NURSING ASSESSMENT POTTER FUNDAMENTALS OF NURSING 9TH MULTIPLE CHOICE UPDATED QUESTIONS AND ANSWERS

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1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database The as... sessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process. 2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? b. Focus on the patient’s presenting situation. A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection. 3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? c. Ask the NAP to record the patient’s vital signs before administering medications. The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action. 4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? c. Respirations 16 Objective data are observations or measurements of a patient’s health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States “doesn’t feel good,” reports a headache, and nausea are all subjective data. Subjective data include the patient’s feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. 5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? c. The patient is apprehensive about discharge. Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed. 6. Which method of data collection will the nurse use to establish a patient’s database? c. Performing a physical examination You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests. [Show More]

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