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WorksheetsNursing Assessment and Patient Interviewing
Total questions: 70
Worksheet time: 37mins
A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.)
The review of patient data in the medical record
Confirming a patient’s self-report of abdominal pain by inspecting the abdomen
Reporting results of an ongoing assessment to a nurse working the next scheduled shift
Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration
Conducting an interview of a family caregiver
Match the assessment activity on the top with the type of assessment on the bottom
1. Assessment conducted at beginning of a nurse’s shift
2. Review of a patient’s chief complaint
3. Completion of admitting history at time of patient admission to a hospital
4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home
A. Problem focused
B. Comprehensive
(a)
A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient’s lungs and hears crackles in the left lower lobe. The patient’s respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, “It is hard for me to get a breath.” Which of the following data sets are examples of subjective data? (Select all that apply.)
Heart rate of 20 per minute and chest congestion
Lung sounds revealing crackles and use of intercostal muscles to breathe
Patient statement, “It’s hard for me to get a breath”
Slumped posture and previous respiratory rate of 16 per minute
Patient report of sore throat and hoarseness
The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?
Orientation
Working phase
Data interpretation
Termination
Place the following steps of the assessment process in the correct order.
1. Compare data with another source to determine data accuracy.
2. As a pattern forms, probe and frame further questions.
3. Interview a patient, observe behavior, and gather physical assessment findings.
4. Cluster cues that relate together, make inferences, and identify emerging patterns.
5. Differentiate important data from the total data you collect.
(a)
Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.)
Recognize normal changes associated with aging
Avoid direct eye contact
Lean forward and smile as you pose questions
Allow for pauses as patient tells his story
Use the list of questions from the clinic assessment form to complete all data
Fill in the blank: First-level priorities in nursing assessment refer to __________ issues (e.g., airway, breathing, circulation).
Life-threatening
Psychosocial
Chronic
Nutritional
Spirituality is best defined as:
An organized system of beliefs, practices, and rituals shared by a group
A broad concept focusing on a person's search for meaning, purpose, and connection with a higher power or the universe
A dietary practice
A family role
Religion is:
A broad concept focusing on a person's search for meaning
An organized system of beliefs, practices, and rituals shared by a group
A communication pattern
A type of nonverbal behavior
Fill in the blank: Cultural Assessment is a systematic examination of the cultural values, beliefs, and practices of an individual or group to provide __________ care.
culturally competent
universal
technical
financial
Open-ended questions require more than a 'yes' or 'no' answer to encourage patients to share detailed information.
True
False
Fill in the blank: Nonverbal behaviors such as posture, gestures, and eye contact significantly impact __________.
communication
nutrition
transportation
mathematics
Interviewing the older adult requires considerations such as:
Pacing the interview
Allowing for more time
Being aware of potential sensory deficits or cognitive changes
All of the above
What is the purpose of collecting a health history?
To collect subjective data about a person's health state to form a comprehensive picture of their past and present health.
To diagnose diseases without any further tests.
To prescribe medication immediately.
To perform surgical procedures.
Subjective data is what the person says about themselves, while objective data is what you observe through measurement, inspection, palpation, percussion, and auscultation.
True
False
Which of the following is an example of objective data?
I have a headache.
Blood pressure reading
I feel tired.
My stomach hurts.
Functional assessment measures a person's self-care ability in areas of general physical health or absence of illness.
True
False
When a patient reports an allergy, what is crucial to ask?
What kind of reaction occurs (e.g., rash, difficulty breathing).
How long the allergy has existed.
If the allergy is common in their family.
Whether they have traveled recently.
You are legally required to report suspected cases of abuse and neglect (child, elder, or vulnerable adult) and domestic violence in some jurisdictions.
True
False
What is the diaphragm of a stethoscope used for?
Used for high-pitched sounds like breath, bowel, and normal heart sounds.
Used for low-pitched sounds like heart murmurs.
Used to measure blood pressure directly.
Used to amplify electrical signals from the heart.
The bell of a stethoscope is used for which type of sounds?
High-pitched sounds
Low-pitched sounds
All sounds
No sounds
A Doppler device is used to detect peripheral pulses or blood pressure when they are difficult to palpate or auscultate.
True
False
The general survey is a study of the whole person, covering their general health state and any obvious physical characteristics.
True
False
Radial pulse is assessed for which of the following?
Rate (beats per minute)
Rhythm (regular or irregular)
Force (strength)
Temperature
What are Korotkoff sounds?
The sounds heard during blood pressure measurement. A two-step BP procedure helps avoid an auscultatory gap.
A type of heart murmur heard during systole.
The sounds produced by the lungs during inspiration.
A type of nerve impulse recorded in EEG.
Factors affecting blood pressure can include age, stress, race, medications, and the cuff size used for measurement.
True
False
What are the expected breath sounds you should know the location for?
Bronchial, bronchovesicular, and vesicular sounds.
Tracheal, alveolar, and pleural sounds.
Laryngeal, diaphragmatic, and pericardial sounds.
Cardiac, gastric, and intestinal sounds.
Which of the following are considered adventitious breath sounds?
Crackles
Wheezes
Rhonchi
All of the above
How is chest expansion assessed?
By placing hands on the posterior chest wall and observing for symmetric movement as the patient breathes.
By measuring the circumference of the chest with a tape measure during inspiration only.
By asking the patient to cough and observing for chest movement.
By palpating the anterior chest for tenderness only.
Light palpation is used to assess for which of the following?
Surface characteristics and tenderness
Underlying organs and masses
Fluid in the abdomen
Cognitive impairment
Deep palpation is used to assess underlying organs and masses.
True
False
What is the purpose of pain assessment in the abdomen?
To assess the location, quality, and severity of abdominal pain.
To determine the patient's blood pressure.
To evaluate lung function.
To check for vision problems.
What does the ABCDEF skin assessment screen for?
Suspicious lesions (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Elevation/Evolution, Funny looking)
Nutritional deficiencies (Anemia, B12, Calcium, Vitamin D, Electrolytes, Folate)
Common skin infections (Bacterial, Fungal, Candida, Dermatophytes, Eczema, Folliculitis)
Allergic reactions (Angioedema, Blisters, Contact dermatitis, Erythema, Flushing, Hives)
How should you perform a lymph node assessment?
Use a gentle, circular motion with the finger pads to palpate lymph nodes, comparing sides for symmetry.
Use firm, deep pressure with your knuckles to palpate lymph nodes quickly.
Tap the lymph nodes lightly with your fingertips to check for tenderness.
Only inspect the lymph nodes visually without touching them.
What should you assess during a pupil assessment?
Size, shape, and reaction to light and accommodation.
Color, temperature, and moisture.
Movement, strength, and coordination.
Hearing, speech, and balance.
The extraocular muscle (EOM) assessment is used to assess for parallel tracking of the eyes using which test?
The diagnostic positions test (six cardinal positions of gaze)
The Snellen chart test
The cover-uncover test
The pupillary light reflex test
What is the Snellen chart used to measure?
Visual acuity
Blood pressure
Hearing ability
Lung capacity
Which age-related change is described as a decreased ability to accommodate for near vision?
Presbyopia
Cataract
Glaucoma
Macular degeneration
A clouding of the lens is known as:
Cataracts
Glaucoma
Conjunctivitis
Astigmatism
For an adult, how should you straighten the S-shaped curve of the ear canal during an ear canal assessment?
Pull the pinna up and back.
Pull the pinna down and back.
Push the tragus inward.
Pull the earlobe up and forward.
What is presbycusis?
Age-related hearing loss, particularly of high-frequency sounds.
A condition causing loss of vision in old age.
A degenerative joint disease common in elderly.
A type of memory loss associated with aging.
What is a common age-related change in the ear involving earwax?
Increased cerumen (earwax) buildup.
Decreased cerumen (earwax) production.
Complete absence of cerumen (earwax).
Change in cerumen (earwax) color to blue.
How do you assess nasal patency?
By having the person sniff inward through one nostril at a time.
By asking the person to open their mouth wide.
By checking the color of the lips.
By tapping lightly on the bridge of the nose.
Where is the Point of Maximal Impulse (PMI) typically located?
At the 5th intercostal space, midclavicular line.
At the 2nd intercostal space, right sternal border.
At the 4th intercostal space, left sternal border.
At the 6th intercostal space, midaxillary line.
What is the difference between a thrill and a murmur?
A thrill is a palpable vibration; a murmur is an auscultated blowing/swooshing sound.
A thrill is an audible sound; a murmur is a visible pulsation.
A thrill is a type of heart valve; a murmur is a type of blood vessel.
A thrill is a type of arrhythmia; a murmur is a type of chest pain.
Which tool is used to assess bruits?
The bell of the stethoscope.
A reflex hammer.
A tuning fork.
An otoscope.
What does Jugular Venous Distention (JVD) indicate?
Right-sided heart failure.
Left-sided heart failure.
Pulmonary embolism.
Hypertension.
How is pitting edema assessed?
On a 4-point scale based on the depth of the pit and how long it remains.
By measuring the circumference of the limb only.
By checking for color changes in the skin.
By asking the patient about their pain level.
Which of the following is a characteristic of arterial insufficiency?
Brownish skin discoloration and edema
Pale, cool skin and intermittent claudication
Shallow ulcers with irregular borders
None of the above
Age-related changes in the hair and nails include (select all that apply)
oily scalp.
scaly scalp.
thinner nails.
thicker, brittle nails.
longitudinal nail ridging.
During the physical examination of a patient’s skin, the nurse would
use a flashlight in a poorly lit room.
note cool, moist skin as a normal finding.
pinch up a fold of skin to assess for turgor.
perform a lesion-specific examination first and then a general inspection.
What are the three components of Health Assessment
Nutrition, Exercise, Medication
Interview, History, & Subjective assessment; Objective/Physical Assessment; Health and Promotion
Diagnosis, Treatment, Follow-up
Prevention, Intervention, Evaluation
What are the two types of assessments in the nursing process?
Subjective and Objective
Preliminary and Secondary
Internal and External
Quantitative and Qualitative
What is the purpose of the diagnosis step in the nursing process?
To actively carry out the plan
To identify the nursing problem
To evaluate the outcomes
To set the goals
What are the components of an Emergency/Urgent assessment according to the ABCDE principle?
Airway, Breathing, Circulation, Delivery, Evaluation
Airway, Breathing, Circulation, Disability, Exposure
Assessment, Breathing, Circulation, Disability, Examination
Airway, Balance, Circulation, Disability, Exposure
What does a Comprehensive Assessment include?
Health History and Mental Assessment
Health History and Physical Assessment
Health History and Psychological Assessment
Health History and Performance Assessment
What is the focus of a Focused Assessment?
On the patient's medical history
On the patient's family history
On the complaint/problem presented by the patient
On the patient's previous treatments
What is the purpose of the Intro part of an interview according to the learning material?
To end the interview
To collect data
To establish trust and develop a rapport
To summarize the information
Which part of the interview is described as the longest?
Intro
Data Collection
Closing/Summary
Recap
What is emphasized during the Data Collection phase of an interview?
Greeting and body language
Active listening and collection of data for assessment
Summarizing the information
Establishing trust
What does the Closing/Summary part of an interview involve?
Greeting the interviewee
The longest part of the interview
Developing a rapport
Summarizing information and appreciating cooperation
What information is typically included in the Demographic Data section of a Health History?
Medical or surgical history
Self care, mobility, & home environment
Name, address, insurance, race, emergency contact, etc.
Food, medications, or environmental allergies
What does the Past Medical History section of a Health History document?
Food, medications, or environmental allergies
Self care, mobility, & home environment
Medical or surgical history
Name, address, insurance, race, emergency contact, etc.
What is included in the Family History section of a Health History?
A narrative description of events leading to illness/problem
Patterns of mental or physical medical problems
A brief description of symptoms or problem
Questions about ALL body systems
What type of information is gathered in the Functional Health History section?
Medical or surgical history
Self care, mobility, & home environment
Food, medications, or environmental allergies
Name, address, insurance, race, emergency contact, etc.
What does the Review of Systems section in a Health History involve?
A narrative description of events leading to illness/problem
Patterns of mental or physical medical problems
Questions about ALL body systems
Self care, mobility, & home environment
What type of information is considered subjective in an assessment?
Information that can be measured
Narrative information reported by the client
Part of a physical examination
Answers that do not prompt further questions
Objective information in an assessment is characterized by being:
Based on the provider's personal opinion
Factual and measurable
A narrative report from the client
Likely to prompt more questions
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply)
Respiratory rate is 22/minute with even, unlabored respirations
The client's partner state, "They said they hurt after walking about 10 minutes."
The client's pain rating is 3 on a scale of 0 to 10.
The client's skin is pink, warm, and dry.
The assistive personnel reports that the client walked with a limp.
What is a finding you might hear by percussing during a physical examination?
Swelling
Movable
Dullness
Texture
