Chapter 16: Nursing Assessment Review questions – Flashcards

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 pattern D) Health perception-health management pattern

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

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

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

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."

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.

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 setting B) Problem-focused C) Objective D) Use of a structured database format

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

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. 1. "You say you've lost weight. Tell me how much weight you have lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor—correct?"

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."

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?

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

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

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

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