As the nurse initiates the general survey examination, you know data collection for this
portion of the review of systems (ROS) begins:
a)As soon as the nurse begins to talk with the patient.
b)As soon as the nurse begins to obtain the vital signs of the patient.
c)As soon as the nurse touches the patient.
d)As soon as the nurse sees the patient. - answerd) As soon as the nurse sees the
patient
Which of the following patient situations would you interpret as requiring an emergency
assessment?
a) A patient in need of an employment physical who is due to start work this week.
b) A patient who is unresponsive to voice commands and is suspected of a drug
overdose.
c) A patient with sunburn who enters the the clinic in a wheelchair.
d) A patient who missed her last period and is concerned that she may be pregnant. -
answerb) A patient who is unresponsive to voice commands and suspected of a drug
overdose.
You are the nurse caring for Mrs. Jones, a 65 y/o female admitted for hip surgery. At
0200 you administer pain medication to Mrs. Jones. At 0300, you enter her room to ask
her about her pain level. What step of the nursing process are you performing?
a) Diagnosis
b) Evaluation
c) Intervention
d) Assessment - answerb) Evaluation
,Your nursing faculty instructor instructs you to obtain objective data from your laboratory
partner. Which of the following indicates the best way from which you can obtain
objective data?
a) Inspection
b) Asking open-ended questions
c) Completing the medical history section of their health history form
d) Utilizing good Interviewing techniques - answera) Inspection
The nurse just interviewed her patient to obtain information related to complaints of a
skin problem. Which of the following documentation in the nurses notes represents
subjective data?
a) Skin is warm, dry, and intact.
b) No lesions or rashes are noted.
c) Patient states she is not having any itching, redness, or rashes.
d) Large lesion noted lateral aspect R anterior arm, intact, no bleeding. - answerc)
Patient states she is not having an itching, redness, or rashes
Which of the following is an example of a symptom?
a) Potassium level of 4.3 mEq/l
b) Increased respirations
c) Chest pain
d) Sweating - answerc) Chest pain
During an assessment in the Emergency Department (ED) the nurse utilizes the CAGE
assessment tool. The patient answers YES to two of the questions. What does this
indicate?
a)The patient may be a victim of domestic violence and should be assessed further for
abuse
b) The patient may have a problem with alcohol and should be assessed further for
alcohol abuse
c) The patient has no identifiable issues
, d) The patient may be depressed and should be assessed further for suicidal ideations
- answerb) The patient may have a problem with alcohol and should be assessed
further for alcohol abuse.
Which type of assessment and database is most appropriate for a person being
admitted to a new long-term care nursing facility?
a) Complete
b) Emergency
c) Episodic
d) Follow-up - answera) Complete
The nurse is caring for an elderly patient and he suspects elder abuse. Which of the
following actions is most appropriate?
a) Notify the authorities of the suspected abuse
b) Confront the caretakers about the suspicions of abuse
c) Ask the patient if it is ok to call the authorities
d) Collect proof of the abuse before alerting the authorities - answera) Notify the
authorities of the suspected abuse
An example of an open-ended question or statement is:
a) On a scale of 0 - 10 what level is your pain now?
b) You are upset about your level of pain, right?
c) Tell me more about your pain.
d) I can see you are very uncomfortable. - answerc) Tell me more about your pain.
You enter your patient's room to perform their physical assessment examination. To
perform a proper examination you know the first technique you will utilize is:
a) Palpation
b) Percussion
c) Inspection
d) Auscultation - answerc) Inspection
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