Session # 1
1. When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?
a. Identify what level of prevention the patient is at
b. Identify in what areas the patient needs the most care
c. Identify in what areas the patient can educate his or her family
d. Identify the patient’s diagnosis
RATIONALE: During the overall assessment of the patient, the nurse is able to utilize the findings and decide which areas
the patient is in need of the most care and which levels of prevention are necessary.
2. What are nurses able to detect through the health assessment?
a. Areas in need of health adjustments
b. Areas that need continuous care
c. Areas that need in-hospital care
d. Areas that need referral to a specialist
RATIONALE: Through the health assessment nurses are able to detect areas in need of health adjustments.
3. Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?
a. Diagnosing
b. Intervening where necessary
c. Formulating a discharge plan
d. Assessing
RATIONALE: Focusing on both the answers (verbal) and the actions (nonverbal) of the patient, the nurse is constantly
assessing and formulating a plan of care to achieve the best possible health for the individual.
4. Your patient complained about her painful right knee and rated as 8/10 using the Pain Scale. A pain scale
which is rated as 8/10 is what type of data?
a. Informative data
b. Objective data
c. Subjective data
d. Confidential data
RATIONALE: Subjective data are information from the client's point of view as symptoms, including feelings, perceptions,
and concerns obtained through interviews.
5. You are in the Emergency room and a victim of a trauma came-in with multiple injuries from a car crash. What
type of an assessment should you most likely to utilize at this point of time?
a. Focused assessment
b. Emergency assessment
c. Ongoing assessment
d. Comprehensive assessment
RATIONALE: During emergency procedures, a nurse is focused on rapidly identifying the root causes of concern for the
patient and assessing the airway, breathing and circulation (ABCs) of the patient. Once the ABCs are stabilized, the
emergency assessment may turn into an initial or focused assessment, depending on the situation.
6. A patient tells you they got their finger cut with a razor about 20 minutes ago and then shows you the cut on
their finger, the cut is one inch long located on the left pinky finger about 1 centimetre deep. The patient states,
“My finger is bleeding, can you get me gauze for the blood?” What type of data is 1 inch cut on left the patient’s
pinky finger, 1 cm deep?
a. Focused data
b. Ongoing data
c. Subjective data
d. Objective data
RATIONALE: The focused assessment is the stage in which the problem is exposed and treated. Due to the importance
of vital signs and their ever-changing nature, they are continuously monitored during all parts of the assessment.
7. You are a nurse in the surgical ward and taking care of an elderly client who had left knee replacement and will
be discharge directly to an Aged care facility today. It is a protocol in the hospital that nurses must assess
patients holistically before a discharge or transfer to any health care facility. What type of assessment is the
nurse employing?
a. Initial Comprehensive assessment
b. Ongoing assessment
c. Focused assessment
d. Emergency assessment
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
care from a health care agency. The purposes are to evaluate the client’s health status, to identify functional health
,a. Admission assessment
b. Time-lapsed assessment
c. Mini-assessment
d. Problem-oriented assessment
RATIONALE: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to
evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods
of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, health and
development screenings)
9. You are a nurse in a medical floor and taking care of a 34-year-old man who had an allergic reaction to seafood.
What the objective data expected for this client? Select all that apply.
a. “I cannot breath!”
b. Oxygen Saturation of 92%
c. Heart rate: 92 cycles per minute
d. BP: 110/70 mmHg
e. Usage of accessory muscles
RATIONALE: Objective data (signs or overt data): are detectable by an observer or can be measured or tested against an
accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.
10. You are a nurse in the Geriatric floor and caring for an 82-year-old male patient who was admitted due to
nutritional deficit. What type of assessment should the nurse utilize to keep check on the patient’s improvement
on a daily basis?
a. Initial comprehensive assessment
b. Focused assessment
c. Problem- oriented assessment
d. Emergency assessment
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
care from a health care agency. The purposes are to evaluate the client’s health status, to identify functional health
patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating
changes in the client’s health status in subsequent assessments.
, Session # 2
1. In what area do nurses use assessment tools?
a. Mobility
b. Skin breakdown
c. Mentation
d. Strength
RATIONALE: Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls,
malnutrition, and skin breakdown.
2. How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data
he or she collects?
a. Initiating a problem list
b. Obtaining an accurate history
c. Developing accurate nursing diagnoses
d. Generating diagnoses early
RATIONALE: By generating plans early and testing them sequentially, experienced nurses improve their efficiency and
enhance the relevance and value of the data they collect. When clustering data, age can be a factor in determining the
number of nursing diagnoses.
3. When constructing a nursing care plan, what should you reference? (Mark all that apply.)
a. Therapy
b. Social support
c. Patient education
d. Personal history
e. Diagnosis
RATIONALE: A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as
recognizing potential needs or risks.
4. When documenting clinical data, what might you write in the physical assessment?
a. Thyroid isthmus barely palpable, lobes not felt
b. Apical impulse indiscrete and tapping
c. Thorax symmetric without equal excursion
d. Extraocular movements full and equal on exam
RATIONALE: It collects objective and subjective data to help identify and evaluate problems and develop a plan of care.
5. You are the office nurse admitting a new patient to the clinic. You have gained your patient’s trust, gathered a
detailed history, and finished your portion of the physical examination. What is your next step in caring for this
patient?
a. Formulate nursing diagnoses
b. Order the appropriate laboratory tests
c. Identify the patient’s problems
d. Notify the physician of your findings
RATIONALE: During the time spent with your patient, you have gained your patient's trust, gathered a detailed history,
and completed the requisite portions of the physical examination. You have reached the critical step of formulating your
Assessment, Nursing Diagnosis, and Plan. You must now analyze your findings and identify the patient's problems, then
share your impressions with the patient, eliciting any concerns and making sure that he or she understands and agrees to
the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format that
communicates the patient's story and your clinical reasoning and plan to other members of the health care team.
6. What is pivotal to determining how to move from each patient problem to its goals?
a. Your clinical reasoning process
b. Your positive interpretation of the patient’s history
c. Your process in collecting physical data
d. Your evaluation as an accurate historian of the patient
RATIONALE: Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and
physical examination, single out the problems listed in assessment, and move from each problem to its goals and then the
implementation with specific nursing interventions.
7. As the nurse caring for a patient you have completed the collection of the subjective data. On what do you
base your decision to do an entire head-to-toe physical assessment or a systems-specific assessment?
a. The patient’s answers
b. Observable signs and symptoms
c. Your knowledge base and expertise
, 8. For each patient problem you identify you develop and record a plan. What must your plan do? (Mark all that
apply.)
a. Begin discharge planning
b. Include referral to dietician
c. Flow logically from identified diagnoses
d. Specify which steps are needed next
e. Identify timing of family involvement
RATIONALE: Identify and record a Plan for each patient problem. Your Plan flows logically from the problems or
diagnoses you have identified. Specify the next steps for each problem. These steps range from tests and procedures to
subspecialty consultations to new or changed medications to arranging a family meeting.
9. Your patient tells you that his chief complaint is “fatigue.” When obtaining the patient history, what additional
information might you want to elicit to try and pinpoint the patient’s “real problem”?
a. More information regarding family history
b. More information regarding secondary complaints
c. More information regarding laboratory data
d. More information regarding psychosocial issues
RATIONALE: Major psychosocial issues included family problems, depression, anxiety, substance abuse, sexual abuse,
and violence. Women were more likely to have suffered violence while many of the men had problems dealing with their
own aggression toward others.
10. What are steps in clinical reasoning?
ANSWERES/RATIONALE: These are the following steps in clinical reasoning such as Identify abnormal findings,
Localize findings anatomically, Cluster the clinical findings., Search for the probable cause of the findings, Cluster the
clinical data, Generate hypotheses about the causes of the patient’s problems, and Test the hypotheses and establish a
working diagnosis. Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information,
generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.
1. When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?
a. Identify what level of prevention the patient is at
b. Identify in what areas the patient needs the most care
c. Identify in what areas the patient can educate his or her family
d. Identify the patient’s diagnosis
RATIONALE: During the overall assessment of the patient, the nurse is able to utilize the findings and decide which areas
the patient is in need of the most care and which levels of prevention are necessary.
2. What are nurses able to detect through the health assessment?
a. Areas in need of health adjustments
b. Areas that need continuous care
c. Areas that need in-hospital care
d. Areas that need referral to a specialist
RATIONALE: Through the health assessment nurses are able to detect areas in need of health adjustments.
3. Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?
a. Diagnosing
b. Intervening where necessary
c. Formulating a discharge plan
d. Assessing
RATIONALE: Focusing on both the answers (verbal) and the actions (nonverbal) of the patient, the nurse is constantly
assessing and formulating a plan of care to achieve the best possible health for the individual.
4. Your patient complained about her painful right knee and rated as 8/10 using the Pain Scale. A pain scale
which is rated as 8/10 is what type of data?
a. Informative data
b. Objective data
c. Subjective data
d. Confidential data
RATIONALE: Subjective data are information from the client's point of view as symptoms, including feelings, perceptions,
and concerns obtained through interviews.
5. You are in the Emergency room and a victim of a trauma came-in with multiple injuries from a car crash. What
type of an assessment should you most likely to utilize at this point of time?
a. Focused assessment
b. Emergency assessment
c. Ongoing assessment
d. Comprehensive assessment
RATIONALE: During emergency procedures, a nurse is focused on rapidly identifying the root causes of concern for the
patient and assessing the airway, breathing and circulation (ABCs) of the patient. Once the ABCs are stabilized, the
emergency assessment may turn into an initial or focused assessment, depending on the situation.
6. A patient tells you they got their finger cut with a razor about 20 minutes ago and then shows you the cut on
their finger, the cut is one inch long located on the left pinky finger about 1 centimetre deep. The patient states,
“My finger is bleeding, can you get me gauze for the blood?” What type of data is 1 inch cut on left the patient’s
pinky finger, 1 cm deep?
a. Focused data
b. Ongoing data
c. Subjective data
d. Objective data
RATIONALE: The focused assessment is the stage in which the problem is exposed and treated. Due to the importance
of vital signs and their ever-changing nature, they are continuously monitored during all parts of the assessment.
7. You are a nurse in the surgical ward and taking care of an elderly client who had left knee replacement and will
be discharge directly to an Aged care facility today. It is a protocol in the hospital that nurses must assess
patients holistically before a discharge or transfer to any health care facility. What type of assessment is the
nurse employing?
a. Initial Comprehensive assessment
b. Ongoing assessment
c. Focused assessment
d. Emergency assessment
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
care from a health care agency. The purposes are to evaluate the client’s health status, to identify functional health
,a. Admission assessment
b. Time-lapsed assessment
c. Mini-assessment
d. Problem-oriented assessment
RATIONALE: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to
evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods
of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, health and
development screenings)
9. You are a nurse in a medical floor and taking care of a 34-year-old man who had an allergic reaction to seafood.
What the objective data expected for this client? Select all that apply.
a. “I cannot breath!”
b. Oxygen Saturation of 92%
c. Heart rate: 92 cycles per minute
d. BP: 110/70 mmHg
e. Usage of accessory muscles
RATIONALE: Objective data (signs or overt data): are detectable by an observer or can be measured or tested against an
accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.
10. You are a nurse in the Geriatric floor and caring for an 82-year-old male patient who was admitted due to
nutritional deficit. What type of assessment should the nurse utilize to keep check on the patient’s improvement
on a daily basis?
a. Initial comprehensive assessment
b. Focused assessment
c. Problem- oriented assessment
d. Emergency assessment
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
care from a health care agency. The purposes are to evaluate the client’s health status, to identify functional health
patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating
changes in the client’s health status in subsequent assessments.
, Session # 2
1. In what area do nurses use assessment tools?
a. Mobility
b. Skin breakdown
c. Mentation
d. Strength
RATIONALE: Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls,
malnutrition, and skin breakdown.
2. How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data
he or she collects?
a. Initiating a problem list
b. Obtaining an accurate history
c. Developing accurate nursing diagnoses
d. Generating diagnoses early
RATIONALE: By generating plans early and testing them sequentially, experienced nurses improve their efficiency and
enhance the relevance and value of the data they collect. When clustering data, age can be a factor in determining the
number of nursing diagnoses.
3. When constructing a nursing care plan, what should you reference? (Mark all that apply.)
a. Therapy
b. Social support
c. Patient education
d. Personal history
e. Diagnosis
RATIONALE: A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as
recognizing potential needs or risks.
4. When documenting clinical data, what might you write in the physical assessment?
a. Thyroid isthmus barely palpable, lobes not felt
b. Apical impulse indiscrete and tapping
c. Thorax symmetric without equal excursion
d. Extraocular movements full and equal on exam
RATIONALE: It collects objective and subjective data to help identify and evaluate problems and develop a plan of care.
5. You are the office nurse admitting a new patient to the clinic. You have gained your patient’s trust, gathered a
detailed history, and finished your portion of the physical examination. What is your next step in caring for this
patient?
a. Formulate nursing diagnoses
b. Order the appropriate laboratory tests
c. Identify the patient’s problems
d. Notify the physician of your findings
RATIONALE: During the time spent with your patient, you have gained your patient's trust, gathered a detailed history,
and completed the requisite portions of the physical examination. You have reached the critical step of formulating your
Assessment, Nursing Diagnosis, and Plan. You must now analyze your findings and identify the patient's problems, then
share your impressions with the patient, eliciting any concerns and making sure that he or she understands and agrees to
the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format that
communicates the patient's story and your clinical reasoning and plan to other members of the health care team.
6. What is pivotal to determining how to move from each patient problem to its goals?
a. Your clinical reasoning process
b. Your positive interpretation of the patient’s history
c. Your process in collecting physical data
d. Your evaluation as an accurate historian of the patient
RATIONALE: Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and
physical examination, single out the problems listed in assessment, and move from each problem to its goals and then the
implementation with specific nursing interventions.
7. As the nurse caring for a patient you have completed the collection of the subjective data. On what do you
base your decision to do an entire head-to-toe physical assessment or a systems-specific assessment?
a. The patient’s answers
b. Observable signs and symptoms
c. Your knowledge base and expertise
, 8. For each patient problem you identify you develop and record a plan. What must your plan do? (Mark all that
apply.)
a. Begin discharge planning
b. Include referral to dietician
c. Flow logically from identified diagnoses
d. Specify which steps are needed next
e. Identify timing of family involvement
RATIONALE: Identify and record a Plan for each patient problem. Your Plan flows logically from the problems or
diagnoses you have identified. Specify the next steps for each problem. These steps range from tests and procedures to
subspecialty consultations to new or changed medications to arranging a family meeting.
9. Your patient tells you that his chief complaint is “fatigue.” When obtaining the patient history, what additional
information might you want to elicit to try and pinpoint the patient’s “real problem”?
a. More information regarding family history
b. More information regarding secondary complaints
c. More information regarding laboratory data
d. More information regarding psychosocial issues
RATIONALE: Major psychosocial issues included family problems, depression, anxiety, substance abuse, sexual abuse,
and violence. Women were more likely to have suffered violence while many of the men had problems dealing with their
own aggression toward others.
10. What are steps in clinical reasoning?
ANSWERES/RATIONALE: These are the following steps in clinical reasoning such as Identify abnormal findings,
Localize findings anatomically, Cluster the clinical findings., Search for the probable cause of the findings, Cluster the
clinical data, Generate hypotheses about the causes of the patient’s problems, and Test the hypotheses and establish a
working diagnosis. Clinical Reasoning is the process by which a therapist interacts with a patient, collecting information,
generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.
