Potter & Perry: Chapter 16 Exam Questions And Answers 100% Pass
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Potter & Perry
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Potter & Perry
Potter & Perry: Chapter 16 Exam Questions
And Answers 100% Pass
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 abdom...
Potter & Perry: Chapter 16 Exam Questions
And Answers 100% Pass
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 - answer✔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 - answer✔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
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