11: Assessing Chapter Review
1) Read the following scenario and identify the term for
the characteristics of patient data that are numbered
below. Place your answers on the lines provided.
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 asks the patient
about the most important details leading up to her
diagnosis, (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 agency policy.
1.
2.
3.
4.
5.
6.
2) 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
3) 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 care professional.
4) When you receive the shift report, you learn that
your patient has no special skin care needs. You are
surprised during the bath to observe reddened areas
over bony prominences. What 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.
5) 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 agency has its own assessment
form you must use.”
6) The nurse collects objective and subjective data
when conducting patient assessments. Which patient
conditions 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 of having a rash on her arm
that is itchy.
e. A patient rates his pain as a 7 on a scale of 1 to
10.
f. A patient vomits after eating supper.
7) When a nurse enters the patient’s room to begin a
nursing history, the patient’s wife is there. What
should the nurse do?
a. Introduce oneself and thank the wife for being
present.
b. Introduce oneself and ask the wife if she wants
to remain.
c. Introduce oneself and ask the wife to leave.
d. Introduce oneself and ask the patient if he would
like the wife to stay.
8) A nurse is performing an initial comprehensive
assessment of an 84-year-old male patient admitted
to a long-term care facility from home. The nurse
begins the assessment by asking the patient, “How
 11: Assessing Chapter Review
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
9) The nurse is surprised to detect an elevated
temperature (102°F) in a patient scheduled for
surgery. The patient has been afebrile and shows no
other signs of being febrile. What is the first thing
the nurse should do?
a. Inform the charge nurse.
b. Inform the surgeon.
c. Validate the finding.
d. Document the finding.
10) A student nurse tells the instructor that a patient is
fine and has “no complaints.” What would be the
instructor’s best response?
a. “You made an inference that she is fine because
she has no complaints. How did you validate
this?”
b. “She probably just doesn’t trust you enough to
share what she is feeling. I’d work on
developing a trusting relationship.”
c. “Sometimes everyone gets lucky. Why don’t
you try to help another patient?”
d. “Maybe you should reassess the patient. She has
to have a problem—why else would she be
here?”