#1
Which of the following is NOT a component of a comprehensive nursing assessment?
Nursing diagnosis
ExplanationNursing diagnosis is not part of the assessment but follows it for treatment planning.
#2
What is the first step in the nursing assessment process?
Obtaining a health history
ExplanationThe initial step involves gathering information about the patient's health history.
#3
Which of the following is a subjective data point in a nursing assessment?
Patient's description of pain
ExplanationSubjective data relies on the patient's self-report, like their description of pain.
#4
What is the purpose of a nursing assessment?
To plan nursing interventions
ExplanationAssessment serves as the foundation for planning appropriate nursing interventions.
#5
What is the purpose of using standardized nursing assessment tools?
To ensure consistency and reliability in assessments
ExplanationStandardized tools enhance reliability and consistency across different assessments.
#6
Which of the following is a component of a holistic nursing assessment?
Taking into account the patient's cultural background
ExplanationConsidering cultural background contributes to a comprehensive understanding of the patient.
#7
Which of the following is a psychosocial factor that nurses assess during a patient interview?
Level of anxiety
ExplanationAssessing the patient's anxiety is crucial for understanding their mental well-being.
#8
During a nursing assessment, what does the acronym 'COLDSPA' stand for?
Character, Onset, Location, Duration, Severity, Precipitating factors, Alleviating factors
ExplanationCOLDSPA helps structure questioning for a thorough assessment of symptoms.
#9
Which of the following is an example of objective data in a nursing assessment?
Patient's temperature is 38°C
ExplanationObjective data is measurable and observable, such as a patient's recorded temperature.
#10
What is the purpose of conducting a health history interview during a nursing assessment?
To establish rapport with the patient
ExplanationBuilding rapport is a primary goal, fostering trust and communication.
#11
During a nursing assessment, which assessment technique involves tapping the body to evaluate underlying structures and organs?
Percussion
ExplanationPercussion is a technique involving tapping to assess the density and resonance of underlying tissues.
#12
When conducting a nutritional assessment, what is an example of an anthropometric measurement?
Body mass index (BMI)
ExplanationBMI is a common anthropometric measurement used to assess nutritional status.
#13
Which of the following is a key aspect of performing a physical assessment in nursing?
Ensuring patient privacy and dignity
ExplanationMaintaining privacy and dignity is crucial for patient comfort and trust during physical examinations.
#14
Which of the following is NOT a part of the ABCDE framework for conducting a focused nursing assessment?
Digestion
ExplanationABC stands for Airway, Breathing, Circulation, and Disability; D does not refer to Digestion.
#15
Which of the following is a component of a neurovascular assessment?
Checking capillary refill
ExplanationAssessing capillary refill is vital in evaluating neurovascular function.
#16
Which of the following is NOT typically included in a pediatric nursing assessment?
Parental occupation
ExplanationParental occupation is not a direct consideration in pediatric assessments.
#17
Which of the following is a common tool used for assessing pain in non-verbal patients?
Behavioral Pain Scale (BPS)
ExplanationThe Behavioral Pain Scale is a tool designed for assessing pain in non-verbal patients.