CHAPTER 12 ASSESSING 61
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:7.During the nursing examination, Mrs. Jones
becomes very tired, but there are still questions
the nurse practitioner would like to address in
order to have data for planning care. Which of
the following actions would be most appropri-
ate in this situation?
a.Ask Mrs. Jones to wake up and try to
answer your questions.
b.Ask Mrs. Jones’s husband to come in and
answer your questions.
c.Wait until the next day to obtain the
answers to your questions.
d.Ask Mrs. Jones if she objects to your
interviewing her husband to obtain the
needed data.
8.Mrs. Anderson, age 50, is admitted to your
unit with the diagnosis of scleroderma. You
are unfamiliar with this condition. Which of
the following would be your best source of
information?
a.Consult with the patient.
b.Consult with the patient’s doctor.
c.Read the patient’s chart.
d.Consult nursing and medical literature.ALTERNATE-FORMAT QUESTIONS
Multiple Response Questions
Circle the letters that correspond to the best
answers for each question.
1.Which of the following nursing actions would
occur during the preparatory phase of the
nursing interview? (Select all that apply.)
a.The nurse ensures that the interview envi-
ronment is private and relaxing.
b.The nurse initiates the interview by stating
his or her name and status.
c.The nurse assesses the patient’s comfort
and ability to participate in the interview.
d.The nurse arranges the seating in the inter-
view room to facilitate an easy exchange of
information.
e.The nurse prepares to meet the patient by
reading current and past records and reports.
f.The nurse recapitulates the interview, high-
lighting key points.
2.Which of the following statements accurately
describe the unique focus of nursing
assessment? (Select all that apply.)a.Nursing assessments duplicate medical
assessments.
b.Nursing assessments target data pointing to
pathologic conditions.
c.Nursing assessments focus on the patient’s
responses to health problems.
d.The findings from a nursing assessment
may contribute to the identification of a
medical diagnosis.
e.The focus of nursing assessment is on
actual, not potential, health problems.
f.An initial assessment establishes a complete
database for problem solving and care
planning.
3.Which of the following statements reflect the
focus of Gordon’s functional health patterns
model for organizing or clustering data? (Select
all that apply.)
a.Data are clustered or organized according
to a hierarchy of basic human needs.
b.Data are collected regarding the health
perception/health management of the
patient.
c.The perception of the major roles and
responsibilities in the patient’s life is
explored.
d.The major body systems are assessed and
data are collected.
e.Data related to human response patterns
are collected and organized.
f.Elimination, activity, sleep, and sexuality
are components of the assessment and data
collection.
4.Which of the following patient data would
be considered subjective data? (Select all that
apply.)
a.A nurse observes a patient wringing her
hands before signing a consent for surgery.
b.A nurse observes redness and swelling at an
IV site.
c.A patient describes his pain as an 8 on the
pain assessment scale.
d.A patient feels nauseated after eating his
breakfast.
e.A patient’s blood pressure is elevated
following physical activity.
f.A patient complains of being cold and
requests an extra blanket.LWBK696-C12_p60-65.qxd 9/2/10 9:25 AM Page 61 Aptara Inc