, "I'm worried that I won't be able to return to work when I planned." -
Correct Answer 1. 4. 5.
Rationale: Tender skin around the wound, drainage from the surgical wound, and a
temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over
8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A
patient's expressed concern about returning to work is his or her subjective response
about a separate issue and is insufficient to form a pattern.
A nurse is checking a patient's intravenous line and, while doing so, notices how the
patient bathes himself and then sits on the side of the bed independently to put on a
new gown. This observation is an example of assessing:
, 4
1. Patient's level of function.
2. Patient's willingness to perform self-care.
3. Patient's level of consciousness.
4. Patient's health management values. - Correct Answer 1.
Rationale: Observing a patient perform activities physical, socially, psychologically, and
developmentally assesses his or her level of function. In the case of this question the
nurse assesses physical functional level. Observation does not measure willingness to
perform self-care but the ability to do so. Observing physical performance of self-
hygiene is not a measure of level of consciousness nor does it reveal a patient's values.
A nurse makes the following statement during a change-of-shift report to another nurse.
"I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his
back 3 days ago. He has some difficulty turning in bed, and he says that he has pain
that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers
to a chair." What can the nurse who is beginning a shift do to validate the previous
nurse's assessment findings when she conducts rounds on the patient? (Select all that
apply.)
1. The nurse asks the patient to rate his pain on a scale of 0 to 10.
2. The nurse asks the patient what caused his fall.
3. The nurse asks the patient if he has had pain in his back in the past.
4. The nurse assesses the patient's lower-limb strength.
5. The nurse asks the patient what pain medication is most effective in managing his
pain. - Correct Answer 1. 4.
Rationale: Validation of assessment data is the comparison of data with another source
to determine its accuracy. The nurse compares data reported by the previous nurse with
data collected directly with the patient, including assessing pain on the rating scale and
assessing the patient's lower limb strength. Asking the patient what caused his fall and
about past back pain and experience with pain medications would offer the nurse new
information about the patient.
A nurse is conducting a patient-centered interview. Place the statements from the
interview in the correct order, beginning with the first statement a nurse would ask.
1. "You say you've lost weight. Tell me how much weight you've lost in the last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a
series of questions to gather your health history."
3. "I have no further questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has
been poor—correct?" - Correct Answer 2, 4, 1, 5, 3
This follows the correct order for the interview.
During a visit to the clinic, a patient tells the nurse that he has been having headaches
on and off for a week. The headaches sometimes make him feel nauseated. Which of
the following responses by the nurse is an example of probing?
Nursing Process (Review Questions
from Fundamentals of Nursing)
If a nurse focuses on a patient's presenting situation and begins with problematic areas
such as incisional pain or limited understanding of postoperative recovery, what
approach to assessment is she/he using? - Correct Answer Problem-oriented approach
Before a patient-centered interview, how should the nurse prepare? - Correct Answer 1.
Review the patient's medical record
2. Review the previous nurse's notes
3. Consider the length of the interview
4. Consider the setting of the interview
How should you begin a patient-centered interview? - Correct Answer Introduce yourself
and your position and explain 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
Which of the following examples are steps of nursing assessment? (Select all that
apply.)
1. Collection of information from patient's family members
2. Recognition that further observations are needed to clarify information
3. Comparison of data with another source to determine data accuracy
4. Complete documentation of observational information
5. Determining which medications to administer based on a patient's assessment data -
Correct Answer 1. 2. 3.
Rationale: Assessment includes collection of data from secondary sources such as the
patient's family. Recognizing that more observation is needed is an example of
validation of data. Comparing data to determine accuracy is a feature of interpretation.
Although complete documentation is an important step in communicating assessment
data, it is not an assessment step.
When a nurse conducts an assessment, data about a patient often comes from which of
the following sources? (Select all that apply.)
1. An observation of how a patient turns and moves in bed
2. The unit policy and procedure manual
3. The care recommendations of a physical therapist
4. The results of a diagnostic x-ray film
5. Your experiences in caring for other patients with similar problems - Correct Answer
1. 3. 4.
, 2
Rationale: There are many sources of data for an assessment, including the patient
through interview, observations, and physical examination; family members or
significant others, health care team members such as a physical therapist, the medical
record (which includes x-ray film results, and the scientific and medical literature.
The nurse observes a patient walking down the hall with a shuffling gait. When the
patient returns to bed, the nurse checks the strength in both of the patient's legs. The
nurse applies the information gained to suspect that the patient has a mobility problem.
This conclusion is an example of:
1. Cue.
2. Reflection.
3. Clinical inference.
4. Probing. - Correct Answer 3.
Rationale: An inference is your judgment or interpretation of cues such as the shuffling
gait and reduced leg strength. Any information gathered through your senses is a cue.
Probing is a technique used in interviewing. Reflection is an internal process of thinking
back about a situation.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse
enters the patient's room and notices him to be diaphoretic, holding his chest and
breathing with difficulty. The nurse immediately checks the patient's heart rate and
blood pressure and asks him, "Tell me where your pain is." Which of the following
assessment approaches does this scenario describe?
1. Review of systems approach
2. Use of a structured database format
3. Back channeling
4. A problem-oriented approach - Correct Answer 4.
Rationale: This is an example of a problem-focused approach. The nurse focuses on
assessing one body system (cardiovascular) to determine the nature of the patient's
pain and other presenting symptoms.
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall
asleep? Do you have difficulty falling or staying asleep? This series of questions would
likely occur during which phase of a patient-centered interview?
1. Orientation
2. Working phase
3. Data validation
4. Termination - Correct Answer 3. Data validation
Rationale: The gathering of information is the working phase of a patient-centered
interview.
, 3
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has
diabetes, and works part time in the kitchen of a restaurant. The patient is facing
surgery for gallbladder disease. Which of the following approaches demonstrates the
nurse's cultural competence in assessing the patient's health care problems?
1. "I can tell that your eating habits have led to your diabetes. Is that right?"
2. "It's been difficult for people to find jobs. Is that why you work part time?"
3. "You have four children; do you have any concerns about going home and caring for
them?"
4. "I wish patients understood how overeating affects their health." - Correct Answer 3.
Rationale: This is the only assessment approach that is not biased or does not show
judgment about the patient's weight or occupational status. With the other options, the
nurse is reacting to the patient on the basis of personal stereotypes and biases.
Which type of interview question does the nurse first use when assessing the reason for
a patient seeking health care?
1. Probing
2. Open-ended
3. Problem-oriented
4. Confirmation - Correct Answer 2.
Rationale: The best interview question for initially determining why a patient is seeking
health care is by asking an open-ended question that allows the patient to tell his or her
story. This is also a more patient-centered approach. Probing questions are asked after
data are gathered to seek more in-depth information. Problem-oriented and confirmation
are not types of interview questions.
A nurse gathers the following assessment data. Which of the following cues together
form(s) a pattern suggesting a problem? (Select all that apply.)
1. The skin around the wound is tender to touch.
2. Fluid intake for 8 hours is 800 mL.
3. Patient has a heart rate of 78 beats/min and regular.
4. Patient has drainage from surgical wound.
5. Body temperature is 38.3° C (101° F).
6. Patient states, "I'm worried that I won't be able to return to work when I planned." -
Correct Answer 1. 4. 5.
Rationale: Tender skin around the wound, drainage from the surgical wound, and a
temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over
8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A
patient's expressed concern about returning to work is his or her subjective response
about a separate issue and is insufficient to form a pattern.
A nurse is checking a patient's intravenous line and, while doing so, notices how the
patient bathes himself and then sits on the side of the bed independently to put on a
new gown. This observation is an example of assessing:
, 4
1. Patient's level of function.
2. Patient's willingness to perform self-care.
3. Patient's level of consciousness.
4. Patient's health management values. - Correct Answer 1.
Rationale: Observing a patient perform activities physical, socially, psychologically, and
developmentally assesses his or her level of function. In the case of this question the
nurse assesses physical functional level. Observation does not measure willingness to
perform self-care but the ability to do so. Observing physical performance of self-
hygiene is not a measure of level of consciousness nor does it reveal a patient's values.
A nurse makes the following statement during a change-of-shift report to another nurse.
"I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his
back 3 days ago. He has some difficulty turning in bed, and he says that he has pain
that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers
to a chair." What can the nurse who is beginning a shift do to validate the previous
nurse's assessment findings when she conducts rounds on the patient? (Select all that
apply.)
1. The nurse asks the patient to rate his pain on a scale of 0 to 10.
2. The nurse asks the patient what caused his fall.
3. The nurse asks the patient if he has had pain in his back in the past.
4. The nurse assesses the patient's lower-limb strength.
5. The nurse asks the patient what pain medication is most effective in managing his
pain. - Correct Answer 1. 4.
Rationale: Validation of assessment data is the comparison of data with another source
to determine its accuracy. The nurse compares data reported by the previous nurse with
data collected directly with the patient, including assessing pain on the rating scale and
assessing the patient's lower limb strength. Asking the patient what caused his fall and
about past back pain and experience with pain medications would offer the nurse new
information about the patient.
A nurse is conducting a patient-centered interview. Place the statements from the
interview in the correct order, beginning with the first statement a nurse would ask.
1. "You say you've lost weight. Tell me how much weight you've lost in the last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a
series of questions to gather your health history."
3. "I have no further questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has
been poor—correct?" - Correct Answer 2, 4, 1, 5, 3
This follows the correct order for the interview.
During a visit to the clinic, a patient tells the nurse that he has been having headaches
on and off for a week. The headaches sometimes make him feel nauseated. Which of
the following responses by the nurse is an example of probing?
