1. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
“Is there anyt... [Show More] hing that you are stressed about right now that I should
a. know?”
b. “What reasons do you think are contributing to your fatigue?”
c. “What are your normal work hours?”
d. “Are you sleeping 8 hours a night?”
ANS: B
The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed- ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of- fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons.
2. A nurse is conducting a nursing health history. Which component will the nurse address?
a. Nurse’s concerns
b. Patient expectations
c. Current treatment orders
d. Nurse’s goals for the patient
ANS: B
Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment 1 orders are located under the Orders section in the patient’s chart and are not
a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database.
Goals that are mutually established, not nurse’s goals, are part of the nursing care plan.
3. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having
a leg cast and developing restless sleep. Which action would have been best
for the nurse to take?
a. Tell the patient to just focus on the leg and cast right now.
b. Document the sleep patterns and information in the patient’s chart.
c. Explain that a more thorough assessment will be needed next shift. Ask the patient about usual sleep patterns and the onset of having
d. difficulty resting.
ANS: D
The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient’s report of a problem or postpone it till the next shift.
4. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal
surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
a. Gordon’s Functional Health Patterns
b. Activity-exercise pattern assessment
c. General to specific assessment
d. Problem-oriented assessment
ANS: D
2
The nurse is not doing a complete, general assessment and then focusing on
specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question.
5. Which statement by a nurse indicates a good understanding about the
differences between data validation and data interpretation?
a. “Data interpretation occurs before data validation.”
b. “Validation involves looking for patterns in professional standards.”
c. “Validation involves comparing data with other sources for accuracy.” “Data interpretation involves discovering patterns in professional
d. standards.” ANS: C
Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.
6. Which scenario best illustrates the nurse using data validation when
making a nursing clinical decision for a patient?
The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new
a. drainage.
The nurse administers pain medicine due at
1700 at 1600 because the
b. patient reports increased pain and the family wants something done.
The nurse immediately asks the health care provider for an order of
3
c. potassium when a patient reports leg cramps.
The nurse elevates a leg cast when the patient reports decreased
d. mobility. ANS: A
The only scenario that validates a patient’s report with a nurse’s observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse’s assessment.
7. While completing an admission database, the nurse is interviewing a
patient who states “I am allergic to latex.” Which action will the nurse take
first?
a. Immediately place the patient in isolation.
b. Ask the patient to describe the type of reaction.
c. Proceed to the termination phase of the interview.
d. Document the latex allergy on the medication administration record.
ANS: B
The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.
8. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
a. Proceed to the next patient’s room to make rounds.
b. Determine the patient does not want any pain medicine.
c. Ask the patient about the facial grimacing with movement.
d. Administer the pain medication ordered for moderate to severe pain.
ANS: C
First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse 4
cannot assume the patient does not want pain medicine just because he reports
a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary.
9. The nurse is interviewing a patient with a hearing deficit. Which area
should the nurse use to conduct this interview?
a. The patient’s room with the door closed
b. The waiting area with the television turned off
c. The patient’s room before administration of pain medication
The waiting room while the occupational therapist is working on leg
d. exercises ANS: A
Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient’s room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone’s ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview.
Assessing a patient while another member of the health care team is working would be distracting and is not the best time for an interview to take place.
10. A new nurse is completing an assessment on an 80-year-old patient who
is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
a. The nurse makes eye contact with the patient.
b. The nurse speaks only to the patient’s daughter.
c. The nurse leans forward while talking with the patient.
d. The nurse nods periodically while the patient is speaking.
ANS: B
Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment. Therefore, the charge nurse must correct this
misconception. When assessing an older adult, nurses need to listen carefully 5
and allow the patient to speak. Positive nonverbal communication, such as
making eye contact, nodding, and leaning forward, shows interest in the patient. Thus, the charge nurse does not need to intervene or follow up.
MULTIPLE RESPONSE
1. A nurse is completing an assessment. Which findings will the nurse
report as subjective data? (Select all that apply.)
a. Patient’s temperature
b. Patient’s wound appearance
c. Patient describing excitement about discharge
d. Patient pacing the floor while awaiting test results
e. Patient’s expression of fear regarding upcoming surgery
ANS: C, E
Subjective data include patient’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient’s health status. In this question, the appearance of the wound and the patient’s temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.
MATCHING
A nurse is completing an assessment using the PQRST to obtain data about the
patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
a. Where is the pain located?
b. What causes the pain?
c. Does it come and go?
d. What does the pain feel like?
e. What is the rating on a scale of 0 to 10?
1. Provokes
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2. Quality [Show Less]
