Review Introduction to Patient Assessment and Documentation

Patient Assessment and Documentation > Fundamentals

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Introduction to Patient Assessment and Documentation

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Total Questions : 6

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Question 1:

A nurse is assessing a client who has been admitted with chest pain.

Which of the following findings should the nurse report to the provider immediately?

A. The client has a history of hypertension and diabetes. B. The client rates the pain as 8 on a scale of 0 to 10. C. The client has crackles in the lower lobes of both lungs. D. The client has an elevated troponin level in the blood.

Answer and Explanation

Choice A:

This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.

Choice B:

This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.

Choice C:

This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.

Choice D:

Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.

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Question 2:

A nurse is documenting the findings of a head-to-toe assessment on a newly admitted client.

Which of the following information should the nurse include in the documentation?

A. The client's vital signs are within normal limits. B. The client's skin is warm, dry, and intact. C. The client's bowel sounds are present in all four quadrants. D. All of the above.

Answer and Explanation

Choice A:

It is not the only information that should be documented.

Choice B:

It is not the only information that should be documented.

Choice C:

This is a correct statement, but it is not the only information that should be documented.

Choice D:

The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.

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Question 3:

A nurse is performing a physical assessment on a client who has abdominal pain.

Which of the following techniques should the nurse use to assess the abdomen?

A. Inspection, palpation, percussion, auscultation B. Inspection, auscultation, percussion, palpation C. Auscultation, inspection, palpation, percussion D. Palpation, auscultation, inspection, percussion

Answer and Explanation

Choice A:

This order may alter bowel sounds by palpating and percussing before auscultating them.

Choice B:

The correct order of techniques for abdominal assessment is inspection, auscultation, percussion, and palpation. This order prevents altering bowel sounds by manipulating the abdomen before listening to them.

Choice C:

This order may miss visual cues by inspecting after auscultating.

Choice D:

This order may alter bowel sounds and miss visual cues by palpating before auscultating and inspecting.

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Question 4:

A nurse is reviewing the medical record of a client who has been diagnosed with pneumonia.

Which of the following data should the nurse use to evaluate the effectiveness of the treatment plan?

A. The client's temperature is 37.2°C (99°F). B. The client's white blood cell count is 12.5 x 10^9/L. C. The client's oxygen saturation is 95% on room air. D. The client's chest x-ray shows clear lung fields

Answer and Explanation

Choice A:

This is a normal finding, but it does not rule out pneumonia as some clients may have low-grade fever or no fever at all with pneumonia.

Choice B:

This is an elevated finding, as the normal range for white blood cell count is 4.5 to 11 x 10^9/L. An elevated white blood cell count indicates inflammation or infection and does not reflect the effectiveness of treatment.

Choice C:

This is a normal finding, as the normal range for oxygen saturation is 95% to 100%. However, it does not indicate the severity or resolution of pneumonia, as some clients may have normal oxygen saturation despite having pneumonia.

Choice D:

A chest x-ray is a diagnostic test that can confirm the presence or absence of pneumonia by showing areas of consolidation or infiltration in the lung tissue. A clear chest x-ray indicates resolution of pneumonia and effectiveness of treatment.

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Question 5:

A nurse is preparing to perform a neurological assessment on a client who has a head injury.

Which of the following tools should the nurse use to assess the client's level of consciousness?

A. Glasgow Coma Scale (GCS) B. Mini-Mental State Examination (MMSE) C. Confusion Assessment Method (CAM) D. Morse Fall Scale (MFS)

Answer and Explanation

Choice A:

Is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.

Choice B:

This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.

Choice C:

This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.

Choice D:

This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.

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Question 6:

A nurse is conducting a health history interview with a client who has a chronic cough.

Which of the following questions should the nurse ask to elicit relevant information about the cough?

A. "How long have you had this cough?" B. "What do you think is causing your cough?" C. "How does your cough affect your daily activities?" D. All of the above.

Answer and Explanation

Choice A:

This is a correct question, but it is not the only question that should be asked.

Choice B:

This is a correct question, but it is not the only question that should be asked.

Choice C:

This is a correct question, but it is not the only question that should be asked.

Choice D:

The nurse should ask open-ended questions that cover the characteristics, duration, frequency, severity, precipitating and relieving factors, associated symptoms, and impact of the cough on the client's health and quality of life.

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Total Questions : 6

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Introduction to Patient Assessment and Documentation

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