n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
Session # 2
et
la
1. In what area do nurses use assessment tools?
n
a. Mobility
b. Skin breakdown
Sp
sh
z
c. Mentation
d. Strength
et
RATIONALE: Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls,
la
malnutrition, and skin breakdown.
n
Sp
sh
z
2. How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data
he or she collects?
et
a. Initiating a problem list
la
b. Obtaining an accurate history
n
c. Developing accurate nursing diagnoses
Sp
d. Generating diagnoses early
sh
z
RATIONALE: By generating plans early and testing them sequentially, experienced nurses improve their efficiency and
et
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.
la
n
3. When constructing a nursing care plan, what should you reference? (Mark all that apply.)
Sp
sh
tz
a. Therapy
b. Social support
ne
c. Patient education
la
d. Personal history
e. Diagnosis
Sp
sh
RATIONALE: A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as
tz
recognizing potential needs or risks.
ne
la
4. When documenting clinical data, what might you write in the physical assessment?
a. Thyroid isthmus barely palpable, lobes not felt
Sp
b. Apical impulse indiscrete and tapping
sh
tz
c. Thorax symmetric without equal excursion
d. Extraocular movements full and equal on exam
ne
RATIONALE: It collects objective and subjective data to help identify and evaluate problems and develop a plan of care.
la
5. You are the office nurse admitting a new patient to the clinic. You have gained your patient’s trust, gathered a
Sp
sh
tz
detailed history, and finished your portion of the physical examination. What is your next step in caring for this
patient?
a. Formulate nursing diagnoses
ne
la
b. Order the appropriate laboratory tests
c. Identify the patient’s problems
Sp
d. Notify the physician of your findings
sh
tz
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
ne
la
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
Sp
the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format that
sh
tz
communicates the patient's story and your clinical reasoning and plan to other members of the health care team.
ne
6. What is pivotal to determining how to move from each patient problem to its goals?
la
a. Your clinical reasoning process
b. Your positive interpretation of the patient’s history
Sp
sh
tz
c. Your process in collecting physical data
d. Your evaluation as an accurate historian of the patient
ne
RATIONALE: Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and
la
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.
Sp
sh
z
7. As the nurse caring for a patient you have completed the collection of the subjective data. On what do you
et
base your decision to do an entire head-to-toe physical assessment or a systems-specific assessment?
a. The patient’s answers
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
8. For each patient problem you identify you develop and record a plan. What must your plan do? (Mark all that
et
apply.)
la
a. Begin discharge planning
n
b. Include referral to dietician
c. Flow logically from identified diagnoses
Sp
sh
z
d. Specify which steps are needed next
et
e. Identify timing of family involvement
RATIONALE: Identify and record a Plan for each patient problem. Your Plan flows logically from the problems or
la
diagnoses you have identified. Specify the next steps for each problem. These steps range from tests and procedures to
n
subspecialty consultations to new or changed medications to arranging a family meeting.
Sp
sh
z
9. Your patient tells you that his chief complaint is “fatigue.” When obtaining the patient history, what additional
et
information might you want to elicit to try and pinpoint the patient’s “real problem”?
la
a. More information regarding family history
n
b. More information regarding secondary complaints
Sp
c. More information regarding laboratory data
sh
z
d. More information regarding psychosocial issues
et
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
la
own aggression toward others.
n
Sp
sh
tz
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
ne
la
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,
Sp
generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
z
et
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
a. Admission assessment
et
b. Time-lapsed assessment
la
c. Mini-assessment
n
d. Problem-oriented assessment
RATIONALE: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to
Sp
sh
z
evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods
et
of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, health and
development screenings)
la
n
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.
Sp
sh
What the objective data expected for this client? Select all that apply.
z
a. “I cannot breath!”
et
b. Oxygen Saturation of 92%
la
c. Heart rate: 92 cycles per minute
n
d. BP: 110/70 mmHg
Sp
e. Usage of accessory muscles
sh
z
RATIONALE: Objective data (signs or overt data): are detectable by an observer or can be measured or tested against an
et
accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.
la
10. You are a nurse in the Geriatric floor and caring for an 82-year-old male patient who was admitted due to
n
nutritional deficit. What type of assessment should the nurse utilize to keep check on the patient’s improvement
Sp
sh
on a daily basis?
tz
a. Initial comprehensive assessment
b. Focused assessment
ne
la
c. Problem- oriented assessment
d. Emergency assessment
Sp
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
sh
tz
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
ne
changes in the client’s health status in subsequent assessments.
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
z
et
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
Session # 3
et
la
1. Learning about the effects of the illness does what for the nurse and the patient?
n
a. Gives them the basis to establish a trusting relationship
b. Gives them each a better understanding of the other
Sp
sh
z
c. Gives them the ability to communicate better
et
d. Gives them the opportunity to create a complete and congruent picture of the problem
RATIONALE: Gives them the opportunity to create a complete and congruent picture of the problem
la
n
2. What occurs during the termination phase of an interview?
Sp
sh
z
a. Plan for follow-up care
b. Address topics that have not yet been addressed
et
c. Assess the patient’s mental status
la
d. Let the patient know you understood all he or she has told you
n
RATIONALE: Planning for follow up care
Sp
sh
z
3. How would the nursing instructor explain the goal of guided questioning to his or her students?
et
a. Obtaining complete data from the patient
la
b. Facilitating the patient’s fullest communication
n
c. Developing a basis for accurate nursing diagnoses
d. Creating an opportunity for the early generation of a plan
Sp
sh
tz
RATIONALE: Facilitating the patients fullest communication
ne
4. “How many steps can you climb before you get short of breath?” is an example of what kind of question?
la
a. A question that offers multiple choices for answers
b. A question that is narrow in focus
Sp
sh
tz
c. A question that elicits a graded response
d. A question that demands an exact response
ne
RATIONALE: A question that elicits a graded response
la
5. While interviewing a new patient, you notice that he is mirroring your position. What can this signify?
Sp
a. An increasing sense of connectedness
sh
tz
b. A desire to be on an equal power level
c. A desire for increased rapport
ne
d. The patient does not take you seriously
la
RATIONALE: An increasing sense of connectedness
Sp
sh
tz
6. Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, “Don’t
worry, everything will be okay.” What might this premature reassurance cause?
ne
a. A feeling of closeness between the patient and the nurse
la
b. The nurse to shorten the interview process
c. The blockage of further disclosures by the patient
Sp
sh
d. A noticeable lessening of the patient’s anxiety
tz
RATIONALE: The blockage of further disclosures by the patient
ne
la
7. What techniques encourage patient disclosures while minimizing the risk for distorting the patient’s ideas or
missing significant details? (Mark all that apply.)
a. Asking a series of questions, one at a time
Sp
sh
tz
b. Using reflection
c. Asking only open-ended questions
ne
d. Encouraging with repetition
la
e. Offering multiple choices for answers
RATIONALE:
Sp
sh
tz
8. A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask
the patient next. What is a useful interview technique for the student to use at this point?
ne
la
a. Transition
b. Summarization
Sp
c. Reassurance
sh
z
d. Termination
et
RATIONALE: Summarization
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
Session # 2
et
la
1. In what area do nurses use assessment tools?
n
a. Mobility
b. Skin breakdown
Sp
sh
z
c. Mentation
d. Strength
et
RATIONALE: Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls,
la
malnutrition, and skin breakdown.
n
Sp
sh
z
2. How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data
he or she collects?
et
a. Initiating a problem list
la
b. Obtaining an accurate history
n
c. Developing accurate nursing diagnoses
Sp
d. Generating diagnoses early
sh
z
RATIONALE: By generating plans early and testing them sequentially, experienced nurses improve their efficiency and
et
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.
la
n
3. When constructing a nursing care plan, what should you reference? (Mark all that apply.)
Sp
sh
tz
a. Therapy
b. Social support
ne
c. Patient education
la
d. Personal history
e. Diagnosis
Sp
sh
RATIONALE: A nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well as
tz
recognizing potential needs or risks.
ne
la
4. When documenting clinical data, what might you write in the physical assessment?
a. Thyroid isthmus barely palpable, lobes not felt
Sp
b. Apical impulse indiscrete and tapping
sh
tz
c. Thorax symmetric without equal excursion
d. Extraocular movements full and equal on exam
ne
RATIONALE: It collects objective and subjective data to help identify and evaluate problems and develop a plan of care.
la
5. You are the office nurse admitting a new patient to the clinic. You have gained your patient’s trust, gathered a
Sp
sh
tz
detailed history, and finished your portion of the physical examination. What is your next step in caring for this
patient?
a. Formulate nursing diagnoses
ne
la
b. Order the appropriate laboratory tests
c. Identify the patient’s problems
Sp
d. Notify the physician of your findings
sh
tz
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
ne
la
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
Sp
the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format that
sh
tz
communicates the patient's story and your clinical reasoning and plan to other members of the health care team.
ne
6. What is pivotal to determining how to move from each patient problem to its goals?
la
a. Your clinical reasoning process
b. Your positive interpretation of the patient’s history
Sp
sh
tz
c. Your process in collecting physical data
d. Your evaluation as an accurate historian of the patient
ne
RATIONALE: Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and
la
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.
Sp
sh
z
7. As the nurse caring for a patient you have completed the collection of the subjective data. On what do you
et
base your decision to do an entire head-to-toe physical assessment or a systems-specific assessment?
a. The patient’s answers
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
8. For each patient problem you identify you develop and record a plan. What must your plan do? (Mark all that
et
apply.)
la
a. Begin discharge planning
n
b. Include referral to dietician
c. Flow logically from identified diagnoses
Sp
sh
z
d. Specify which steps are needed next
et
e. Identify timing of family involvement
RATIONALE: Identify and record a Plan for each patient problem. Your Plan flows logically from the problems or
la
diagnoses you have identified. Specify the next steps for each problem. These steps range from tests and procedures to
n
subspecialty consultations to new or changed medications to arranging a family meeting.
Sp
sh
z
9. Your patient tells you that his chief complaint is “fatigue.” When obtaining the patient history, what additional
et
information might you want to elicit to try and pinpoint the patient’s “real problem”?
la
a. More information regarding family history
n
b. More information regarding secondary complaints
Sp
c. More information regarding laboratory data
sh
z
d. More information regarding psychosocial issues
et
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
la
own aggression toward others.
n
Sp
sh
tz
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
ne
la
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,
Sp
generating and testing hypotheses, and determining optimal diagnosis and treatment based on the information obtained.
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
z
et
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
a. Admission assessment
et
b. Time-lapsed assessment
la
c. Mini-assessment
n
d. Problem-oriented assessment
RATIONALE: Time lapsed reassessment, another type of assessment, takes place after the initial assessment to
Sp
sh
z
evaluate any changes in the clients functional health. Nurses perform time-lapsed reassessment when substantial periods
et
of time have elapsed between assessments (e.g., periodic output patient clinic visits, home health visits, health and
development screenings)
la
n
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.
Sp
sh
What the objective data expected for this client? Select all that apply.
z
a. “I cannot breath!”
et
b. Oxygen Saturation of 92%
la
c. Heart rate: 92 cycles per minute
n
d. BP: 110/70 mmHg
Sp
e. Usage of accessory muscles
sh
z
RATIONALE: Objective data (signs or overt data): are detectable by an observer or can be measured or tested against an
et
accepted standard. They can be seen, heard, felt, or smelt, and they are obtained by observation or physical examination.
la
10. You are a nurse in the Geriatric floor and caring for an 82-year-old male patient who was admitted due to
n
nutritional deficit. What type of assessment should the nurse utilize to keep check on the patient’s improvement
Sp
sh
on a daily basis?
tz
a. Initial comprehensive assessment
b. Focused assessment
ne
la
c. Problem- oriented assessment
d. Emergency assessment
Sp
RATIONALE: An initial assessment, also called an admission assessment, is performed when the client enters a health
sh
tz
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
ne
changes in the client’s health status in subsequent assessments.
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
tz
ne
la
Sp
sh
z
et
, n et
NURS MISC>HEALTH ASSESSMENT SESSION 1-30 100% CORRECT(LATEST).
sh
z
Session # 3
et
la
1. Learning about the effects of the illness does what for the nurse and the patient?
n
a. Gives them the basis to establish a trusting relationship
b. Gives them each a better understanding of the other
Sp
sh
z
c. Gives them the ability to communicate better
et
d. Gives them the opportunity to create a complete and congruent picture of the problem
RATIONALE: Gives them the opportunity to create a complete and congruent picture of the problem
la
n
2. What occurs during the termination phase of an interview?
Sp
sh
z
a. Plan for follow-up care
b. Address topics that have not yet been addressed
et
c. Assess the patient’s mental status
la
d. Let the patient know you understood all he or she has told you
n
RATIONALE: Planning for follow up care
Sp
sh
z
3. How would the nursing instructor explain the goal of guided questioning to his or her students?
et
a. Obtaining complete data from the patient
la
b. Facilitating the patient’s fullest communication
n
c. Developing a basis for accurate nursing diagnoses
d. Creating an opportunity for the early generation of a plan
Sp
sh
tz
RATIONALE: Facilitating the patients fullest communication
ne
4. “How many steps can you climb before you get short of breath?” is an example of what kind of question?
la
a. A question that offers multiple choices for answers
b. A question that is narrow in focus
Sp
sh
tz
c. A question that elicits a graded response
d. A question that demands an exact response
ne
RATIONALE: A question that elicits a graded response
la
5. While interviewing a new patient, you notice that he is mirroring your position. What can this signify?
Sp
a. An increasing sense of connectedness
sh
tz
b. A desire to be on an equal power level
c. A desire for increased rapport
ne
d. The patient does not take you seriously
la
RATIONALE: An increasing sense of connectedness
Sp
sh
tz
6. Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, “Don’t
worry, everything will be okay.” What might this premature reassurance cause?
ne
a. A feeling of closeness between the patient and the nurse
la
b. The nurse to shorten the interview process
c. The blockage of further disclosures by the patient
Sp
sh
d. A noticeable lessening of the patient’s anxiety
tz
RATIONALE: The blockage of further disclosures by the patient
ne
la
7. What techniques encourage patient disclosures while minimizing the risk for distorting the patient’s ideas or
missing significant details? (Mark all that apply.)
a. Asking a series of questions, one at a time
Sp
sh
tz
b. Using reflection
c. Asking only open-ended questions
ne
d. Encouraging with repetition
la
e. Offering multiple choices for answers
RATIONALE:
Sp
sh
tz
8. A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask
the patient next. What is a useful interview technique for the student to use at this point?
ne
la
a. Transition
b. Summarization
Sp
c. Reassurance
sh
z
d. Termination
et
RATIONALE: Summarization
