Nokea
What type of assessment is performed continuously throughout nurse-patient contact?
- A. Complete
- B. Body systems
- C. Focused
- D. Subjective
Correct Answer: C
Rationale: Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.
You may also like to solve these questions
During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient is coughing.
- B. The patient has cyanosis of the lips.
- C. The patient experiences tachypnea.
- D. The patient complains of generalized discomfort.
Correct Answer: D
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data.
What is an example of an appropriate patient problem?
- A. Constipation
- B. Patient complains of constipation
- C. Need for laxatives
- D. Patient has a duodenal ulcer
Correct Answer: A
Rationale: Constipation is an example of a patient problem, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis.
Which is an example of a medical diagnosis?
- A. Constipation
- B. Diabetes mellitus
- C. Impaired skin integrity
- D. Altered nutrition: less than body requirements
Correct Answer: B
Rationale: Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of patient problems.
A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
- A. Risk for impaired skin integrity related to physical immobilization
- B. Physical immobilization secondary to risk for impaired skin integrity
- C. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
- D. Physical immobilization secondary to decreased cognitive ability
Correct Answer: A
Rationale: Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.
All of the following patients have been admitted to the acute care setting. On admission which patient should receive a focused assessment?
- A. 53-year-old admitted with a perforated ulcer
- B. 5-year-old admitted for the implant of grommets in the middle ear
- C. 76-year-old admitted for a knee replacement
- D. 40-year-old admitted for possible bowel obstruction
Correct Answer: A
Rationale: A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.