NS 332 Fundamentals Exam II WITH
|\ |\ |\ |\ |\ |\
ANSWERS
A nursing student tells the clinical instructor that their patient is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fine and has "no complaints." Which question by the faculty
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
coaches the student to provide evidence that supports their
|\ |\ |\ |\ |\ |\ |\ |\ |\
assessments?
A. "Could you tell me how you validated this?"
|\ |\ |\ |\ |\ |\ |\ |\
B. "Do you think your patient feels free to share their concerns?"
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. "That's good to hear. Tell me about the care you provided."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. "Please reassess the patient; they were admitted with a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
serious problem." - CORRECT ANSWERS ✔✔a. The instructor is
|\ |\ |\ |\ |\ |\ |\ |\ |\
reminding the student that all data must be validated. |\ |\ |\ |\ |\ |\ |\ |\ |\
Questioning the use of the word "fine" allows the nurse to |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
determine if this is a social and reflexive response, and there
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
may be another need the nurse can meet. Concluding that the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
patient does not trust the student is premature and is based on
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
an invalidated inference. Saying "That's good to hear" and asking
|\ |\ |\ |\ |\ |\ |\ |\ |\
the student to describe the care provided is incorrect because it
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accepts the invalidated inference. Telling the student to reassess
|\ |\ |\ |\ |\ |\ |\ |\ |\
the patient because they were admitted with a serious problem is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
incorrect because it is possible that the condition is resolving.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
A nursery nurse notifies the nurse practitioner (NP) that a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
newborn has signs of jaundice. The NP performs a brief skin
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment, then orders a blood test for bilirubin levels. Which |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
type of assessment has the NP performed?
|\ |\ |\ |\ |\ |\
,A. Comprehensive
|\
B. Initial
|\
C. Time-lapsed
|\
D. Quick priority - CORRECT ANSWERS ✔✔d. A quick priority
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment (QPA) is a short, focused assessment to obtain the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
most important information first. A comprehensive initial
|\ |\ |\ |\ |\ |\ |\
assessment is performed shortly after admission. The time-lapsed |\ |\ |\ |\ |\ |\ |\
assessment is used to compare a patient's current status to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
baseline data obtained earlier. |\ |\ |\
The nurse is admitting a pregnant patient to the hospital for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
treatment of pregnancy-induced hypertension. The patient asks |\ |\ |\ |\ |\ |\ |\
the nurse, "Why are you doing a history and physical exam when
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the doctor just did one?" What statements will the nurse use to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
explain the primary purpose of the nursing assessment? Select
|\ |\ |\ |\ |\ |\ |\ |\ |\
all that apply.
|\ |\
A. "The nursing assessment will allow us to plan and deliver
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
individualized, holistic nursing care that draws on your |\ |\ |\ |\ |\ |\ |\ |\
strengths."
B. "It's hospital policy. I know we ask a lot of questions, but I will
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
try to make this quick."
|\ |\ |\ |\
C. "As a nursing student, I need to develop assessment skills
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
about your health status and need for nursing care."
|\ |\ |\ |\ |\ |\ |\ |\
D. "This validates that your responses with the medical exam are
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consistent and that all our data are accurate."
|\ |\ |\ |\ |\ |\ |\ |\
E. "I will check your health status and see what kind of nursing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
care you may need." |\ |\ |\
,F. "This is to determine the necessity for referring your nur -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔a, e, f. Medical assessments target data |\ |\ |\ |\ |\ |\ |\ |\ |\
pointing to pathologic conditions, whereas nursing assessments
|\ |\ |\ |\ |\ |\ |\
focus on the patient's responses to actual and potential health
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
problems. The initial comprehensive nursing assessment results |\ |\ |\ |\ |\ |\ |\
in baseline data that enable the nurse to make a judgment about
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a patient's health status, the ability to manage their own health
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
care and the need for nursing. It also helps nurses plan and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
deliver individualized, holistic nursing care that draws on the
|\ |\ |\ |\ |\ |\ |\ |\ |\
patient's strengths and promotes optimum functioning, |\ |\ |\ |\ |\ |\
independence, and well-being, and enables the nurse to refer the |\ |\ |\ |\ |\ |\ |\ |\ |\
finding(s) to the health care provider or collaborate with other
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
health care professionals where indicated. Citing hospital policy
|\ |\ |\ |\ |\ |\ |\ |\
or student learning is a secondary reason, and although it may
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
be true that a nurse may need to develop assessment skills, it is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
not the main reason for a nursing history and assessment. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment augments the medical examination but is not |\ |\ |\ |\ |\ |\ |\ |\
performed to check its accuracy. |\ |\ |\ |\
During shift report, a nurse says that a patient has no
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
integumentary changes or skin care needs. During assessment, |\ |\ |\ |\ |\ |\ |\ |\
the nurse observes reddened areas over bony prominences.
|\ |\ |\ |\ |\ |\ |\ |\
What action will the nurse take? |\ |\ |\ |\ |\
A. Correct the initial assessment form
|\ |\ |\ |\ |\
B. Redo the initial assessment and document current findings
|\ |\ |\ |\ |\ |\ |\ |\
C. Conduct and document an emergency assessment
|\ |\ |\ |\ |\ |\
D. Perform and document a focused assessment of skin integrity
|\ |\ |\ |\ |\ |\ |\ |\ |\
- CORRECT ANSWERS ✔✔d. Perform a focused skin assessment
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
for the new problem, documenting the current date. The initial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment was entered in the permanent health record, correct |\ |\ |\ |\ |\ |\ |\ |\ |\
, at the time, and cannot legally be rewritten. An emergency
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment is performed for a life-threatening problem. |\ |\ |\ |\ |\ |\
A nursing student is performing a nursing history for the first
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
time. The student asks the primary nurse how anyone learns all
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the questions needed to get complete baseline data. What would
|\ |\ |\ |\ |\ |\ |\ |\ |\
be the nurse's best reply?
|\ |\ |\ |\ |\
A. "There's a lot to learn at first, but once it becomes part of you,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
you just ask the same questions over and over in each situation
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
until you can do it in your sleep!"
|\ |\ |\ |\ |\ |\ |\
B. "You make the basic questions a part of you and apply critical
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
thinking to modify them, to help you plan quality care."|\ |\ |\ |\ |\ |\ |\ |\ |\
C. "It is really hard to learn how to do this well, as each history is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
different. I often feel like I'm starting fresh with each new |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
patient."
D. "Don't worry about learning all of the questions to ask. Every
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
facility has its own assessment form you must use." - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔b. Once a nurse learns what constitutes the |\ |\ |\ |\ |\ |\ |\ |\ |\
minimum data set, it can be adapted to each patient situation. It |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is not true that each assessment is the same even when using
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the same minimum data set, nor is it true that each assessment
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is uniquely different. Nurses committed to thoughtful, person-
|\ |\ |\ |\ |\ |\ |\
centered practice individualize their questions to each patient
|\ |\ |\ |\ |\ |\ |\ |\
and situation. When using a standard facility assessment tool the
|\ |\ |\ |\ |\ |\ |\ |\ |\
nurse must still use critical thinking to individualize questions or
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
follow up on patient information. |\ |\ |\ |\
|\ |\ |\ |\ |\ |\
ANSWERS
A nursing student tells the clinical instructor that their patient is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fine and has "no complaints." Which question by the faculty
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
coaches the student to provide evidence that supports their
|\ |\ |\ |\ |\ |\ |\ |\ |\
assessments?
A. "Could you tell me how you validated this?"
|\ |\ |\ |\ |\ |\ |\ |\
B. "Do you think your patient feels free to share their concerns?"
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. "That's good to hear. Tell me about the care you provided."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. "Please reassess the patient; they were admitted with a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
serious problem." - CORRECT ANSWERS ✔✔a. The instructor is
|\ |\ |\ |\ |\ |\ |\ |\ |\
reminding the student that all data must be validated. |\ |\ |\ |\ |\ |\ |\ |\ |\
Questioning the use of the word "fine" allows the nurse to |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
determine if this is a social and reflexive response, and there
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
may be another need the nurse can meet. Concluding that the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
patient does not trust the student is premature and is based on
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
an invalidated inference. Saying "That's good to hear" and asking
|\ |\ |\ |\ |\ |\ |\ |\ |\
the student to describe the care provided is incorrect because it
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accepts the invalidated inference. Telling the student to reassess
|\ |\ |\ |\ |\ |\ |\ |\ |\
the patient because they were admitted with a serious problem is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
incorrect because it is possible that the condition is resolving.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
A nursery nurse notifies the nurse practitioner (NP) that a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
newborn has signs of jaundice. The NP performs a brief skin
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment, then orders a blood test for bilirubin levels. Which |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
type of assessment has the NP performed?
|\ |\ |\ |\ |\ |\
,A. Comprehensive
|\
B. Initial
|\
C. Time-lapsed
|\
D. Quick priority - CORRECT ANSWERS ✔✔d. A quick priority
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment (QPA) is a short, focused assessment to obtain the |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
most important information first. A comprehensive initial
|\ |\ |\ |\ |\ |\ |\
assessment is performed shortly after admission. The time-lapsed |\ |\ |\ |\ |\ |\ |\
assessment is used to compare a patient's current status to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
baseline data obtained earlier. |\ |\ |\
The nurse is admitting a pregnant patient to the hospital for
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
treatment of pregnancy-induced hypertension. The patient asks |\ |\ |\ |\ |\ |\ |\
the nurse, "Why are you doing a history and physical exam when
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the doctor just did one?" What statements will the nurse use to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
explain the primary purpose of the nursing assessment? Select
|\ |\ |\ |\ |\ |\ |\ |\ |\
all that apply.
|\ |\
A. "The nursing assessment will allow us to plan and deliver
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
individualized, holistic nursing care that draws on your |\ |\ |\ |\ |\ |\ |\ |\
strengths."
B. "It's hospital policy. I know we ask a lot of questions, but I will
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
try to make this quick."
|\ |\ |\ |\
C. "As a nursing student, I need to develop assessment skills
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
about your health status and need for nursing care."
|\ |\ |\ |\ |\ |\ |\ |\
D. "This validates that your responses with the medical exam are
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
consistent and that all our data are accurate."
|\ |\ |\ |\ |\ |\ |\ |\
E. "I will check your health status and see what kind of nursing
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
care you may need." |\ |\ |\
,F. "This is to determine the necessity for referring your nur -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔a, e, f. Medical assessments target data |\ |\ |\ |\ |\ |\ |\ |\ |\
pointing to pathologic conditions, whereas nursing assessments
|\ |\ |\ |\ |\ |\ |\
focus on the patient's responses to actual and potential health
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
problems. The initial comprehensive nursing assessment results |\ |\ |\ |\ |\ |\ |\
in baseline data that enable the nurse to make a judgment about
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
a patient's health status, the ability to manage their own health
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
care and the need for nursing. It also helps nurses plan and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
deliver individualized, holistic nursing care that draws on the
|\ |\ |\ |\ |\ |\ |\ |\ |\
patient's strengths and promotes optimum functioning, |\ |\ |\ |\ |\ |\
independence, and well-being, and enables the nurse to refer the |\ |\ |\ |\ |\ |\ |\ |\ |\
finding(s) to the health care provider or collaborate with other
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
health care professionals where indicated. Citing hospital policy
|\ |\ |\ |\ |\ |\ |\ |\
or student learning is a secondary reason, and although it may
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
be true that a nurse may need to develop assessment skills, it is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
not the main reason for a nursing history and assessment. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment augments the medical examination but is not |\ |\ |\ |\ |\ |\ |\ |\
performed to check its accuracy. |\ |\ |\ |\
During shift report, a nurse says that a patient has no
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
integumentary changes or skin care needs. During assessment, |\ |\ |\ |\ |\ |\ |\ |\
the nurse observes reddened areas over bony prominences.
|\ |\ |\ |\ |\ |\ |\ |\
What action will the nurse take? |\ |\ |\ |\ |\
A. Correct the initial assessment form
|\ |\ |\ |\ |\
B. Redo the initial assessment and document current findings
|\ |\ |\ |\ |\ |\ |\ |\
C. Conduct and document an emergency assessment
|\ |\ |\ |\ |\ |\
D. Perform and document a focused assessment of skin integrity
|\ |\ |\ |\ |\ |\ |\ |\ |\
- CORRECT ANSWERS ✔✔d. Perform a focused skin assessment
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
for the new problem, documenting the current date. The initial
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment was entered in the permanent health record, correct |\ |\ |\ |\ |\ |\ |\ |\ |\
, at the time, and cannot legally be rewritten. An emergency
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
assessment is performed for a life-threatening problem. |\ |\ |\ |\ |\ |\
A nursing student is performing a nursing history for the first
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
time. The student asks the primary nurse how anyone learns all
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the questions needed to get complete baseline data. What would
|\ |\ |\ |\ |\ |\ |\ |\ |\
be the nurse's best reply?
|\ |\ |\ |\ |\
A. "There's a lot to learn at first, but once it becomes part of you,
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
you just ask the same questions over and over in each situation
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
until you can do it in your sleep!"
|\ |\ |\ |\ |\ |\ |\
B. "You make the basic questions a part of you and apply critical
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
thinking to modify them, to help you plan quality care."|\ |\ |\ |\ |\ |\ |\ |\ |\
C. "It is really hard to learn how to do this well, as each history is
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
different. I often feel like I'm starting fresh with each new |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
patient."
D. "Don't worry about learning all of the questions to ask. Every
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
facility has its own assessment form you must use." - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔b. Once a nurse learns what constitutes the |\ |\ |\ |\ |\ |\ |\ |\ |\
minimum data set, it can be adapted to each patient situation. It |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is not true that each assessment is the same even when using
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the same minimum data set, nor is it true that each assessment
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
is uniquely different. Nurses committed to thoughtful, person-
|\ |\ |\ |\ |\ |\ |\
centered practice individualize their questions to each patient
|\ |\ |\ |\ |\ |\ |\ |\
and situation. When using a standard facility assessment tool the
|\ |\ |\ |\ |\ |\ |\ |\ |\
nurse must still use critical thinking to individualize questions or
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
follow up on patient information. |\ |\ |\ |\
