CHAPTER 6: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 6: Assessment Multiple Choice Questions 1. When caring for a retired World War II veteran with pneumonia, which nursing action demonstrates appropriate generational awareness to establish rapport? A. Shake the patient's hand and allow time for them to warm up B. Expect the patient to be optimistic and question everything C. Allow the patient to multitask and use brief communication D. Assume the patient is technologically literate Answer: A Explanation: Veterans from this generation (born before 1945) typically value formal communication, respect authority, and may need time to establish trust - making a respectful handshake and patience appropriate. Why Other Options Are Wrong: B describes Baby Boomer traits. C characterizes Generation X communication. D applies to Millennials/Generation Y. 2. During the orientation phase of a patient interview, which action by the nurse is most important for establishing trust? A. Collect demographic data using open-ended questions B. Ask how the patient prefers to be addressed C. Gather general information with closed-ended questions D. Stand at the bedside to ask necessary questions Answer: B Explanation: Determining the patient's preferred name/title shows respect for their identity and begins building the therapeutic relationship during this initial phase. Why Other Options Are Wrong: A should use focused questions. C is better for later phases. D creates power imbalance by standing over patient. 3. When conducting a health interview, which nonverbal behavior best helps establish trust with a newly admitted patient? A. Avoiding eye contact to reduce intimidation B. Maintaining professional demeanor by not smiling C. Sitting close and leaning slightly toward patient D. Speaking slowly with a low vocal tone Answer: C Explanation: Appropriate proximity and leaning forward demonstrates engagement while maintaining professional boundaries - key for trust-building. Why Other Options Are Wrong: A may convey disinterest. B could seem cold/unapproachable. D might appear condescending. 4. How should a nurse respond when a febrile, nauseated patient requests to postpone admission questions? A. "It won't take long - I'll hurry through it" B. "We need this information to complete paperwork" C. "I'll return later to start over completely" D. "Let me address your nausea first, then we'll talk" Answer: D Explanation: Prioritizing patient comfort by treating nausea first shows patient-centered care and will yield better data when the patient feels better. Why Other Options Are Wrong: A and B disregard patient discomfort. C unnecessarily delays all assessment rather than just postponing parts. 5. Which assessment technique is being used when a nurse listens to heart sounds with a stethoscope? A. Inspection B. Percussion C. Palpation D. Auscultation Answer: D Explanation: Auscultation specifically refers to listening to internal body sounds using a stethoscope, including heart, lung, and bowel sounds. Why Other Options Are Wrong: A uses vision/smell. B involves tapping. C uses touch for texture/temperature. 6. What assessment technique is demonstrated when a nurse strikes the costovertebral angle to check for kidney tenderness? A. Inspection B. Percussion C. Palpation D. Auscultation Answer: B Explanation: Percussion involves striking body surfaces to assess underlying structures through vibration and sound characteristics. Why Other Options Are Wrong: A doesn't involve physical contact. C uses direct touch without striking. D requires a stethoscope. 7. Which technique would a nurse use to assess abdominal skin temperature and tenderness in a liver failure patient? A. Inspection B. Percussion C. Palpation D. Auscultation Answer: C Explanation: Palpation uses hands to assess texture, temperature, moisture, tenderness and other tactile characteristics. Why Other Options Are Wrong: A observes but doesn't touch. B assesses through vibration. D listens to sounds. 8. In triage, which patient should be prioritized as most critical? A. Disoriented 68-year-old with dehydration B. Anxious 14-year-old with respiratory distress C. 46-year-old with multiple superficial cuts D. 38-year-old with hip fracture and severe pain Answer: B Explanation: Respiratory distress is a Level 1 emergency (immediate life-threat) per triage protocols, surpassing other urgent but non-critical conditions. Why Other Options Are Wrong: A and D are Level 2. C is Level 3. 9. Which assessment type is being performed when a nurse rapidly evaluates an ashen faced patient with cool, clammy skin? A. Emergency assessment B. Focused assessment C. Complete assessment D. Initial comprehensive Answer: A Explanation: Emergency assessments prioritize immediate life threats (ABCs) when time is critical, as with potential circulatory collapse. Why Other Options Are Wrong: B targets specific concerns. C/D are thorough but time consuming. 10. What type of assessment occurs when a nurse evaluates new facial drooping not reported in handoff? A. Emergency assessment B. Focused assessment C. Complete physical D. Comprehensive assessment Answer: B Explanation: Focused assessments investigate new or specific concerns like neurological changes while omitting unrelated systems. Why Other Options Are Wrong: A addresses imminent threats. C/D evaluate all systems regardless of relevance. 11. Which statement by a patient represents subjective data? A. "My last bowel movement was 4 days ago" B. Abdomen distended and firm C. Hard, dark-colored stool D. Pink skin, warm and dry Answer: A Explanation: Subjective data are patient-reported symptoms (like bowel habits) that cannot be independently verified. Why Other Options Are Wrong: B-D are objective signs observable/measurable by the nurse. 12. What type of data is health history information provided by a dementia patient's son? A. Primary, objective B. Primary, subjective C. Secondary, objective D. Secondary, subjective Answer: D Explanation: Family-provided information is secondary (not from patient) and subjective (based on reports rather than measurements). Why Other Options Are Wrong: A/B come directly from patient. C involves measurable observations. 13. How is a patient's self-report about new IV-related hyperglycemia classified? A. Primary, objective B. Primary, subjective C. Secondary, objective D. Secondary, subjective Answer: B Explanation: Firsthand patient reports are primary data, while symptom descriptions are subjective. Why Other Options Are Wrong: A requires measurable observations. C/D involve others' input. 14. What is the best response when a UAP reports a patient crying during a comedy show? A. "Maybe they don't find it funny" B. "Don't worry - family says this is normal" C. "I'll assess the situation immediately" D. "Document your observation in the notes" Answer: C Explanation: Validating unexpected behaviors through direct assessment prevents assumptions and identifies potential distress. Why Other Options Are Wrong: A/B make inappropriate assumptions. D delays assessment. 15. How can a nurse validate a patient's report of dark, foul-smelling urine? A. Ask about back pain B. Review urinalysis results C. Obtain vital signs D. Check UTI history Answer: B Explanation: Lab tests provide objective data to confirm or refute subjective patient reports. Why Other Options Are Wrong: A/C/D don't directly validate urinary symptoms. 16. What should a nurse do when a preoperative patient says "Not much" was explained about their procedure? A. Develop full teaching plan B. Clarify what the patient understands C. Contact surgeon immediately D. Focus on postoperative care Answer: B Explanation: First assessing the patient's actual knowledge gaps prevents unnecessary teaching and identifies true needs. Why Other Options Are Wrong: A is premature. C is inappropriate without assessing first. D avoids the immediate concern. 17. Which framework provides the most holistic patient data organization? A. Head-to-toe B. Functional Health Patterns C. Cephalic-caudal D. Body systems Answer: B Explanation: Gordon's Functional Health Patterns integrate physical, psychological, and social data rather than just anatomical systems. Why Other Options Are Wrong: A/C/D focus on physical assessment sequencing. 18. Which Functional Health Pattern includes wound assessment data for a diabetic patient? A. Nutrition/metabolism B. Activity/exercise C. Sleep/rest D. Elimination Answer: A Explanation: Nutrition/metabolism patterns include tissue integrity and healing - directly relevant to wound evaluation. Why Other Options Are Wrong: B addresses mobility. C covers rest patterns. D involves excretory function. 19. Which framework best documents calf pain during walking in a health history? A. Head-to-toe B. Functional Health Patterns C. Body systems D. Cephalic-caudal Answer: C Explanation: The body systems model localizes symptoms to specific anatomical systems (here, musculoskeletal/vascular). Why Other Options Are Wrong: A/D are physical exam sequences. B integrates multiple domains. Multiple Response Questions 1. Which components are included in a comprehensive health history? (Select all that apply.) A. Demographic data B. Allergy information C. Family disease history D. Health promotion practices E. Past illness/surgery Answer: A, B, C, D, E Explanation: Complete health histories encompass all these elements to inform holistic care planning and identify risk factors. Why Other Options Are Wrong: All options are correct components. 2. Which actions validate suspected diabetes education needs? (Select all that apply.) A. Assess cognitive/language barriers B. Determine current knowledge C. Observe glucose monitoring D. Use standardized care plans E. Prepare third-grade materials Answer: B, C Explanation: Direct knowledge assessment (B) and skill demonstration (C) objectively identify learning gaps before addressing them. Why Other Options Are Wrong: A is preliminary but doesn't validate needs. D/E assume needs without assessment. 3. What should be reviewed before examining a patient with leg lesions? (Select all that apply.) A. Blood tests B. X-ray results C. Recent vitals D. Health history E. Subjective reports Answer: A, B, C Explanation: Diagnostic results (A/B) and current vitals (C) provide objective baseline data for comparison during physical assessment. Why Other Options Are Wrong: D/E are important but gathered separately from test results. 4. Which patients are appropriate for UAPs to obtain vitals? (Select all that apply.) A. 28-year-old pending discharge B. Stable 49-year-old COPD patient C. 78-year-old with new rectal bleeding D. 35-year-old transfer to rehab E. 40-year-old new ED admission Answer: A, B, D Explanation: Stable patients (A/B/D) with predictable vital signs are within UAP scope, unlike acute/unstable cases (C/E). Why Other Options Are Wrong: C/E require RN assessment due to instability. 5. Which examples represent objective data? (Select all that apply.) A. RR 24/min B. Platelets 350,000 C. 3cm x 2cm wound D. Temp 98.4°F E. "Severe abdominal pain" Answer: A, B, C, D Explanation: Measurable observations (A-D) are objective, unlike patient-reported symptoms (E). Why Other Options Are Wrong: E is subjective data. 6. What does patient-centered care require? (Select all that apply.) A. Understanding patient preferences B. Awareness of family values C. Recognizing patient expectations D. Basing care on nurse's experiences E. Standardized care approaches Answer: A, B, C Explanation: Patient-centered care prioritizes individual/family values (A/B) and expectations (C) over generalized or nurse-centric approaches. Why Other Options Are Wrong: D imposes nurse bias. E ignores individualization.