The Nurse’s Role in Assessment

Every question here, with the answer

1. A nurse is completing the initial assessment of a patient admitted for exacerbation of congestive heart failure. The patient is having significant difficulty breathing, appears anxious, and is fatigued. Which action should the nurse prioritize first?

   1. Use therapeutic communication to explore the patient’s anxiety.
   2. Collaborate with the dietitian about dietary modifications and hydration.
   3. Make sure the airway is clear and initiate oxygen therapy to improve oxygenation.
   4. Arrange spiritual support based on the patient’s religious preferences.

   Answer: Make sure the airway is clear and initiate oxygen therapy to improve oxygenation.

   The patient’s breathing difficulty indicates an immediate physiological need, which the nurse prioritizes in the initial assessment. Anxiety, nutrition, hydration, and spiritual needs are also important, but the section’s example prioritizes airway and oxygenation first.

2. A patient with a history of cardiovascular disease reports shortness of breath and chest pain. The nurse is assessing the psychosocial domain. Which information should the nurse gather? Select all that apply.

   1. The patient’s coping mechanisms
   2. The patient’s cultural beliefs and values
   3. The patient’s skin color, hydration status, and posture
   4. The patient’s blood pressure, pulse rate, and respiratory rate
   5. The patient’s social support network

   Answer: The patient’s coping mechanisms, The patient’s cultural beliefs and values, The patient’s social support network

   Coping mechanisms, support network, and cultural beliefs and values are part of the psychosocial domain. Vital signs, skin color, hydration status, and posture are physical assessment findings, not psychosocial data.

3. A postoperative patient is grimacing, guarding the surgical site, and verbally reporting discomfort. The nurse notes redness, swelling, and tenderness at the incision, and the patient rates pain as 8 out of 10. How should the nurse interpret this assessment finding?

   1. This is an actual problem requiring nursing intervention.
   2. This is only a potential problem because the patient is at risk but has no symptoms.
   3. This is primarily a spiritual need because the patient needs comfort.
   4. This is only a functional assessment finding because activities of daily living are affected.

   Answer: This is an actual problem requiring nursing intervention.

   The patient has current symptoms and clinical evidence, so the nurse identifies an actual problem. A potential problem is a risk that is not currently manifesting symptoms, which does not fit this scenario.

4. A nurse is assessing two patients: one is bedridden with no current pressure ulcers, and another has a history of falls but no current injury. Which nursing actions reflect assessment of potential problems? Select all that apply.

   1. Assess fall risk factors such as medication side effects or environmental hazards.
   2. Recognize the bedridden patient’s risk for pressure ulcers even though ulcers are not present.
   3. Wait to plan interventions until a pressure ulcer or fall injury is present.
   4. Conclude that no preventive assessment is needed because neither patient has current symptoms.
   5. Implement preventive measures such as regular repositioning and skin assessments.

   Answer: Assess fall risk factors such as medication side effects or environmental hazards., Recognize the bedridden patient’s risk for pressure ulcers even though ulcers are not present., Implement preventive measures such as regular repositioning and skin assessments.

   Potential problems are risks that are not currently manifesting symptoms, so the nurse should identify risks and use preventive care. Waiting until injury occurs or assuming no assessment is needed would allow potential problems to become actual problems.

5. A nurse completed an admission assessment and developed an individualized care plan. Later, the patient’s condition changes and the original plan no longer fits the patient’s needs. What should the nurse do next?

   1. Delay changes to the care plan because assessment is not a dynamic process.
   2. Focus only on laboratory results and clinical signs, not patient concerns or behaviors.
   3. Rely only on the original health history because assessment is completed at admission.
   4. Continue collecting data, assess the patient’s responses, and adapt the care plan.

   Answer: Continue collecting data, assess the patient’s responses, and adapt the care plan.

   The section describes assessment as ongoing and dynamic, requiring the nurse to reassess and adjust the plan as the patient’s condition progresses. Treating assessment as a one-time task or ignoring patient concerns conflicts with holistic nursing assessment.

6. A patient says faith is important when coping with illness. Which nurse responses are appropriate for the spiritual domain of assessment? Select all that apply.

   1. Use open and nonjudgmental communication when discussing spiritual beliefs.
   2. Avoid asking about spirituality because it is unrelated to treatment preferences.
   3. Ask, “Please tell me about your spiritual and religious preferences.”
   4. Ask about religious practices that may impact health care.
   5. Ask whether the patient desires prayer, religious rituals, or pastoral support.

   Answer: Use open and nonjudgmental communication when discussing spiritual beliefs., Ask, “Please tell me about your spiritual and religious preferences.”, Ask about religious practices that may impact health care., Ask whether the patient desires prayer, religious rituals, or pastoral support.

   The nurse should respectfully explore spiritual beliefs, practices, coping, and desired spiritual support so these needs can be included in the treatment plan if desired. Avoiding the topic is not consistent with the section’s guidance for spiritual assessment.