Chapter 16 Review Qs Book Flashcards
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that apply)
1. The review of patient data in the medical record
2. Confirming a patients self-report of abdominal pain by inspect-
ing the abdomen
3. Reporting results of an ongoing assessment to a nurse working
the next scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
5. Conducting an interview of a family caregiver
1,2,4,5
Match the assessment activity on the left with the type of assess-
ment on the right.
A. Problem focused
B. Comprehensive
- Assessment conducted at beginning
- Review of a patient’s chief complaint
- Completion of admitting history at
time of patient admission to a hospital - Completion of the Long Term Care
Minimum Data Set during an elderly
patient admission to a nursing home
1A, 2A, 3B, 4B
A nurse initiates a brief interview with a patient who has come
to the medical clinic because of self-reported hoarseness, sore
throat, and chest congestion. The nurse observes that the patient
has a slumped posture and is using intercostal muscles to breathe.
The nurse auscultates the patient’s lungs and hears crackles in
the left lower lobe. The patient’s respiratory rate is 20 per minute
compared with an average of 16 per minute during previous clinic
visits. The patient tells the nurse, “It is hard for me to get a breath.”
Which of the following data sets are examples of subjective data?
(Select all that apply.)
1. Heart rate of 20 per minute and chest congestion
2. Lung sounds revealing crackles and use of intercostal muscles
to breathe
3. Patient statement, “It’s hard for me to get a breath”
4. Slumped posture and previous respiratory rate of 16 per minute
5. Patient report of sore throat and hoarseness
3
The nurse asks a patient the following series of questions:
“Describe for me how much you exercise each day? “How do you
tolerate the exercise?” “Is the amount of exercise you get each
day the same, less, or more than what you did a year ago?” This
series of questions would likely occur during which phase of a
patient-centered interview?
1. Orientation
2. Working phase
3. Data interpretation
4. Termination
2
A young male patient enters the emergency department with
fever and signs of a possible sexually transmitted infection. The
nurse enters the patient’s cubicle and begins to enter a history on
the computer screen. Before beginning the nurse introduces him-
self and tells the patient all information will be held confidentially.
The nurse starts data collection by establishing eye contact with
the patient and then looks at the computer prompts to select a
series of questions. As the nurse fills out questions on the com-
puter, the patient asks a question about his treatment. The nurse
states, “Let me get through these questions first.” Which action
interferes with the nurse’s ability to use connection as a communi-
cation skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse’s questions a priority
4. Assuring the patient all information is confidential
3
A nurse observes a patient walking down the hall with a shuf-
fling gait. When the patient returns to bed, the nurse checks the
strength in both of the patient’s legs. The nurse applies the infor-
mation gained to suspect that the patient has a mobility problem.
This conclusion is an example of:
1. Reflection.
2. Clinical inference.
3. Cue.
4. Validation.
2
Place the following steps of the assessment process in the correct
order.
1. Compare data with another source to determine data accuracy.
2. As a pattern forms, probe and frame further questions.
3. Interview a patient, observe behavior, and gather physical
assessment findings.
4. Cluster cues that relate together, make inferences, and identify
emerging patterns.
5. Differentiate important data from the total data you collect.
3,5,4,2,1
In preparing to collect a nursing history for a patient admitted for
elective surgery, which of the following data are part of the review
of present illness in the nursing health history?
1. Current medications
2. Patient expectations of planned surgery
3. Review of patient’s family support system
4. History of allergies
5. Patient’s explanation for what might be the cause of symptoms
that require surgery
5
A nurse is conducting a patient-centered interview. Place the
statements from the inter view in the correct order, beginning with
the first statement a nurse would ask.
1.
“You say you’ve lost weight. Tell me how much weight you’ve
lost in the past month.’
2.
“My name is Terry. I’ll be the nurse taking care of you today?’
3.
“I have no further questions. Is there anything else you wish to
ask me?”
4.
“Tell me what brought you to the hospital?
5.
“So, to summarize, you’ve lost about 6 pounds in the past
month, and your appetite has been poor-correct?”
2,4,1,5,3
Which of the following approaches are recommended when gath-
ering assessment data from an 82-year-old male patient entering a
primary care clinic for the first time? (Select all that apply.)
1. Recognize normal changes associated with aging.
2. Avoid direct eye contact.
3. Lean forward and smile as you pose questions.
4. Allow for pauses as patient tells his story.
5. Use the list of questions from the clinic assessment form to
complete all data.
1,3,4
