NURS 213 Exam 1: Questions & Complete Answers
Read the following scenario and identify the adjective used to describe the
characteristics of patient data that are numbered below. Put your answers in
the correct order.
The nurse is conducting an initial assessment of a 79-year-old female patient
admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses
clinical reasoning to identify the need to perform a comprehensive
assessment and gather the appropriate patient data. (2) First the nurse asks
the patient about the most important details leading up to her diagnosis. Then
the nurse (3) collects as much information as possible to understand the
patient's health problems; (4) collects the patient data in an organized
manner; (5) verifies that the data obtained is pertinent to the patient care
plan; and (6) records the data according to facility's policy. Right Ans - (1)
Purposeful: The nurse identifies the purpose of the nursing assessment
(comprehensive) and gathers the appropriate data.
(2) Prioritized: The nurse gets the most important information first.
(3) Complete: The nurse gathers as much data as possible to understand the
patient health problem and develop a care plan.
(4) Systematic: The nurse gathers the information in an organized manner.
(5) Accurate and relevant: The nurse verifies that the information is reliable.
(6) Recorded in a standard format: The nurse records the data according to
the facility's policy so that all caregivers can easily access what is learned.
The nurse practitioner is performing a short assessment of a newborn who is
displaying signs of jaundice. The nurse observes the infant's skin color and
orders a test for bilirubin levels to report to the primary care provider. What
type of assessment has this nurse performed?
a. Comprehensive
b. Initial
c. Time-lapsed
d. Quick priority Right Ans - d. Quick priority
The nurse is admitting a 35-year-old pregnant woman to the hospital for
treatment of preeclampsia. The patient asks the nurse: "Why are you doing a
history and physical exam when the doctor just did one?" Which statements
,best explain the primary reasons a nursing assessment is performed? Select
all that apply.
a. "The nursing assessment will allow us to plan and deliver individualized,
holistic nursing care that draws on your strengths."
b. "It's hospital policy. I know it must be tiresome, but I will try to make this
quick!"
c. "I'm a student nurse and need to develop the skill of assessing your health
status and need for nursing care."
d. "We want to make sure that your responses to the medical exam are
consistent and that all our data are accurate."
e. "We need to check your health status and see what kind of nursing care you
may need."
f. "We need to see if you require a referral to a physician or other health c
Right Ans - a. "The nursing assessment will allow us to plan and deliver
individualized, holistic nursing care that draws on your strengths."
e. "We need to check your health status and see what kind of nursing care you
may need."
f. "We need to see if you require a referral to a physician or other health care
professional."
A nurse notes that a shift report states that a patient has no special skin care
needs. The nurse is surprised to observe reddened areas over bony
prominences during the patient bath. What nursing action is appropriate?
a. Correct the initial assessment form.
b. Redo the initial assessment and document current findings.
c. Conduct and document an emergency assessment.
d. Perform and document a focused assessment of skin integrity. Right Ans
- d. Perform and document a focused assessment of skin integrity.
A student nurse attempts to perform a nursing history for the first time. The
student nurse asks the instructor how anyone ever learns all the questions the
nurse must ask to get good baseline data. What would be the instructor's best
reply?
a. "There's a lot to learn at first, but once it becomes part of you, you just keep
asking the same questions over and over in each situation until you can do it
in your sleep!"
b. "You make the basic questions a part of you and then learn to modify them
for each unique situation, asking yourself how much you need to know to plan
good care."
, c. "No one ever really learns how to do this well because each history is
different! I often feel like I'm starting afresh with each new patient."
d. "Don't worry about learning all of the questions to ask. Every facility has its
own assessment form you must use." Right Ans - b. "You make the basic
questions a part of you and then learn to modify them for each unique
situation, asking yourself how much you need to know to plan good care."
The nurse collects objective and subjective data when conducting patient
assessments. Which patient situations are examples of subjective data? Select
all that apply.
a. A patient tells the nurse that she is feeling nauseous.
b. A patient's ankles are swollen.
c. A patient tells the nurse that she is nervous about her test results.
d. A patient complains that the skin on her arms is tingling.
e. A patient rates his pain as a 7 on a scale of 1 to 10.
f. A patient vomits after eating supper. Right Ans - a. A patient tells the
nurse that she is feeling nauseous.
c. A patient tells the nurse that she is nervous about her test results.
d. A patient complains that the skin on her arms is tingling.
e. A patient rates his pain as a 7 on a scale of 1 to 10.
When a nurse enters the patient's room to begin a nursing history, the
patient's wife is there. After introducing herself to the patient and his wife,
what should the nurse do?
a. Thank the wife for being present.
b. Ask the wife if she wants to remain.
c. Ask the wife to leave.
d. Ask the patient if he would like the wife to stay Right Ans - d. Ask the
patient if he would like the wife to stay
A nurse is performing an initial comprehensive assessment of a patient
admitted to a long-term care facility from home. The nurse begins the
assessment by asking the patient, "How would you describe your health status
and well-being?" The nurse also asks the patient, "What do you do to keep
yourself healthy?" Which model for organizing data is this nurse following?
a. Maslow's human needs
b. Gordon's functional health patterns
c. Human response patterns
d. Body system model Right Ans - b. Gordon's functional health patterns.
Read the following scenario and identify the adjective used to describe the
characteristics of patient data that are numbered below. Put your answers in
the correct order.
The nurse is conducting an initial assessment of a 79-year-old female patient
admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses
clinical reasoning to identify the need to perform a comprehensive
assessment and gather the appropriate patient data. (2) First the nurse asks
the patient about the most important details leading up to her diagnosis. Then
the nurse (3) collects as much information as possible to understand the
patient's health problems; (4) collects the patient data in an organized
manner; (5) verifies that the data obtained is pertinent to the patient care
plan; and (6) records the data according to facility's policy. Right Ans - (1)
Purposeful: The nurse identifies the purpose of the nursing assessment
(comprehensive) and gathers the appropriate data.
(2) Prioritized: The nurse gets the most important information first.
(3) Complete: The nurse gathers as much data as possible to understand the
patient health problem and develop a care plan.
(4) Systematic: The nurse gathers the information in an organized manner.
(5) Accurate and relevant: The nurse verifies that the information is reliable.
(6) Recorded in a standard format: The nurse records the data according to
the facility's policy so that all caregivers can easily access what is learned.
The nurse practitioner is performing a short assessment of a newborn who is
displaying signs of jaundice. The nurse observes the infant's skin color and
orders a test for bilirubin levels to report to the primary care provider. What
type of assessment has this nurse performed?
a. Comprehensive
b. Initial
c. Time-lapsed
d. Quick priority Right Ans - d. Quick priority
The nurse is admitting a 35-year-old pregnant woman to the hospital for
treatment of preeclampsia. The patient asks the nurse: "Why are you doing a
history and physical exam when the doctor just did one?" Which statements
,best explain the primary reasons a nursing assessment is performed? Select
all that apply.
a. "The nursing assessment will allow us to plan and deliver individualized,
holistic nursing care that draws on your strengths."
b. "It's hospital policy. I know it must be tiresome, but I will try to make this
quick!"
c. "I'm a student nurse and need to develop the skill of assessing your health
status and need for nursing care."
d. "We want to make sure that your responses to the medical exam are
consistent and that all our data are accurate."
e. "We need to check your health status and see what kind of nursing care you
may need."
f. "We need to see if you require a referral to a physician or other health c
Right Ans - a. "The nursing assessment will allow us to plan and deliver
individualized, holistic nursing care that draws on your strengths."
e. "We need to check your health status and see what kind of nursing care you
may need."
f. "We need to see if you require a referral to a physician or other health care
professional."
A nurse notes that a shift report states that a patient has no special skin care
needs. The nurse is surprised to observe reddened areas over bony
prominences during the patient bath. What nursing action is appropriate?
a. Correct the initial assessment form.
b. Redo the initial assessment and document current findings.
c. Conduct and document an emergency assessment.
d. Perform and document a focused assessment of skin integrity. Right Ans
- d. Perform and document a focused assessment of skin integrity.
A student nurse attempts to perform a nursing history for the first time. The
student nurse asks the instructor how anyone ever learns all the questions the
nurse must ask to get good baseline data. What would be the instructor's best
reply?
a. "There's a lot to learn at first, but once it becomes part of you, you just keep
asking the same questions over and over in each situation until you can do it
in your sleep!"
b. "You make the basic questions a part of you and then learn to modify them
for each unique situation, asking yourself how much you need to know to plan
good care."
, c. "No one ever really learns how to do this well because each history is
different! I often feel like I'm starting afresh with each new patient."
d. "Don't worry about learning all of the questions to ask. Every facility has its
own assessment form you must use." Right Ans - b. "You make the basic
questions a part of you and then learn to modify them for each unique
situation, asking yourself how much you need to know to plan good care."
The nurse collects objective and subjective data when conducting patient
assessments. Which patient situations are examples of subjective data? Select
all that apply.
a. A patient tells the nurse that she is feeling nauseous.
b. A patient's ankles are swollen.
c. A patient tells the nurse that she is nervous about her test results.
d. A patient complains that the skin on her arms is tingling.
e. A patient rates his pain as a 7 on a scale of 1 to 10.
f. A patient vomits after eating supper. Right Ans - a. A patient tells the
nurse that she is feeling nauseous.
c. A patient tells the nurse that she is nervous about her test results.
d. A patient complains that the skin on her arms is tingling.
e. A patient rates his pain as a 7 on a scale of 1 to 10.
When a nurse enters the patient's room to begin a nursing history, the
patient's wife is there. After introducing herself to the patient and his wife,
what should the nurse do?
a. Thank the wife for being present.
b. Ask the wife if she wants to remain.
c. Ask the wife to leave.
d. Ask the patient if he would like the wife to stay Right Ans - d. Ask the
patient if he would like the wife to stay
A nurse is performing an initial comprehensive assessment of a patient
admitted to a long-term care facility from home. The nurse begins the
assessment by asking the patient, "How would you describe your health status
and well-being?" The nurse also asks the patient, "What do you do to keep
yourself healthy?" Which model for organizing data is this nurse following?
a. Maslow's human needs
b. Gordon's functional health patterns
c. Human response patterns
d. Body system model Right Ans - b. Gordon's functional health patterns.
