Exam 1: NR226/ NR 226 Fundamentals
Patient Care Exam Prep| 100% Correct
Questions and Verified Answers (2023/ 2024
Update)- Chamberlain
Q: Which of the following are examples of data validation? (Select all that apply.)
A. The nurse assesses the patient’s heart rate and compares the value with the last value entered
in the medical record.
B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity.
C. The nurse observes a patient reading a teaching booklet and asks the patient if he has
questions about its content.
D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat
the measurement.
E. The nurse asks the patient to describe a symptom by saying, “Go on.”
Answer:
A & D
-Validation involves comparing data with another source. By asking the patient about pain and
then having it rated the nurse collects two assessment findings. The nurse asking an open-ended
question about the patient’s understanding of the booklet is not data validation. Telling the
patient to “go on” is back channeling.
Q: A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3
days and he vomited twice yesterday. Which of the following responses by the nurse is an
example of probing?
A. So you’ve had an upset stomach and began vomiting—correct?
B. Have you taken anything for your stomach?
C. Is anything else bothering you?
D. Have you taken any medication for your vomiting?
Answer:
C. Is anything else bothering you?
-A probing question encourages a full description without trying to control the direction of the
patient’s story. It requires further open-ended statements. Confirming an upset stomach and
vomiting is an example of summarizing findings. The questions about medications taken are
examples of closed-ended questions that control the patient’s response and do not ensure a full
objective view from the patient.
Q: The nurse is assessing the character of a patient’s migraine headache and asks, “Do you feel
nauseated when you have a headache?” The patient’s response is “yes.” In this case the finding of
nausea is which of the following?
A. An objective finding
B. A clinical inference
C. A validation
D. A concomitant symptom
Answer:
D. A concomitant symptom
-A concomitant symptom is a symptom that occurs along with a primary symptom. The finding
is subjective based on patient self-report. There is no clinical inference since the nurse is not
trying to find the meaning of the findings. The patient is reporting nausea, but there is no
validation or confirmation with another source.
Q: During the review of systems in a nursing history, a nurse learns that the patient has been
coughing mucus. Which of the following nursing assessments would be best for the nurse to use
to confirm a lung problem? (Select all that apply.)
A. Family report
B. Chest x-ray film
C. Physical examination with auscultation of the lungs
D. Medical record summary of x-ray film findings
Answer:
C & D
-The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray
film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse
could review that report to confirm a lung problem.
Q: A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just
entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath
with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The
nurse’s knowledge about this patient results in which of the following assessment approaches at
this time? (Select all that apply.)
A. A problem-focused approach
B. A structured comprehensive approach
C. Using multiple visits to gather a complete database
D. Focusing on the functional health pattern of role-relationship
Answer:
A & C
-The nurse should use a focused approach initially to determine the patient’s respiratory status.
However, to gather an admission assessment, multiple visits are needed because of the patient’s
age and level of physical distress. A structured comprehensive approach is not appropriate for
this acute situation. Eventually the nurse will want to assess the patient’s role-relationship health
pattern because of his wife’s death. But it is not appropriate at this time.
Q: A 58-year-old patient with nerve deafness has come to his doctor’s office for a routine
examination. The patient wears two hearing aids. The advanced practice nurse who is conducting
the assessment uses which of the following approaches while conducting the interview with this
patient? (Select all that apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient’s answers through head nodding
D. Limit direct eye contact
Answer:
B & C
-Leaning forward shows that the nurse is aware and attending to what the patient is saying. The
use of head nodding regulates the interaction and makes it easier for the patient to know the
nurse’s responses to his comments. A neutral expression does not express warmth or immediacy,
which is needed to establish a positive relationship. Good eye contact communicates the nurse’s
interest in what the patient has to say.
Q: Review the following nursing diagnoses and identify the diagnoses that are stated correctly.
(Select all that apply.)
A. Anxiety related to fear of dying
B. Fatigue related to chronic emphysema
C. Need for mouth care related to inflamed mucosa
D. Risk for infection
Answer:
A & D