Question 1

Which of the following best describes the primary purpose of the assessment phase in the nursing process?

Accepted Answer

To gather data about the patient's state of wellness, functional ability, and responses to health problems

Question 2

A nurse is assessing a patient who reports, "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

During a physical assessment, a nurse notes that a patient is diaphoretic and pale, with 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 use assessment data to identify patient responses to health problems, while physicians use it to make medical diagnoses.

Question 5

A nurse is preparing to assess a confused, nonverbal patient. Which source of data should the nurse prioritize?

Accepted Answer

Secondary sources: family members and medical records

Question 6

Which of the following best illustrates the process of data validation in nursing assessment?

Accepted Answer

Repeating a blood pressure measurement after an abnormal reading

Question 7

A nurse is conducting an initial assessment on a newly admitted patient. What is the primary aim of this assessment?

Accepted Answer

To establish baseline information for future comparison

Question 8

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 symptoms

Question 9

A nurse notes a discrepancy between a patient's statement, "I never go outside," and the observation that the patient appears suntanned. What is the most appropriate next step?

Accepted Answer

Validate the data by asking additional questions or consulting other sources

Question 10

Which assessment technique involves listening to body sounds, such as heart or lung sounds, using a stethoscope?

Accepted Answer

Auscultation

Question 11

A nurse is using Maslow's hierarchy of needs to organize assessment data. This is an example of which activity in the assessment process?

Accepted Answer

Organization of data

Question 12

Which of the following best describes the difference between subjective and objective data?

Accepted Answer

Objective data are observable and measurable, while subjective data are reported by the patient and cannot be directly measured

Question 13

A nurse is performing a focused assessment on a patient who complains of shortness of breath. Which action is most appropriate?

Accepted Answer

Assess the specific problem area and related systems

Question 14

Which of the following is NOT a reason for conducting a nursing assessment?

Accepted Answer

To prescribe medication for the patient

Question 15

A nurse is documenting assessment findings in a patient's health record. Which of the following is most important to remember?

Accepted Answer

Documentation should be clear, systematic, and a permanent part of the health record

Question 16

A nurse is preparing to interview a patient for a nursing history. Which phase involves establishing trust and alleviating anxiety?

Accepted Answer

Introductory phase

Question 17

Which of the following best describes the process of percussion during a physical assessment?

Accepted Answer

Tapping the body surface to produce sounds that indicate underlying tissue density

Question 18

A nurse is assessing a patient in a noisy, crowded emergency room. Which environmental modification would best support accurate data collection?

Accepted Answer

Move the patient to a quiet, private space if possible

Question 19

A nurse is reviewing a patient's laboratory results and consulting with other healthcare team members to clarify findings. This is an example of using which type of data source?

Accepted Answer

Secondary source

Question 20

A nurse is planning to use all senses during the assessment process. Which sense is primarily used during inspection?

Accepted Answer

Sight

Nursing Assessment: Foundations and Processes

Guida di studio - Domande di pratica

Study guide - Flashcard