A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen
3. Reporting results of an on...
Potter & Perry: Chapter 16 Exam
Questions And Answers
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse working
the next scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
5. Conducting an interview of a family caregiver - ANS Answer: 1, 2, 4, 5. Assessment
involves the step of collection of information from a primary source (a patient) and secondary
sources (e.g., family caregiver, family members or friends, health professionals, medical record).
The second step of assessment involves the interpretation and validation of data to determine
whether more data are needed or the database is complete. Reporting results is important for
continuity of care but is not an assessment step for the nurse reporting. The nurse receiving the
report will use the data in the report for assessment information.
Match the assessment activity on the left with the type of assessment on the right.
1. Assessment conducted at beginning
of a nurse's shift
2. Review of a patient's chief complaint
3. Completion of admitting history at
time of patient admission to a hospital
4. Completion of the Long Term Care
Minimum Data Set during an elderly
patient admission to a nursing home
A. Problem focused
B. Comprehensive - ANS Answer: 1. A, 2. A, 3. B, 4. B. Assessments can be either
comprehensive or problem focused. A periodic assessment is a problem-focused approach that
begins with a patient's presenting situation and specific problematic areas. A comprehensive
assessment about a patient includes a detailed assessment of a patient's
physical, psychosocial, cultural, spiritual, and lifestyle needs.
A nurse initiates a brief interview with a patient who has come
to the medical clinic because of self-reported hoarseness, sore
throat, and chest congestion. The nurse observes that the patient
has a slumped posture and is using intercostal muscles to breathe.
, The nurse auscultates the patient's lungs and hears crackles in
the left lower lobe. The patient's respiratory rate is 20 per minute
compared with an average of 16 per minute during previous clinic
visits. The patient tells the nurse, "It is hard for me to get a breath."
Which of the following data sets are examples of subjective data?
(Select all that apply.)
1. Heart rate of 20 per minute and chest congestion
2. Lung sounds revealing crackles and use of intercostal muscles
to breathe
3. Patient statement, "It's hard for me to get a breath"
4. Slumped posture and previous respiratory rate of 16 per minute
5. Patient report of sore throat and hoarseness - ANS Answer: 3 and 5. Subjective data are
your patients' verbal descriptions of their health problems, in this case hoarseness, sore throat,
and the statement, "It is hard for me to get a breath." All other data are objective data.
The nurse asks a patient the following series of questions:
"Describe for me how much you exercise each day." "How do you
tolerate the exercise?" "Is the amount of exercise you get each
day the same, less, or more than what you did a year ago?" This
series of questions would likely occur during which phase of a
patient-centered interview?
1. Orientation
2. Working phase
3. Data interpretation
4. Termination - ANS Answer: 2. The working phase of a relationship involves gathering
accurate, relevant, and complete information about a patient's condition. It usually begins with
open-ended questions.
A young male patient enters the emergency department with
fever and signs of a possible sexually transmitted infection. The
nurse enters the patient's cubicle and begins to enter a history on
the computer screen. Before beginning the nurse introduces him-
self and tells the patient all information will be held confidentially.
The nurse starts data collection by establishing eye contact with
the patient and then looks at the computer prompts to select a
series of questions. As the nurse fills out questions on the com-
puter, the patient asks a question about his treatment. The nurse
states, "Let me get through these questions first." Which action
interferes with the nurse's ability to use connection as a communi-
cation skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse's questions a priority
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