NUR 3212 Final Exam Review Questions
And Answers 100% Guaranteed Success.
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 - correct 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
Is the following assessment problem focused or comprehensive?
Assessment conducted at the beginning of a nurse's shift - correct answer. Problem
Focused
Is the following assessment problem focused or comprehensive?
Review of a patient's chief complaint - correct answer. Problem Focused
Is the following assessment problem focused or comprehensive?
Completion of admitting history at time of patient admission to a hospital - correct
answer. Comprehensive
Is the following assessment problem focused or comprehensive?
,Completion of the Long Term Care Minimum Data Set during an elderly patient
admission to a nursing home - correct answer. Comprehensive
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 - correct 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 - correct 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
himself 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
computer, 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 communication skill.
1. Introducing self to patient
2. Using the computer as a prompt for questions
3. Making the nurse's questions a priority
4. Assuring the patient all information is confidential - correct answer. 3. Introducing
self is a form of courtesy, as is informing the patient of the confidentiality of patient
information. Using the computer as only a prompt and not solely focusing on the
,computer is appropriate. However, making your assessment questions more of a priority
than those of the patient interferes with and prevents good connection.
A nurse observes a patient walking down the hall with a shuffling gait. When the patient
returns to bed, the nurse checks the strength in both of the patient's legs. The nurse
applies the information gained to suspect that the patient has a mobility problem. This
conclusion is an example of:
1. Reflection.
2. Clinical inference.
3. Cue.
4. Validation. - correct answer. 2. You begin to cluster cues that seem to relate
together, make inferences, and identify emerging patterns. Clinical inference is part of
the clinical decision-making process and precedes any judgment or decision about what
are a patient's problems. It is the interpretation of the cues
Place the following steps of the assessment process in the correct order.
1. Compare data with another source to determine data accuracy.
2. As a pattern forms, probe and frame further questions.
3. Interview a patient, observe behavior, and gather physical assessment findings.
4. Cluster cues that relate together, make inferences, and identify emerging patterns.
5. Differentiate important data from the total data you collect. - correct answer. 3, 5,
4, 2, 1. The assessment process begins with thorough and appropriate data collection,
gained through patient interview, observation, and physical examination. Once all data
are collected, you then differentiate important data from the total data you collect;
emerging signs of a problem are important to focus on compared with normal findings
for a body function. Cluster the cues that relate together and begin to identify a pattern
for a problem area. Once a pattern forms, probe further with the interview or
observations. Finally, during validation compare data with other sources to determine
accuracy.
In preparing to collect a nursing history for a patient admitted for elective surgery, which
of the following data are part of the review of present illness in the nursing health
history?
1. Current medications
2. Patient expectations of planned surgery
3. Review of patient's family support system
4. History of allergies
5. Patient's explanation for what might be the cause of symptoms that require surgery -
correct answer. 5. The nursing health history has several components. A review of
present illness or health concerns includes a question asking the patient what provokes
or precipitates symptoms. Gathering a patient's explanation for what might be the cause
of symptoms is the appropriate approach. Past health history is the component that
includes a medication history and history of allergies. Patient expectations of treatment
is another component. A review of family interaction and support is part of the family
history component.
, A nurse is conducting a patient-centered interview. Place the statements from the
interview in the correct order, beginning with the first statement a nurse would ask.
1. "You say you've lost weight. Tell me how much weight you've lost in the past month."
2. "My name is Terry. I'll be the nurse taking care of you today."
3. "I have no further questions. Is there anything else you wish to ask me?"
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite
has been poor—correct?" - correct answer. 2, 4, 1, 5, 3. A patient-centered interview
begins with a nurse's self-introduction. It then proceeds to an open ended question that
allows a patient to tell his or her story about any health concerns. Listening and
acknowledging a patient's concerns then allows you to probe for further information.
Summarization lets the patient confirm accuracy of your interpretation of data. Finally,
you end an interview by telling the patient you are finished, and letting him or her ask
any final questions.
Which of the following approaches are recommended when gathering assessment data
from an 82-year-old male patient entering a primary care clinic for the first time? (Select
all that apply.)
1. Recognize normal changes associated with aging.
2. Avoid direct eye contact.
3. Lean forward and smile as you pose questions.
4. Allow for pauses as patient tells his story.
5. Use the list of questions from the clinic assessment form to complete all data. -
correct answer. 1, 3, 4. When assessing older adults, listen patiently and allow for
pauses and time for patients to tell their story. Do not just focus on the list of questions
on an assessment form. The questions might not be relevant to the patient's problems.
Recognize normal changes associated with aging. Older-adult symptoms are often
muted or less obvious, vague, or nonspecific compared with younger adults. Maintain a
patient-directed gaze. Eye contact shows interest in what the patient is saying
A nursing student is working with a faculty member to identify a nursing diagnosis for an
assigned patient. The student has assessed that the patient is undergoing radiation
treatment, has liquid stool, and the skin is clean and intact. The student selects the
nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student
has made a diagnostic error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment - correct answer. 2. A standard for the nursing
diagnosis of Impaired Skin Integrity is the actual alteration in skin integrity, not the skin
being clean and intact. The student needs to review data and compare more closely
with the standard assessment findings for a correct diagnosis.
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman
is married and lives in a condo with her husband. She reports having frequent voiding
and pain when she passes urine. The nurse asks whether she has to go to the
