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Chapter 15 Assessing
care. Sometimes the phases of the process interact
or overlap.’
d. ‘Think about this person. Non-pharmacological
interventions wouldn’t be effective with her.’
2.
When a person you are admitting to the unit asks you
why you are doing a health history and physical exami-
nation since the doctor just did one, your best reply is:
a. ‘In addition to providing us with valuable
information about your health status, the nursing
and midwifery assessment will allow us to plan and
deliver individualised, holistic person-centred care
that draws on your strengths.’
b. ‘It’s hospital policy. I know it must be tiresome, but
I will try to make this quick.’
c. ‘I’m a student nurse/midwife and need to develop
the skill of assessing your health status and need for
care. This information will help me develop a
person-centred plan of care, individualised to your
unique needs.’
d. ‘We want to make sure that your responses are
consistent and that all our data are accurate.’
3.
When you receive the shift report, you learn that the
person that you are caring for has no special skin care
needs. You are surprised during the bath to observe red-
dened areas over bony prominences. You should:
a. Correct the initial assessment form
b. Redo the initial assessment and document current
findings
c. Conduct and document an emergency assessment
d. Perform and document a focused assessment on
skin integrity
4.
Fearful of attempting your first health history, you ask
your facilitator how anyone ever learns everything you
have to ask to get good baseline data. You are most likely
to hear:
a. ‘There’s a lot to learn at first, but once it becomes
part of you, you just keep asking the same questions
over and over in each situation until you can do it in
your sleep!’
b. ‘You make the basic questions a part of you and
then learn to modify them for each unique situation,
asking yourself how much you need to know to
plan good care.’
c. ‘No-one ever really learns how to do this well
because each history is different! I often feel like
I’m starting afresh with each new person.’
d. ‘Don’t worry about learning all of the questions to
ask. Every facility has its own assessment form you
must use.’
5.
A person complains about feeling nauseated after lunch.
This is an example of what type of data?
a. Subjective
b. Objective
c. Signs and symptoms
d. Overt
6.
When you enter the person’s room to begin your health
history, the person’s wife is there. You should:
a. Introduce yourself to both and thank the wife for
being present
b. Introduce yourself to both and ask the wife if she
wants to remain
c. Introduce yourself to both and ask the wife to leave
d. Introduce yourself and ask the person if he would
like the wife to stay
7.
The person you are assessing is Vietnamese and does
not speak English. Her son is with her and does speak
English. How should you respond?
a. Ask the son if he is willing to translate and be sure
to thank him if he says yes
b. Determine if the son can translate medical informa-
tion and if so, begin
c. After determining that the son can translate, evalu-
ate if he can do so objectively and if the person
wants him to serve in this capacity
d. Explain to the son that hospital policy discourages
using family members as interpreters and you will
need to organise a hospital-approved interpreter
8.
You are surprised to detect an elevated temperature
(39.5°C) in a person scheduled for surgery. The person
has been afebrile and shows no other signs of being
febrile. The first thing you do is to:
a. Inform the charge nurse/midwife
b. Inform the surgeon
c. Validate your finding
d. Document your finding
9.
You tell your facilitator that the person you are nursing
is fine and has ‘no complaints’. You are likely to hear:
a. ‘You made an inference that she is fine because she
has no complaints. How did you validate this?’
b. ‘She probably just doesn’t trust you enough to share
what she is feeling. I’d work on developing a trusting
relationship.’
c. ‘Sometimes everyone gets lucky. Why don’t you try
to help another person?’
d. ‘Maybe you should reassess the person. She has to
have a problem—why else would she be here?’
Answers with rationale
1.
The correct answer is
c
. There may be much interaction
and overlap among the process of care phases. In this
case, though you want to evaluate the effect of the med-
ication you administered (options
a
and
b
), there is no
reason to wait for this to happen before exploring other
valid options. Answer
d
is incorrect because it is not
possible to judge the effectiveness of non-pharmacolog-
ical methods before their use, and the facilitator’s
response possibly indicates a prejudice toward comple-
mentary and alternative modalities.
2.
The correct answer is
a
. Though it may be true that you
need to develop assessment skills (
c
), the chief reason
you are doing a history and examination is because there
needs to be a documented admission assessment to serve
