Chapter 16 Nursing Assessment

Question 0

1. A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?” The nurse’s assessment covers which of Gordon’s functional health patterns?
   A. Value-belief pattern
   B. Cognitive-perceptual pattern
   C. Coping–stress-tolerance patters
   D. Health perception–health management pattern

Answer 0

D

Rationale:
The nurse is attempting to learn about the patient’s self-report of health practices, clinic appointments, and exercise plan designed to improve his health.

Question 1

2. The nurse asks a patient, “Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a patient-centered interview?

A. Setting the stage
B. Gathering information about the patient’s chief concerns
C. Collecting the assessment
D. Termination

Answer 1

C

Rationale:
The nurse is focusing on the patient’s nutritional status and asking specific questions to assess his diet history.

Question 2

3.	What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.)
A.	Active listening
B.	Open-ended questioning
C.	Closed-ended questioning
D.	Problem-oriented questioning

Answer 2

C and D

Rationale:
The nurse’s technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse’s knowledge about the character of his pain.

Question 3

4. What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.)

A.	Active listening
B.	Back channeling
C.	Validating
D.	Use of open-ended questions
E.	Use of closed-ended questions

Answer 3

A, B and D

Rationale:
Active listening allows the patient to speak and shows the nurse’s respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse’s desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.

Question 4

5. A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.)
   A. The skin around the wound is tender to touch.
   B. Fluid intake for 8 hours is 800 mL.
   C. Patient has a heart rate of 78 and regular.
   D. Patient has drainage from surgical wound.
   E. Body temperature is 101° F (38.3° C).
   F. Patient asks, “I’m worried that I won’t return to work when I planned.”

Answer 4

A, D, and E

Rationale:
These form a pattern of a problem with wound healing. Fluid intake of 800 mL in 8 hours and having a heart rate of 78 are normal findings. The patient indicating some worry about not returning to work when planned may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem.

Question 5

6. The nurse makes the following statement during a change of shift report to another nurse. “I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don’t think it’s that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?” What does the nurse’s conclusion suggest?

A. The nurse is making an accurate clinical inference.
B. The nurse has gathered cues to identify a potential problem area.
C. The nurse has allowed stereotyping to influence her assessment.
D. The nurse wants to validate her information with the other nurse.

Answer 5

C

Rationale:
The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse’s opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain.

Question 6

7. A nurse checks a patient’s intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?

A. Agenda settling
B. Problem-focused
C. Objective
D. Use of a structured database format

Answer 6

B

Rationale:
The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient’s report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.

Question 7

8. A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon’s functional health patterns, which pattern does the nurse assess?
   A. Health perception–health management pattern
   B. Value-belief pattern
   C. Cognitive-perceptual pattern
   D. Coping–stress tolerance pattern

Answer 7

A

Rationale:
The nurse assesses the patient’s understanding of his therapy and level of adherence. She also assesses his health practices.

Question 8

9. Which of the following are examples of data validation? (Select all that apply.)
   A. The nurse assesses the patient’s heart rate and compares the value with the last value entered in the medical record.
   B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity.
   C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content.
   D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.
   E. The nurse asks the patient to describe a symptom by saying, “Go on.”

Answer 8

A and D

Rationale:
Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient’s understanding of the booklet is not data validation. Telling the patient to “go on” is back channeling.

Question 9

10. A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing?

A. So you’ve had an upset stomach and began vomiting—correct?
B. Have you taken anything for your stomach?
C. Is anything else bothering you?
D. Have you taken any medication for your vomiting?

Answer 9

C

Rationale:
A probing question encourages a full description without trying to control the direction of the patient’s story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient’s response and do not ensure a full objective view from the patient.

Question 10

11. The nurse is assessing the character of a patient’s migraine headache and asks, “Do you feel nauseated when you have a headache?” The patient’s response is “yes.” In this case the finding of nausea is which of the following?

A. An objective finding
B. A clinical inference
C. A validation
D. A concomitant symptom

Answer 10

D

Rationale:
A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.

Question 11

12. During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.)
    A. Family report
    B. Chest x-ray film
    C. Physical examination with auscultation of the lungs
    D. Medical record summary of x-ray film findings

Answer 11

C and D

Rationale:
The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.

Question 12

13. A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse’s knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.)
    A. A problem-focused approach
    B. A structured comprehensive approach
    C. Using multiple visits to gather a complete database
    D. Focusing on the functional health pattern of role-relationship

Answer 12

A and C

Rationale:
The nurse should use a focused approach initially to determine the patient’s respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient’s age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient’s role-relationship health pattern because of his wife’s death. But it is not appropriate at this time.

Question 13

14. A 58-year-old patient with nerve deafness has come to his doctor’s office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.)
    A. Maintain a neutral facial expression
    B. Lean forward when interacting with the patient
    C. Acknowledge the patient’s answers through head nodding
    D. Limit direct eye contact

Answer 13

B and C

Rationale:
Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse’s responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse’s interest in what the patient has to say.