Chapter 3 Nursing Process: Assessment

Chapter 3  Nursing Process: Assessment

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Which of the following is an example of data that should be validated?
a)
The client’s weight measures 185 lb at the clinic.
b)
The client’s liver function test results are elevated.
c)
The client’s blood pressure reading is 160/94 mm Hg; he states that is typical for him.
d)
The client states she eats a low-sodium diet; she reports eating processed food.

ANS: D
Validation should be done when the client’s statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Application

PTS: 1

2. Which of the following examples includes both objective and subjective data?
a)
The client’s blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min.
b)
The client’s cholesterol is elevated, and he states he likes fried food.
c)
The client states she has trouble sleeping and that she drinks coffee in the evening.
d)
The client states he gets frequent headaches and that he takes aspirin for the pain.

ANS: B
Elevated cholesterol is objective and “states he likes fried food” is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or laboratory and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. “States . . . trouble sleeping and . . . drinks coffee . . .” are both subjective. States “. . . frequent headaches and . . . takes aspirin . . .” are both subjective.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive level: Analysis

PTS: 1

3. The Joint Commission requires which type of assessment to be performed on all patients?
a)
Functional ability
b)
Pain
c)
Cultural
d)
Wellness

ANS: B
The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

4. Which of the following is an example of an ongoing assessment?
a)
Taking the patient’s temperature 1 hour after giving acetaminophen (Tylenol)
b)
Examining the patient’s mouth at the time she complains of a sore throat
c)
Requesting the patient to rate intensity on a pain scale at the first perception of pain
d)
Asking the patient in detail how he will return to his normal exercise activities

ANS: A
An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patient’s complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know whether it is initial or ongoing.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Application

PTS: 1

5. When should the nurse make systematic observations about a patient?
a)
When the patient has specific complaints
b)
With the first assessment of the shift
c)
Each time the nurse gives medications to the patient
d)
Each time the nurse interacts with the patient

ANS: D
The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient.

Difficulty: Easy
Nursing Process: Assessment
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application

PTS: 1