Nursing Assessment Questions

Question 1

Question 1

Nursing assessment is the first stage of the nursing process. State four reasons why a nursing history is performed on admission?

Question 2  Part A

Explain why it is important to involve your client and/or their family whilst conducting nursing assessments?

Part B   what is meant by holistic care?

Question 3

List 4 points relating to the documentation guidelines that you must comply with when recording any information.

Question 4

You are asked to take vital signs on a client. State 4 indications to complete vital

 Question 5

Match the appropriate term with the correct temperature range

Hyperthermic		36.2 -37.5 0C
Afebrile		35.0        36.0 0C
Hypothermic		37.5 – 39.0 0C

Question 6

It is recommended to take a confused person’s temperature via the oral route

True

False

Explain your answer

Question 7

is an abnormal pulse rate greater than 100 beats/minute

Question 8

List 4 factors that affect body temperature

Question 9 When taking a client’s pulse, what 3 characteristics must be assessed?

Question 10

List the 4 most common sites for taking a pulse measurement.

Question 11

The term for a pulse rate below 60 beats per minute is a  

Question 12

When taking a client’s respirations, what 3 characteristics must be assessed?

Question 13

A normal respiratory rate for a child is ________________________breaths per minute.

Question 14

List four factors which may affect pulse oximetry

Question 15

List the normal range of pulse oximetry in a healthy adult.

Question 16

Define systolic blood pressure.

Question 17

Define diastolic blood pressure

Question 18

An elderly client has a blood pressure of 184/102.  The client is

Question 19

A client has a urinary tract infection.  The client will have an increased level of _________ present in his urine. 

Question 20

Outline the normal characteristics of urine.

Question 21  

The medical term for shortness of breath is

Question 22

A client’s blood glucose level prior to breakfast was 3.1mmol/l, this result is a

Question 23

Question 24

 A client with a BMI of 33.4 is considered to be  

Question 25

Blood glucose target ranges may differ depending on age, duration of diabetes and medications.  Normal blood glucose levels are between

Question 26

Individual human development is a lifelong continuous process beginning at conception and ending with death and is perceived as involving a series of orderly and predictable changes, which can be classified as physical, social, emotional and intellectual.  Complete the following referring to Erikson’s eight stages of development Stages Conflict to be resolved Examples Oral-Sensory (birth to 1 year) Musculo-Anal (1-3 Years) Locomotor-Genital (3-5 Years) Latency (6 -11 Years) Adolescence (12-18 Years) Young Adulthood (19-35 Years) Middle adulthood (40 to 65 years) Maturity (65 to death)

 Question 27

Outline the specific assessment technique(s) you would use to assess the following clients:

A client who has fallen and is suspected of having a head injury

A client who is dyspneic 

A client with diabetes 

A client who is complaining of pain on micturition

A person who has a plaster cast on their arm post a recent fracture 

Question 28

A fluid balance chart has been ordered for Mr. Leech (UR 0123456789) DOB: 30/06/1949. Complete FBC on the following page below using the following information:

0730 hrs — orange juice 150 mL, milk 140ml	1350 hrs — cup of tea 250 mL, water 100 mL
1030 hrs — cup of tea 180 mL	1430 hrs — voided 250 ml
1115 hrs — water 120 mL	1630 hrs --- vomited 150ml, bile stained fluid
1230 hrs — cup of tea 120 mL jelly 200 mL	1800 hrs --- Bowels open – loose, approximately 100mls
1230 hrs — voided 150 mL urine

The Total intake for the day is
The total output for day is
Is Mr Midler in a positive or negative fluid balance?

Question 29

The urinalysis is another common test routinely taken in almost all acute hospitals as an admission lab screening test. What can a urinalysis reveal?

Question 30

Provide a definition for the following terms 

question 31

Provide a definition for the following terms

Jaundice

__________________________________________________________________________________________________________________________________________________

Pallor

__________________________________________________________________________________________________________________________________________________

Turgor

__________________________________________________________________________________________________________________________________________________

Petechial

__________________________________________________________________________________________________________________________________________________

 

Question 32

When completing a nursing assessment, data that is the client’s perception, ideas and sensations is known as

Question 33

What is a holistic assessment?

Part B

While undertaking the nursing admission, you note that the General Practitioner has stated in the referral that the child is allergic to a medication, however the Medical Officer has written up a stat dose.  What are your actions?

Question 36

You are asked to create a discharge care plan for Mrs Marjorie White who is an 83 year old lady who was admitted for a hip replacement. Outline what is required in the discharge plan. 

Question 37

Part A

You have just completed a blood pressure measurement of your client. It was 185/105. List the steps you would take;

Part B

List 2 likely causes of this high readin

Question 38

You are caring for Jess, a 19yr old male who had been recently admitted for asthma.

Explain how you could assist in the health education of Jess prior to discharge.     

Question 39

The mother of a 7 month old Zoe asks you if Zoe should reach the same milestones at the same time as her older siblings.  What would be an appropriate response?

Question 40

Mrs Joan Smith is a 61 year old lady (UR 333666) was admitted to your ward for day surgery.

Document the following admission observations accurately on the graph observation chart provided.

1400 hrs    T – 36.7,          P – 100,          R – 22,            B/P – 140/90.  

Weight is 68 kg

Urinalysis reveals a ph  of 8.0, positive for leucocytes and SC 1015

No other abnormalities

• Helps to identify the biological, social as well as psychological determinants of health that is affecting the patient
• Collect cues for diagnosing the disorders
• Develop ideas about the other prior treatments that had been conducted and its success or failure rates (Morton et al., 2017)
• Develop ideas about the family history, allergic reactions, preferences and others

Question 2:

Part a: involving patients and their family members makes them feel empowered and help them participate n their own decision making about their health. These have positive outcomes. It also helps to know whether the patient has any cultural inhibitions that the nurses need to know before proceeding with the treatment.

Part b: holistic nursing mainly involves providing care that improves the quality of life of the patients as a whole. It mainly looks over the person’s need like that of the physical, intellectual, emotional, social cultural as well as spiritual. The nurses thereby provide opportunities to the patients by which they can develop life in all aspects (Butcher et al., 2018)

Question 3:

• Maintain confidentiality about the information documented
• While medication administration, complete the information under date, time, name , route, site, dosage and signature
• During collaboration, date and time of contact, name of the collaborator, information provided to or by them, response from others, intervention resulting from collaboration.
• Conclusions should be documented that are supported by data. Value judgments and unfounded conclusions should be avoided 9zimmerman et al., 2014)

Question 4:

• Person suffering from fever states that temperature should be taken
• Person suffering from breathlessness indicates that respiratory rate should be measured
• A person with medical history of hypertension needs blood pressure to be measured
• Patient with cardiovascular disorder needs to measure heart rate

Question 5:

• Hyperthermic 37.5 – 39.0 ⁰C
• Afebrile 36.2 -37.5 ⁰C
• Hypothermic 35 to 36 0 ⁰C

Question 6:

False

A patient who is confused should not be given oral temperature measurement technique. Confused persons are usually confused as well as disturbed and there is a high chance that he may bite the thermometer harming lips and tongue (Bach et al., 2016). Therefore, this procedure is not correct.

Question 7:

Sinus tachycardia

Question 8:

• Extreme environmental conditions
• Physical activity
• Diseases
• Stress and anxiety (Urden et al., 2017)

Question 9:

• Pulse rate is to be noted
• Strength of the pulse
• Rhythm that refers to evenness of the beats

Question 10:

• Temporal pulse that is palpated in front of ear
• Carotid pulse that is found in neck
• Brachial pulse in the bend of the arm
• Radial pulse found on the inside of the wrist (Moorhead et al., 2018)

Question 11:

Bradycardia

Question 12:

• Rate of the respiration
• Depth of the respiration
• Rhythm of the respiration
• Quality of respiration (Patel et al., 2014)

Question 13:

30 to 60 breaths per minute

Question 14:

• Perfusion at the site of the monitoring
• Technique
• Dysfunctional hemoglobin
• Unreliable readings

Question 15:

The normal pulse oximeter readings usually range from 95 to 100 percent

Question 16:

Systolic blood pressure mainly refers to the pressure in the blood vessel when the heart beats 9stephan et al., 2015).

Question 17:

Diastolic blood pressure mainly refers to the blood pressure when the heart is seen to rest between the beats. 

Question 18:

The client is suffering from hypertension. He is at risk of heart attack, stroke as well as other acute life threatening problems that require emergency attention (Castellan et al., 2016).

Question 19:

Bacteria

Question 20:

• Color of urine is pale yellow to deep amber
• The odor is odorless
• Volume is 750 to 2000 mL in 24 hours
• The pH is 405 to 8.0

Question 21:

The shortness of breath is called dyspnea

Question 22:

The client is suffering from hypoglycemia which occurs when the blood glucose level  has dropped too low which is below 4 mmol/L. if the blood glucose levels fall below that, there remains a high chance that the patient will become unwell (Potter et al., 2016). 

Question 23:

The body mass index is mainly calculated by measuring the height and weight of the person. The formula of basal metabolic index is = kg/m² . Here Kg is the person’s weight in kilograms and m² is the height of the person that is squared (stuart et al., 2014).

Question 24:

Question 2

A client with a BMI of 33.4 is considered to be obese. Researchers are of the opinion that persons who are above the BMI of 30 have greater risk of developing additional health problems.

Question 25:

Normal blood glucose levels are mainly between 3.9 and 5.5 mmol/L or that of 70 to 100 mg/dL

Question 26:

Stages	Conflict to be resolved	Examples
Oral-Sensory (birth to 1 year)	Trust others mainly for people who care for their basic needs	Trusting mother and father
Musculo-Anal (1-3 Years)	Learn to take care of themselves like changing own clothe, feeding themselves	Mothers should help children to be independent and do their own activities
Locomotor-Genital (3-5 Years)	Explore and learn new things	Learn new concepts in school
Latency (6 -11 Years)	Children matures and their level of self awareness develops, logical reasoning take place	Children apply logic behind scientific facts
Adolescence (12-18 Years)	Develop sexual identity	Discovering oneself and finding new meaning to person hood
Young Adulthood (19-35 Years)	People find partner and stabilize in romantic relationships	People share lifelong commitment towards their partners
Middle adulthood (40 to 65 years)	Try to contribute something meaningful to the society	Develop health promotion program for the disadvantaged people, charity
Maturity (65 to death)	Develop a sense of fulfillment knowing that they have succeeded in life	Looking back in the life people feel contempt after completion of the above stages successfully

Question 27:

• 
  It is very important for the professionals to identify any unusual symptoms for clients who have faced a head injury following a fall. Severe blow on the head may result in swelling as well as damage to the brain. It is vitally important for the professionals to recognize early as well as worrying signs of any types of increased pressure on the brain. A clear indicator of more serious injury is when the person loses consciousness or shows signs of confusion. Unconsciousness, abnormal breathing, disturbance of speech, vision, weakness, dizziness, paralysis, bleeding or clear fluid from the nose and many others can also provide cues of serious injuries (Feltnar et al., 2014). Citi scan and MRI should also be done.
• Electrocardiogram as well as chest radiographs mainly help in assessing the disorder. These modalities are inexpensive, safe and can be easily accomplished
• For assessing diabetes patient, blood glucose monitoring is important. HbA1C can be taken. Home capillary glucose monitoring is also done.non fasting lipid profile should be measured. Estimated glomerular filtration rate should be measured to check diabetic nephropathy. Weight, abdominal circumference, height and BMi should be checked. Urinalysis should also be done
• Medical history should be taken. Possible investigations that should be involved are urine dipstick, microscopy and culture analysis, pregnency test, test for sexually transmitted disease, ultrasound of the urinary tract, plain kidney, ureters and bladder (KUB) X-ray to find out renal tract stones, urine cytology, and others.
• The professionals should first examine the portion that is within the cast before removing the cast. The doctor will take an X ray of the cast along with the broken part inside it altogether. He would also check the pain level. Only after the professional is satisfied, then he will take off the cast with the help of a special saw.

Question 28

FLUID BALANCE WORKSHEET ONLY					ATTACH LABEL OR RECORD PATIENTS: U.R. NUMBER- UR 0123456789 SURNAME- Leech GIVEN NAME- Mr.Leech DOB- 30/06/1949
DATE- / /		DO NOT FILE IN MEDICAL RECORDS FOLDER
	INTAKE IN ML				OUTPUT IN ML
TIME (hrs)	ORAL	INTRAVENOUS	GASTRIC TUBE	NATURE OF FLUID	URINE	VOMITUS OR ASPIRATION	BOWEL/FISTULA/BLOOD LOSSS	REMARKS
0730	150			Orange juice
0730	140			Milk				Milk
1030	180			Tea				Tea
1115	120			Water				water
1230	120			Tea
1230	200							Jelly
1350	250			Tea
1350	100			Water
1430					250
1630						150		Bile stained vomit
1800						100		Loose bowel
TOTAL	1260			TOTAL	500

The Total intake for the day is	1260 ml
The total output for day is	500 ml
Is Mr Midler in a positive or negative fluid balance?	positive

Question 29:

Urinalysis can be defined as the procedure that can help in identifying a number of diseases even them which had not causes important signs as well as symptoms. It is commonly used a the part of routine health screening (Felnar et al., 2014). It is mainly used to diagnose kidney or urinary tract infection that helps in evaluation of the causes of kidney failures. It also helps in screening for progression of some chronic conditions like that of hypertension and high blood pressure. 

Question 30:

• Bradycardia can be defined as the condition when the heart of human beings is seen to beat slower than normal. The normal heart rate is 60 to 100 times per minute but in case of the disorder, it beats slower than 60 beats per minute.
• Tacghypnea can be defined as the disorder where the person faces abnormal respiration rate. Normal respiration rate is 12 to 20 beats per minute where in case of the disorders, the respiration rate increases greater than 20 beats per minute
• Cyanosis is the condition where bluish cast occurs to the skin as well as to the mucous membranes. Peripheral cyanosis can be seen to occur when there is bluish coloration to hands and feet. This mainly occurs due to low amount of oxygen in the red blood corpuscles or when there is problem getting oxygen to the body.
• Hypotension is the condition when the blood pressure in the body decreases than the normal. Blood pressure is the force of blood that is pushed against the walls of the artery. In this condition, the systolic blood pressure decreases less than 90 mm of mercury and the diastolic pressure decreases less than 60 mm of mercury

Question 31:

• Jaundice – increased amount of bilirubin in the blood results in yellow discoloration of the skin, whites of the eyes and even in the mucous membranes. Its is the sign of an underlying disorders (Potter et al., 2016).
• Pallor – pallor is the condition when the skin has pale coloration. It is mainly caused by the illness, emotional shock, anemia, stimulant use. It is mainly the result of reduced amount of oxy-hemoglobin in the blood. It is mainly visible in the mucous membrane and skin conjunctivae.
• Turgor – it can be defined as the degree of skin elasticity and is mainly referred to as the skin turgor. The skin turgor assessment mainly helps in determining the extent of dehydration as well as fluid loss in the body.
• Petechial – this is the condition when the red or purple spot occurs on the surface of the skin. This is mainly caused by minor bleeding from broken capillary blood vessels

Question 32:

• Subjective data

Question 33:

Holistic assessment is a  type of assessment that is mainly seen to include a complete psychological assessment as well as the naturopathic assessment. This assessment is mainly seen to cover emotional, biochemical, psychological, historical, social as well as spiritual causes of the mental health issues.

Question 34:

There are three important components that are the eye which has 4 important scales to be diagnosed. There is the verbal response that has five important grades that include no verbal response, incomprehensive sounds, and inappropriate words, confused as well as oriented (stuart et al., 2014). Then there is the motor response that has 6 grades like no response, decorticate posturing, decorticate posturing, withdrawal of pain, localization to pain and obeying commands 

Question 35:

Part A:

The child should be assessed to find out whether the child falls in the category of “No clinically detectable dehydration” where the nurse should find out consciousness of the child, thirst, urine output, skin color, warmth of hands and feet. The next category is the “clinical dehydration” where the nurses need to find out the child is irritable or lathergic, increased thirst, decreased urine output, skin color and warmth of hands and feet. The third category is the clinical shock  where the nurse need to find out whether the child is in depressed conscious state, pale of mottled skin, cold hands and feet.

Part b:

The nurse should immediately ask the parents or the guardian about the medication that the child is allergic to. Moreover, she would also need to find out that the stat dose medication are causing any drug-drug interaction or not. This would help in prevention of nay medication errors and would help the child to be safe.

Question 3

Question 36:

• Home care: taking pain medication as directed, no driving until advised, wearing support stockings, getting up and moving round to reduce discomfort, staples removing arrangement after two weeks
• Incision care: to be done daily for redness, swelling, drainage, tenderness, avoiding infection by hand washing, avoiding soaking the incision in water, waiting few days before showering
• Silting and sleeping: not sitting for more than 30 minutes, not leaning forward, not crossing the legs, keeping feet flat on floor, using elevated toilet seat, sitting on firm cushion (Morton et al., 2017)
• Moving safely: not bending hip too much, using cane, crutches, walker, prescribed exercises, walking often, removing clutters from walking ways, using non-slip mats and many others

Question 37:

Part a:

 The nurse should make the patient lie down, check that all medications are taken in proper ways, and adjust the medication doses to bring down the blood pressure. The nurse should then check whether any medication is resulting in high pressure or not. The nurse should take the vital signs and then consult with the doctor accordingly. Hypertension may affect other organs like heart brain and precautions to be take accordingly. Nurse should then educate the patients by proper lifestyle management.

Part b:

• Smoking, lack of physical exercises, overweight and obesity are the causes
• Too much salt in the diet and too much alcohol consumption

Question 38:

• He should be taught about the signs and symptoms of asthma
• Goals of asthma treatment would be taught
• Asthma triggers should be made to understand in details so that the patient can avoid them like pet dander. Dust mites, tobacco smoke, cold air and others
• How to use a peak flow meter to understand the passageway condition of the lungs
• Finding the personal best like green zone, yellow zone. Red zone
• Monitoring symptoms and detection of attacks (Basch et al., 2016)
• Proper following of plans and effective evaluation about when to seek for emergency services and to analyze the results

Question 39:

Every child had different pace of their growth of development of cognitive abilities, physical development, development of intelligence quotient, emotional development and others. One child may have faster growth in the childhood years whereas others may not. Therefore, the nurse should ask the mother to not worry and provide him independence to grow on his own pace so that he can enjoy the time and does not feel pressurized. Pressurizing might have negative effect on his brain development and emotional attachments.

Question 40:

1015 leucocyte

8

68 kg

140/90

22

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