Question 1

A nurse is conducting an initial assessment on a newly admitted patient. Which of the following best describes the primary purpose of this initial assessment?

Accepted Answer

To establish baseline information for future comparison

Question 2

During a nursing assessment, a patient states, "I have a sharp pain in my stomach after I eat." This statement is an example of which type of data?

Accepted Answer

Subjective data

Question 3

A nurse notes that a patient is diaphoretic and pale, and records a blood pressure of 140/90 mmHg. These findings are best classified as:

Accepted Answer

Objective data

Question 4

Which of the following is a key difference between the nurse's and the physician's use of assessment data?

Accepted Answer

Nurses focus on the patient's state of wellness and functional ability

Question 5

A nurse is validating assessment data. Which of the following actions best demonstrates validation?

Accepted Answer

Repeating a blood pressure measurement to confirm an abnormal reading

Question 6

A patient is confused and unable to provide a reliable health history. Which source of data should the nurse use as the PRIMARY source in this situation?

Accepted Answer

The patient's family or significant others

Question 7

Which of the following best describes the process of clustering data during the assessment phase?

Accepted Answer

Grouping related information to identify patterns and potential problems

Question 8

A nurse is using palpation during a physical assessment. Which of the following findings is most likely to be obtained through this technique?

Accepted Answer

Assessing skin temperature and moisture

Question 9

Which of the following is an example of a secondary source of data in nursing assessment?

Accepted Answer

A family member's account of the patient's home situation

Question 10

A nurse is preparing to interview a patient. Which action best supports accurate and complete data collection?

Accepted Answer

Conducting the interview in a quiet, private space

Question 11

A nurse is assessing a patient who appears suntanned but denies sun exposure. What is the most appropriate next step?

Accepted Answer

Validate the data by asking additional questions or consulting other sources

Question 12

Which of the following best describes the purpose of documenting assessment findings in a systematic format?

Accepted Answer

To provide a reference point for comparison and monitor changes

Question 13

A nurse is using Maslow's hierarchy of needs as a framework during assessment. Which of the following patient needs should be prioritized according to this framework?

Accepted Answer

Physiological needs such as breathing and circulation

Question 14

Which of the following best illustrates the use of auscultation during a physical assessment?

Accepted Answer

Listening to bowel sounds with a stethoscope

Question 15

A nurse is conducting a focused or problem-oriented assessment. Which scenario best fits this type of assessment?

Accepted Answer

A patient with a known wound is being evaluated for signs of infection

Question 16

Which of the following is a critical reason for validating data during the assessment phase?

Accepted Answer

To ensure that cues and inferences are accurate and unbiased

Question 17

A nurse is using inspection as an assessment technique. Which of the following findings is most likely to be obtained through inspection?

Accepted Answer

Observing signs of distress such as grimacing or guarding

Question 18

A nurse is reviewing a patient's laboratory results as part of the assessment. Which type of data is this considered?

Accepted Answer

Secondary objective data

Question 19

A nurse is planning to use a systems approach to organize assessment data. Which of the following best describes this method?

Accepted Answer

Organizing data by body systems such as cardiac, respiratory, and gastrointestinal

Question 20

A nurse is conducting an emergency assessment. Which of the following best describes the focus of this assessment?

Accepted Answer

Identifying life-threatening situations requiring immediate intervention

Nursing Assessment: Foundations and Processes (CH. 6, NUR 200)

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