11 Nursing Assessment Practice for NCLEX Questions

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• 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) Purposeful (2) Prioritized (3) Complete (4) Systematic (5) Factual and accurate (6) Recorded in a standard manner

• 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?

• Comprehensive
• Initial
• Time-lapsed
• Quick priority
• Quick priority
• 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.

• "The nursing assessment will allow us to plan and

deliver individualized, holistic nursing care that draws on your strengths."

• "It's hospital policy. I know it must be tiresome, but I

will try to make this quick!"

• "I'm a student nurse and need to develop the skill of

assessing your health status and need for nursing care."

• "We want to make sure that your responses to the

medical exam are consistent and that all our data are accurate."

• "We need to check your health status and see what

kind of nursing care you may need."

• "We need to see if you require a referral to a physician

or other health care professional.

• "The nursing assessment will allow us to plan and deliver individualized, holistic

nursing care that draws on your strengths."

• "We need to check your health status and see what kind of nursing care you

may need."

• "We need to see if you require a referral to a physician or other health care

professional.

• 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?

• Correct the initial assessment form.
• Redo the initial assessment and document current

findings.

• Conduct and document an emergency assessment.
• Perform and document a focused assessment of skin

integrity.

• Perform and document a focused assessment of skin integrity.
• 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?

• "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!"

• "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."

• "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."

• "Don't worry about learning all of the questions to ask.

Every agency has its own assessment form you must use."

• "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."

• The nurse collects objective and subjective data when

conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply.

• A patient tells the nurse that she is feeling nauseous.
• A patient's ankles are swollen.
• A patient tells the nurse that she is nervous about her

test results.

• A patient complains of having a rash on her arm that is

itchy.

• A patient rates his pain as a 7 on a scale of 1 to 10.
• A patient vomits after eating supper.
• A patient tells the nurse that she is feeling nauseous.
• A patient tells the nurse that she is nervous about her test results.
• A patient complains of having a rash on her arm that is itchy.
• A patient rates his pain as a 7 on a scale of 1 to 10.

• When a nurse enters the patient's room to begin a

nursing history, the patient's wife is there. What should the nurse do?

• Introduce oneself and thank the wife for being present.
• Introduce oneself and ask the wife if she wants to

remain.

• Introduce oneself and ask the wife to leave.
• Introduce oneself and ask the patient if he would like

the wife to stay.

• Introduce oneself and ask the patient if he would like the wife to stay.
• 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 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?

• Maslow's human needs
• Gordon's functional health patterns
• Human response patterns
• Body system model
• Gordon's functional health patterns
• 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?

• Inform the charge nurse.
• Inform the surgeon.
• Validate the finding.
• Document the finding.
• Validate the finding.