Ch 3 Assessment

Question 1

Delegation of nurses care is regulated by which of the following
A. ANA
B. Hospital policy
C. Joint commission 
D. State practice acts

Answer 1

D. State practice acts

Question 2

Taylor, a 7yr old boy, is brought to urgent care center by his father. He is bleeding from a wound on the back of his head. You inspect the wound visually and assess that you will need to clean the wound area to determine the length depth and severity. What additional component of the physical assessment will you perform while cleansing the wound 
A. Auscultation
B. Percussion
C. Palpation
D. Developmental

Answer 2

C. Palpation

Question 3

You are preparing to perform an initial nursing assessment on an 89yr old Lucy J. She is petite, thin, and seated in a wheel chair in her assigned room. As you enter the room you observer her sobbing into a tissue. Your initial intervention to help her prepare for the interview is which of the following.
A. Ask her if she would like you to call a family member
B. Asked her if she would like to talk about what’s upsetting her
C. Walk over to her. Take her hand. And reassure her that things will be okay
D. Walk over to her and introduce your self by name, position, and role

Answer 3

D. Walk over to we and introduce yourself by name, position, and role.

Question 4

Vital signed, level of consciousness, and skin color that you observe are which type of data?

A. Secondary
B. Objective
C. Subjective
D. Focused

Answer 4

B. Objective

Question 5

Medication assessment is part of the initial assessment. Pts are asked if they take vitamins or supplements in order to gather which of the following:
A. Information about the pts culture and ethnicity
B. Data about the pts health concerned such as osteoporosis
C. Information about the value the pt places on health
D. Data that might reveal an interaction with prescribed meds

Answer 5

D. Data that might reveal an interaction with prescribed meds

Question 6

Of the following, which is n example of an open ended question:
A. Do you live alone or with family
B. What problems have you had since your injury
C. Did you injure your hand at work
D. Where did the accident occur

Answer 6

B. What problems have you had since your injury

Question 7

Mr. Long has a surgical repair of the abdominal hernia. He will be discharged tomorrow. You are assigned as his nurse for the evening shift. To identify his discharge planning needs you will perform a ???? Assessment
A. Special needs
B. Psychosocial
C. Focused
D. Comprehensive

Answer 7

C. Focused

Question 8

You were assigned to the care of Sally combs in the 2300 to 0700 shift yesterday. You have talked with her extensively about her home and any problems she anticipated upon discharge. You documented her concerns about her limited mobility and reach. But today you recall you forgot to document her concerns about her ability to pay bills. You should do which of the following:
A. Document it in today’s progress note, identify data and time collected
B. Leave a note for the social worker explaining the pts concerns
C. Add info to original database
D. A&B
E. A &C

Answer 8

D. A&B

Question 9

Cue or inference:

Marti states “I don’t know if I’ll be able to get pregnant with my erratic cycle”

Answer 9

Cue

Question 10

Cue or inference:

Marti describes her menstrul cycle as “lasting about 3 days but very unpredictable”

Answer 10

Cue

Question 11

Cue or inference:

Madrid exercise regime and weight are contributing to her irregular mensus

Answer 11

Inference

Question 12

Cue or inference:

Marti states her sister had a great deal of difficulty conceiving her first child. She says she is concerned she will have the same difficulty

Answer 12

Cue

Question 13

Cue or inference:

Marti is anxious and preoccupied with her irregular mensus

Answer 13

Inference

Question 14

Which organizations standards require all pts be assessed specifically for pain

A. ANA
B. State nurses practice act
C. National council of state boards of nursing
D. Joint commission

Answer 14

D. The joint commission

Question 15

Using the mnemonic H E L P, which of the following correctly illustrates the letter H (help)

A. Is the oxygen running
B. Who else is in the room
C. Are there any spills
D. Is the pt in pain

Answer 15

D. Is the pt in pain

Question 16

Using the mnemonic H E L P, which of the following correctly illustrates the letter L (look)

A. Is the oxygen running
B. Who else is in the room
C. Are there any spills
D. Take a thorough look at the pt

Answer 16

D. Take a thorough look at the Pt

Question 17

Using the mnemonic H E L P, which of the following correctly illustrates the letter E

A. Is the oxygen running
B. Who else is in the room
C. Are there any spills
D. Take a thorough look at the pt

Answer 17

A. Is the oxygen running

Question 18

Using the mnemonic H E L P, which of the following correctly illustrates the letter P

A. Is the oxygen running
B. Who else is in the room
C. Are there any spills
D. Take a thorough look at the pt

Answer 18

B. Who else is in the room with the pt

Question 19

Which of the following is an example of data that should be validated
A. The urinalysis report indicated there are WBC in the urine
B. The client states he feels feverish; you measure the oral temp at 98F
C. The client has clear breath sounds, you count 18bpm
D. The chest x Ray report indicated the client has pneumonia in the right lower lobe

Answer 19

B. The client states he feels feverish; you measure the oral temp at 98F

Question 20

Which of the following is an example of appropriate behavior when conducting a client interview

A. Recording all the info on the agency approved form during the interview
B. Ask the client “why did you feel it necessary to seek healthcare at this time?
C. Use precise medical terminology when asking the client questions
D. Sitting, facing the client in a chair at the clients bedside using active listening

Answer 20

D. Sitting, facing the client in a chair at the clients bedside using active listening

Question 21

The nurse intends to identify nursing diagnoses for a pt. she can best do this by using a data collection form organized according to

A. A body system model
B. A head to toe framework
C. Maslows hierarchy of needs
D. Gordon’s functional health patterns

Answer 21

A. A body system model

B. Gordon’s functional health patterns.

Question 22

The nurse is recording assessment data. She writes “the it seems worried about his surgery. Other than that he has had a good night” which error did the nurse make. Select all that apply

A. Used a vague generality
B. Did not use the pts exact words
C. Used a “waffle” word
D. Recorded an inference rather than cues

Answer 22

A used a vague generality

C. Used a “waffle” word (seems)

Question 23

As the nurse is inserting a urinary catheter she observes blood in the tubing. Which two nursing process phases does this demonstrate. 
A. Assessment
B. Diagnosis
C. Implementation
D. Planning: interventions

Answer 23

A. Assessment

C. Implementation

Question 24

As the nurse is inserting a urinary catheter she observes blood in the tubing. Which principle of assessment does this best illustrate

A. Assessment must be accurate because the remainder of the nursing process depends on it
B. Nursing assessments focus on pts responses rather than disease processes
C. Assessment is a responsibility of the professional nurse and cannot be delegated.
D. Assessment is related to and overlaps with other steps of the nursing process

Answer 24

D. Assessment is related to and overlaps with other steps of the nursing process.

Question 25

A pt is admitted with S. O. B. The nurse specifically wants to know when the problem began, how often it occurs, what makes it worse, and what the pt has done to relieve it. What should the nurse do to obtain this info.
A. Complete a comprehensive admission assessment
B. Interview the pt. about the history of the illness
C. Perform a review of the body systems and functional abilities.
D. Ask the pt about her expectations for care

Answer 25

B. Interview the pt about the history of her present illness

Question 26

What is the fold of the joint commission in regards to pt assessment? The joint commission:
A. States what assessments are collected by individuals with different credentials
B. Regulates the time frames for when assessments should be completed
C. Identifies how data are to be collected and documented
D. Set standards for what and when to assess the pt

Answer 26

D. Set standards for what and when to assess the pt.

Question 27

The American nurses associations code of ethics for nurses provision (2008) states, “the nurses determine the appropriate ??? Of tasks consistent with the nurses obligation to provide optimum ???

Answer 27

Delegation; patient care