Types of Assessment

Every question here, with the answer

1. A patient has just been admitted to a medical-surgical unit. The patient is stable, and the nurse needs to establish a baseline for future care planning. Which assessment should the nurse perform first?

   1. An initial assessment that includes health history and a head-to-toe examination
   2. A time-lapsed assessment comparing changes over several months
   3. An emergency assessment focused only on airway, breathing, and circulation
   4. A problem-focused assessment of the most recent symptom

   Answer: An initial assessment that includes health history and a head-to-toe examination

   The initial assessment is used when a patient begins receiving care and establishes a baseline understanding of the patient’s overall health. The other options are narrower or reserved for later comparison or life-threatening situations.

2. During an initial assessment, the nurse wants to understand the social determinants that may affect the patient’s health needs. Which areas should the nurse assess? Select all that apply.

   1. Social support networks
   2. Socioeconomic status
   3. Access to health care
   4. Facial drooping and arm weakness
   5. Housing stability

   Answer: Social support networks, Socioeconomic status, Access to health care, Housing stability

   Housing, socioeconomic status, access to care, and support networks are specifically identified as social determinants of health that help the nurse understand the patient’s needs in context. Facial drooping and arm weakness are findings the nurse may assess in a possible stroke, not social determinants.

3. A patient who was previously stable reports new acute abdominal pain with nausea. Which type of assessment is most appropriate for the nurse to perform?

   1. Time-lapsed assessment
   2. Problem-focused assessment
   3. Emergency assessment for cardiac arrest
   4. Initial assessment

   Answer: Problem-focused assessment

   A problem-focused assessment targets a specific new or worsening symptom and allows the nurse to evaluate the relevant body area and associated symptoms. An initial assessment is broader, a time-lapsed assessment compares progress over time, and an emergency assessment is used for life-threatening situations.

4. A nurse is completing ongoing assessments for a postoperative patient at planned intervals. Which findings should the nurse monitor as part of this assessment? Select all that apply.

   1. Signs of infection
   2. Wound healing
   3. Nausea and vomiting
   4. Pain levels
   5. Blood pressure trends over several months to evaluate hypertension treatment

   Answer: Signs of infection, Wound healing, Nausea and vomiting, Pain levels

   For a postoperative patient, ongoing assessment includes frequent monitoring for wound status, pain, nausea and vomiting, vital signs, and infection. Reviewing blood pressure changes over several months is more consistent with a time-lapsed assessment in chronic disease management.

5. A patient arrives in the emergency department unconscious and unresponsive after collapsing at home. What should the nurse prioritize during the initial emergency assessment?

   1. Reviewing changes in the patient’s condition over the past several months
   2. Collecting a complete lifestyle history, including diet and exercise habits
   3. Performing a focused foot assessment for signs of neuropathy
   4. Assessing vital signs and airway, breathing, and circulation

   Answer: Assessing vital signs and airway, breathing, and circulation

   In an emergency, the nurse rapidly assesses vital signs and the ABCs to determine stability and the need for urgent interventions. Lifestyle history, long-term comparison, and focused chronic-condition assessments are not the priority for an unconscious, unresponsive patient.

6. A patient in the emergency department is experiencing acute emotional distress and expresses possible intent to harm themselves. Which nursing actions are appropriate during the emergency assessment? Select all that apply.

   1. Ensure the patient’s safety
   2. Use a time-lapsed assessment to compare changes over the next few months
   3. Delay assessment until the patient can provide a complete medical history
   4. Identify immediate psychological needs
   5. Evaluate the patient’s mental status

   Answer: Ensure the patient’s safety, Identify immediate psychological needs, Evaluate the patient’s mental status

   In a psychological crisis, the emergency assessment focuses on mental status, safety, and immediate psychological needs. Delaying assessment or using a time-lapsed approach would not address the immediate risk described in the section.