Collection of Assessment Data

Every question here, with the answer

1. A nurse is collecting assessment data from a patient who avoids direct eye contact during the interview. Which response by the nurse best supports accurate data collection?

   1. Delay the assessment until the patient maintains direct eye contact.
   2. Ask the family to answer all questions because the patient is not engaged.
   3. Document that the patient is disinterested in the assessment.
   4. Recognize that avoiding direct eye contact may be a sign of respect and continue the assessment respectfully.

   Answer: Recognize that avoiding direct eye contact may be a sign of respect and continue the assessment respectfully.

   The section explains that communication styles vary by culture and that avoiding eye contact should not automatically be interpreted negatively. Respecting this difference helps the nurse gather more accurate data and maintain trust.

2. A nurse is assessing a patient with Alzheimer disease who is unable to provide a complete history. Which information may the nurse appropriately seek from family members? Select all that apply.

   1. A final diagnosis without further assessment
   2. Information that corroborates the patient’s reports
   3. Replacement of the nurse’s own clinical observations
   4. Historical information about the patient
   5. The patient’s normal behavior and daily functioning

   Answer: Information that corroborates the patient’s reports, Historical information about the patient, The patient’s normal behavior and daily functioning

   Family members are useful secondary data sources, especially when the patient cannot communicate effectively. They can add history, confirm reports, and describe baseline functioning, but they do not replace nursing assessment or determine the diagnosis alone.

3. A patient arrives after trauma with swelling that may obstruct the airway. The patient is anxious, has family at the bedside, and needs a full assessment. What should the nurse prioritize first?

   1. Assessing the patient’s social support system
   2. Evaluating long-term psychological needs
   3. Ensuring the airway is open and clear
   4. Beginning education about the assessment process

   Answer: Ensuring the airway is open and clear

   Using the ABC framework, airway is the first priority because obstruction can rapidly lead to respiratory arrest. Other needs may be important, but they are addressed after the most urgent safety concern.

4. A postoperative patient has not fully recovered from anesthesia and sedation and cannot clearly describe discomfort. Which observations should the nurse use as nonverbal cues of pain or discomfort? Select all that apply.

   1. Guarding
   2. Expected resonance during percussion
   3. Grimacing
   4. Normal bowel sounds
   5. Restlessness

   Answer: Guarding, Grimacing, Restlessness

   The section identifies grimacing, guarding, and restlessness as nonverbal signs that inform pain assessment. Percussion sounds and bowel sounds are assessment findings, but they are not listed as nonverbal cues of pain or discomfort.

5. During an abdominal assessment, a nurse uses the hands to feel for an abnormal mass and assess characteristics that cannot be determined by looking alone. Which assessment technique is the nurse using?

   1. Inspection
   2. Auscultation
   3. Palpation
   4. Percussion

   Answer: Palpation

   Palpation involves using the hands to feel the body for abnormalities and to assess characteristics such as texture, temperature, moisture, and size. Inspection is visual, percussion uses tapping, and auscultation uses listening.