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A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:
- A. a complete physical examination.
- B. a medical assessment.
- C. an individualized plan of care.
- D. writing nursing orders.
Correct Answer: C
Rationale: The information contained in the database is the basis for an individualized plan of care.
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A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Lateral recumbent
Correct Answer: D
Rationale: The lateral recumbent position aids in detecting heart murmurs.
A health care provider documents that a patient has a sallow complexion. How does the nurse interpret this information?
- A. Yellow color to the skin
- B. Blue color to the skin
- C. Red color to the skin
- D. Gray color to the skin
Correct Answer: A
Rationale: Sallow is an unhealthy, yellow color; usually said of a complexion or skin.
A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?
- A. The patient complains of chest pain.
- B. The patient states "I am having trouble breathing."
- C. The patient complains of coughing up sputum.
- D. The patient expectorates red-tinged sputum.
Correct Answer: D
Rationale: Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data.
The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?
- A. Health history
- B. Review of systems
- C. Family history
- D. Nursing assessment
Correct Answer: D
Rationale: The nursing assessment is the critical step in forming the nursing care plan.
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of chest pain.
- B. Is experiencing dyspnea.
- C. Appears to be anxious.
- D. Expectorates red-tinged sputum.
Correct Answer: A
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data.