Chapter 3: Enhancing Assessment Skills
TRUE/FALSE
1.
The functional assessment brings the client’s living environment and physical needs together
to establish a holistic picture.
ANS: True
PTS:
1
MULTIPLE CHOICE
1.
A client’s respirations are 14. His respirations are:
a. apneic.
c. tachypneic.
b. eupneic.
d. bradypneic.
ANS: b
2.
A nurse evaluates a client’s pulse and finds it strong, equal, and normal in amplitude. She
charts the pulse as a:
a. 1+.
c. 3+.
b. 2+.
d. 4+.
ANS: c
3.
PTS: 1
The gathering of objective data from the nurse’s observations, diagnostic procedures, and
health record information that together reviews a client’s physical state is a:
a. physical assessment.
c. functional health pattern.
b. nursing health history.
d. subjective data assessment.
ANS: a.
4.
PTS: 1
PTS: 1
A client is recovering from a football accident and is participating in physical therapy. When
the nurse assesses his muscle strength, she notes that he can ambulate by himself with the
assistance of a cane. When asked, the client squeezes both of the nurse’s hands moderately
firm but can only push with some resistance against the nurses’ hand. How would you rate his
muscle strength?
a. 0 = no muscular contraction
d. 4 = active movement against gravity
and some resistance
b. 1 = barely flicker of contraction
e. 5 = active movement against full
resistance with no fatigue
c. 2 = active movement against gravity
ANS: d
PTS: 1
5.
What is the rating for edema when it depresses approximately 6mm, stays for > 1 min, and
appears swollen?
a. 1+
b. 2+
ANS: c
c. 3+
d. 4+
PTS: 1
MULTIPLE RESPONSE
Select all answers that apply.
1.
Gordon’s Functional Health Patterns is a good assessment tool because it:
a. determines what to assess.
d. guides data collection.
b. provides structure for organizing data. e. uses a head-to-toe format.
c. uses a body systems format.
f. aids in client problem identification.
ANS: a, b, d, f
2.
When assessing a client’s pain, the nurse would assess the:
a. intactness.
d. duration.
b. location.
e. intensity.
c. pitch.
f. predisposing factors.
ANS: b, d, e, f
3.
PTS: 1
Gordon’s functional health pattern of cognitive/perceptual assesses:
a. facial expression.
d. pupil reaction.
b. pain.
e. perceptions of responsibilities in life.
c. long and short term memory.
f. visual impairment.
ANS: b, c, d, f
4.
PTS: 1
PTS: 1
Gordon’s functional health pattern of coping/stress tolerance assesses:
a. usual method of problem solving.
d. patterns of relating to others.
b. concern with meaning of life/death.
e. ability to reason and make sound
decisions.
c. recent loss or change in life situation. f. developmental stage of life.
ANS: a, c, e
PTS: 1
SHORT ANSWER
1.
Name 4 of the 11 of Gordon’s Functional Health Care Patterns used in nursing assessments
and a question you might ask in each of these 4 categories.
ANS: Students’ answers will vary. Please refer to Gordon’s Functional Health Care Patterns
chart in the chapter to evaluate student answers.
PTS: 8
ESSAY
1.
Which assessment tool provides the best assessment of the client: Gordon’s Functional Health
Patterns, body system format, or head-to-toe assessment? Support your answer with concepts
from the textbook.