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Nursing Assessment and Clinical Priorities
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Nursing Assessment and Clinical Priorities
Nursing Assessment and Clinical Priorities
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1
Question
How should a nurse prioritize immediate threats over chronic concerns?
Page 3
Answer
Address first-level problems that threaten life immediately, using airway, breathing, and circulation priorities when appropriate. A patient struggling to breathe takes priority over one reporting chronic knee pain.
2
Question
How do second-level and third-level priority problems differ in urgency?
Page 3
Answer
Second-level problems require prompt attention but are not immediate life threats. Third-level concerns are less urgent and can usually wait until immediate threats are addressed.
3
Question
How does subjective data differ from objective assessment data?
Page 3
Answer
Subjective data are experiences, feelings, or symptoms reported by the patient. Objective data are findings the nurse observes or measures through examination or testing.
4
Question
How do primary, secondary, and tertiary prevention differ?
Page 3
Answer
Primary prevention prevents disease or injury before it occurs. Secondary prevention detects disease early. Tertiary prevention reduces complications and disability after disease develops.
5
Question
How does diagnostic reasoning progress from assessment to evaluation?
Page 3
Answer
Collect data, analyze and cluster cues, identify possible problems, then take action and evaluate the response. A hypothesis is a possible explanation, and validation checks whether information is accurate and consistent.
6
Question
Why should a nurse prioritize respiratory assessment for a patient with concerning breathing findings?
Page 4
Answer
A respiratory rate of 30/min, accessory muscle use, and SpO₂ 88% form a concerning cluster suggesting impaired breathing. Prioritize respiratory assessment and intervention.
7
Question
How does an open-ended question differ from a closed-ended question?
Page 4
Answer
An open-ended question encourages a detailed answer. A closed-ended question requests a specific answer.
8
Question
Why can a leading question interfere with a patient interview?
Page 4
Answer
A leading question encourages a particular answer, which can influence how the patient responds.
9
Question
How should a nurse interview a patient with limited English proficiency?
Page 5
Answer
Use a qualified medical interpreter when needed. Avoid relying on children or untrained family members for important interpretation.
10
Question
How should an interview typically progress from broad questions to focused questions?
Page 5
Answer
Begin with an open-ended question to obtain detailed information, then use focused questions to clarify details.
11
Question
Which information belongs in the health history's review of systems?
Page 6
Answer
A systematic review of symptoms organized by body system.
12
Question
How should a nurse document a patient's reason for seeking care?
Page 6
Answer
Use the patient's own words when possible, and do not insert an unconfirmed diagnosis.
13
Question
When should a nurse begin performing the general survey?
Page 6
Answer
Begin at first contact and continue throughout the assessment, observing appearance, behavior, mobility, and signs of distress.
14
Question
How should a nurse respond to pallor, heavy sweating, and difficulty breathing during a routine assessment?
Page 6
Answer
Recognize the concerning findings and address immediate needs rather than continuing a routine examination.
15
Question
Which adult reference range is given for respiratory rate?
Page 7
Answer
12–20 breaths/min.
16
Question
Why should a blood pressure below 90/60 mmHg be interpreted in context?
Page 7
Answer
That reading is not automatically an emergency; symptoms, baseline, and clinical circumstances matter.
17
Question
How should a nurse count respirations when the pattern is irregular?
Page 8
Answer
Count respirations for a full minute. Avoid drawing attention to the count because the patient may consciously change breathing.
18
Question
Which findings can indicate respiratory distress despite a respiratory rate within range?
Page 8
Answer
Accessory muscle use, nasal flaring, retractions, or other signs of distress.
19
Question
How should the patient's position and arm be prepared for blood pressure measurement?
Page 8
Answer
Support the back, keep feet flat and legs uncrossed, place the cuff on a bare upper arm, and support the arm at heart level.
20
Question
How can simultaneous apical and radial pulse assessment identify a pulse deficit?
Page 8
Answer
Assess both pulses simultaneously and compare them; a pulse deficit is the difference between apical heart rate and radial pulse rate.
21
Question
How is orthostatic hypotension commonly defined after standing?
Page 9
Answer
A sustained decrease of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing.
22
Question
Which blood pressure errors can produce falsely high readings?
Page 9
Answer
A cuff that is too small and an arm positioned below heart level can produce falsely high readings.
23
Question
How should blood pressure and pulse be assessed for orthostatic changes?
Page 9
Answer
After the patient rests supine, generally at least five minutes, measure blood pressure and pulse. If standing is safe, repeat them commonly at one and three minutes.
24
Question
Which temperature route is suitable for a cooperative patient who can hold a thermometer safely?
Page 9
Answer
The oral route is convenient for such patients.
25
Question
Why can tympanic temperature readings be affected by technique?
Page 9
Answer
Correct positioning is important, and earwax, positioning, and ear conditions can affect readings.
26
Question
Which positioning errors may increase a blood pressure reading?
Page 9
Answer
An unsupported back, unsupported feet or crossed legs, and talking during measurement may increase the reading.
27
Question
What does a heart rate of 48 with dizziness indicate?
Page 10
Answer
Symptomatic bradycardia that needs prompt assessment.
28
Question
How should a blood pressure of 82/48 mmHg with confusion be interpreted?
Page 10
Answer
It is concerning for poor perfusion and requires urgent assessment.
29
Question
Which elements of pain history are assessed by OLDCART?
Page 10
Answer
Onset, location, duration, characteristics, aggravating factors, relieving factors, and timing.
30
Question
How does PQRST assess a patient's pain experience?
Page 10
Answer
It assesses provocation or palliation, quality, region or radiation, severity, and timing.