Diploma of Nursing: Nursing Assessment Questions and Answers

This document presents a comprehensive set of answers to nursing assessment questions, designed for a Diploma of Nursing program. The assignment covers a wide range of topics, including the importance of nursing history, the significance of involving clients and their families in assessments, and the principles of holistic care. It delves into documentation guidelines, the assessment of vital signs (temperature, pulse, respiration, and blood pressure), and factors influencing these measurements. The document also addresses the interpretation of pulse oximetry readings, the characteristics of urine, and the assessment of blood glucose levels. Furthermore, it explores Erikson's stages of development and provides guidance on assessment techniques for specific client scenarios, such as head injuries, dyspnea, diabetes, and pain during micturition. Finally, the document includes a fluid balance chart analysis and definitions of key medical terms.

Diploma of Nursing
Nursing Assessment
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Question 1
Nursing assessment is the first stage of the nursing process. State four
reasons why a nursing history is performed on admission?
Nursing history is performed at the time of admission in-order to understand the
patient’s past medical illnesses which serves as a guide for the patient care. It helps
to understand about their cultural values and beliefs so as to plan care based on it. It
helps us to understand about the present signs and symptoms so as to plan care
based on the patient’s needs. It helps the nurses to provide more appropriate care
directly based on their features. Moreover, it helps nurses to develop therapeutic
communication with patients as well as relatives, which helps to render a complete
holistic care to the patient (Douglas, 2012). By understanding the physiological,
psychological, spiritual, cultural and social aspects of patient, nursing assessment
can be framed accurately allowing the nurses to plan appropriate patient- centered
care.
Question 2
Part A
Explain why it is important to involve your client and/or their family whilst
conducting nursing assessments?
Nursing assessments should be conducted directly in patient by observing him/her
so as to identify patient needs and problems. Collecting the history directly will give
an accurate and more appropriate subjective data. Involving family in nursing
assessment will help them to understand the patient’s problem as well as to gain
cooperation from them throughout the nursing care. This will help the nurses to plan
apt nursing care to both the patients (problems) as well as for family coping.
Part B
What is meant by holistic care?
Holistic care is the total or complete care rendered to the patient. This involves
addressing not only the physiological and psychological needs of client but also their
sociological, spiritual, developmental as well as cultural needs (Douglas, 2012).
Question 3
List 4 points relating to the documentation guidelines that you must comply
with when recording any information.
The documents should be clear, legible, concise, accurate and appropriate. Date
and time should be written on every document in order to avoid bias. The involved
nurses should document for her/ him not by others. Overwriting or erasing should
never be done. Only the facts should be entered.
Question 4
You are asked to take vital signs on a client. State 4 indications to complete
vital signs
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1). Vital signs should be assessed at the time of admission of the clients in a hospital
or health care facility. 2). Assessed as routine process in a health care organization
according to the doctor’s order or institutional policy. 3). Before and after a surgery or
diagnostic (invasive) procedures. 4). Before, during as well as after administering
medications to patients that could affect cardio-vascular, temperature- control
measures or respiratory functions.
Question 5
Match the appropriate term with the correct temperature range
Hyperthermic 37.5 – 39.0 0C
Afebrile 36.2 -37.5 0C
Hypothermic 35.0- 36.0 0C
Question 6
It is recommended to take a confused person’s temperature via the oral route
Answer: False
Because the confused patient may bite down the thermometer.
Question 7
Tachycardia is an abnormal pulse rate greater than 100
beats/minute
Question 8
List 4 factors that affect body temperature
1). Age
2). Increased exercise or physical activity
3). Hormonal changes
4). Stress level
Question 9
When taking a client’s pulse, what 3 characteristics must be assessed?
The rate, rhythm, strength and equality of the pulse should be assessed.
Question 10
List the 4 most common sites for taking a pulse measurement.
1).Radial- assessed on the thumb side of forearm or wrist
2). Apical- assessed on 4th to 5th inter-costal space at mid- clavicular line (left).
3). Ulnar- forearm’s or wrist’s ulnar side
4). Carotid- palpated along the sterno-cleidomastoid muscles’ medial edge in neck
(Douglas, 2012).
Question 11
The term for a pulse rate below 60 beats per minute is a
Bradycardia
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Question 12
When taking a client’s respirations, what 3 characteristics must be assessed?
Respiratory rate- by observing the number of full respirations (inspiration and
expiration) in a minute
Respiratory rhythm- involves determination of breathing pattern by observing the
chest/ abdomen
Ventilatory depth- is determined by observing the degree of chest wall movement or
excursion (Douglas, 2012).
Question 13
A normal respiratory rate for a child is 20- 30 breaths per minute.
Question 14
List four factors which may affect pulse oximetry
The light from external sources may interfere with the ability of pulse oximetry in
processing reflected light (Lewis, 2013)
Patient movement may interfere with light processing.
Intravascular dyes can absorb light similar to deoxyhemoglobulin and can lower
oxygen saturation artificially.
Carbon monoxide (from smoke inhalation) can elevate SPO2 artifically by absorbing
light as like oxygen.
Question 15
List the normal range of pulse oximetry in a healthy adult.
Normal range is from 95 to 100 percent in adults.
Question 16
Define systolic blood pressure (SBP)
It is the maximum pressure that is exerted by the blood on the vessel walls at the
time of ventricular systole (when the left-sided ventricle forces blood into aorta). The
normal range of SBP in healthy adults is 90- 140 mmHg (Douglas, 2012).
Question 17
Define diastolic blood pressure (DBP)
It is the minimum pressure exerted by the remaining arterial blood at the time of
ventricles relaxation, just before the commencement of left-sided ventricular
contraction. The normal range of DBP in healthy adults is <90 mm/Hg (Douglas,
2012).
Question 18
An elderly client has a blood pressure of 184/102.
The elderly client has stage- 3 Hypertension as his/her systolic BP is above 180
mmHg and diastolic BP is above 100 mmHg. It shows that the client is at an
increased risk fro developing myocardial infarction and stroke and hence the nurse
should notify this client’s blood pressure to senior staffs and physician for further
management.
Question 19
A client has a urinary tract infection. The client will have an increased level of
White Blood cells present in his urine.
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Question 20
Outline the normal characteristics of urine.
Color : Pale yellow to deep amber. When the urine quantity
increases, the color will be pale while if the urine quantity
decreases, the color will be deep yellow
Odor : mostly odorless
Urine-Volume : 750 to 2000 mL/ 24 hr
pH : 4.5 to 8.0
Appearance : clear without deposits
Specific- gravity : 1.003 to 1.032
Osmolarity-urine : 40 to 1350 mOsmol/ kg
Uro-bilinogen : 0.2 to 1 mg/ 100 mL
WBCs : 0 to 2 HPF
Leukocyte- esterase : Nil
Protein : Nil or trace
Bilirubin : <0.3 mg/ 100 mL
Ketones : Nil
Nitrates : Nil
Blood : Nil
Glucose : Nil
Question 21
The medical term for shortness of breath is
Dyspnea
Question 22
A client’s blood glucose level prior to breakfast was 3.1mmol/l. Result is
It indicates that the client is in hyperglycemic state as his/ her fasting glucose is less
than that of the normal glucose level of 3.89- 6.66 mmol/L
Question 23
The correct formula to calculate the body mass index (BMI) is which of the
following
BMI is a simple index that is used to measure weight relating to height of a person. It
is used to calculate the obesity, overweight or underweight of a person. It is the best
method as compared to the traditional height- weight measurement. It is measured
by dividing weight (Kg) by height (meter- squares) of a client.
BMI= weight (Kg)/ height*2 (m2). The BMI of less than 20 indicates underweight and
above 35 indicates overweight of a person (Park, 2017).
Question 24
A client with a BMI of 33.4 is considered to be
Obese Class- I grade with moderate risk for co morbidities as cardiovascular
diseases, diabetes and hypertension.
Question 25
Blood glucose target ranges may differ depending on age, duration of diabetes
and medications. Normal level is
Fasting glucose (blood) levels: 70 to 120 mg/dl or 3.89 to 6.66 mmol/L
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Post- prandial blood glucose levels: 110 to 140 mg/dl i.e. less than 7.8 mmol/L
Question 26
Erikson’s eight stages of development
Stage Conflict Example
Oral- Sensory Stage
(from birth to one
year)
Trust Vs mistrust Baby will understand that things as well
as persons exist even if they can’t
visualize them. Here trust develops.
Musculo- Anal Stage
(1 to 3 yrs) Autonomy Vs
Shame with Doubt
Child will learn to become self sufficient
in their daily activities such as eating,
toileting, running and talking. Or else
may doubt their abilities.
Locomotor- Genital
Stage
(3 to 5 yrs)
Initiative Vs Guilt Child will try to take adult-like activities
but at times over-stepping their limits
may cause guilt.
Latency Stage
(6 to 11 yrs) Industry Vs
Inferiority
Child will learn to be competent as well
as productive but sometimes may feel
inferior if something went wrong.
Adolescence Stage
(12 to 18 yrs) Identity Vs
Role Confusion
Adolescents will figure out themselves
as ‘Who am I?’ but sometimes confused
about their roles to play.
Young Adult Stage
(19 to 35 yrs) Intimacy Vs
Isolation
Young people seek friendship and love
with other person but at times may
become isolated.
Middle adult Stage
(40 to 65 yrs) Generativity Vs
Stagnation
Middle adult will be productive and
perform needful work, but may become
stagnant at times.
Maturity Stage (65
till death) Integrity Vs
Despair
Older people will make sense of their
lives Or despairing at goals that was not
achieved.
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
The important part of assessment involves performing GCS score assessment,
neurological status assessment as well as determination of CSF leak. In GCS
scoring, eye opening and best verbal along with best motor response should be
graded. The highest grade is 15 and lowest grade is 3 (Lewis, 2013).
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A client who is dyspneic
Standard spirometry should be used to assess the level of dyspnea. Dyspnea can
also be graded by using Borg- category- ratio scale from 0 to 10 to note the level of
shortness of breath encounter by the client.
A client with diabetes
Regardless of types of diabetes, the client should be diagnosed by ruling out if
 Fasting glucose: more than 126 mg/dL or 7.0 mmol/ L
 Random sugar: >200mg/dL or 11.1 mmol/ L
 Two hours- glucose tolerance test: >200mg/dL
A client who is complaining of pain on micturition
Complete urinalysis should be done to rule out the causative organism for urinary
tract infection as pain in micturition mostly occurs due to UTI both in males and
females.
A person who has a plaster cast on their arm post a recent fracture
Peripheral pulses (distal pulse) should be checked once in 2- 4 hours to assess the
blood flow to the arm as the plaster cast may obstruct the blood flow.
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
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The Total intake for the day is 1260
The total output for day is 520
Is Mr Midler in a positive or negative
fluid balance?
+740
Mr Midler is in a positive fluid
balance
(3marks)
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Question 29
What can a urinalysis reveal?
Urinalysis is used to assess the overall health of a person; to diagnose a medical
illness or disorder (urinary tract infections, renal disorders, diabetes and
hypertension) and to monitor a medical condition. Pregnancy testing as well as drug
screenings was also done through urinalysis.
Question 30
Provide a definition for the following terms
Bradycardia
It is a condition in which a person’s heart rate is below 60 beats per min
Tachypnea
It is a condition in which the respiratory rate is more than 20 breaths per minute.
Cyanosis
It is a bluish discoloration of the skin due to decreased oxygenation of tissues. It
could be central or peripheral cyanosis.
Hypotension
It is a condition in which the blood pressure drops below 90/60 mmHg
Question 31
Provide a definition for the following terms
Jaundice
It is condition with yellowish discoloration of the skin, eyes, tissues, as well as
body fluids due to the deposition of bile pigments
Pallor
Pallor indicates pale color of a person’s skin which may be caused by diseases,
emotional stress, shock, use of stimulants and/or anaemia, that results in decreased
oxyhaemoglobin causing visible pallor in the skin eye (conjunctivae) and mucous
membrane.
Turgor
Turgor also called as skin turgor is the degree of elasticity of a person’s skin.
Assessing skin turgor helps to determine the dehydration, or fluid status in a person.
Petechial
It is a smaller reddish/ purple colored spot (1–2 mm) on the skin that occurs due to
minor bleeding from damaged capillaries.
Question 32
When completing a nursing assessment, data that is the client’s perception,
ideas and sensations is known as
Subjective data
Question 33
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What is a holistic assessment?
Holistic assessment is practiced in nursing to provide foundations for client based on
the nursing process. Through this holistic care assessment along with therapeutic
communication and history collection (objective & subjective data), the staff-nurses
will be able to render efficient client- centered care.
Question 34
3 characteristics of a Glasgow Coma scale
 Eye opening
 Best verbal- response
 Best motor- response
Question 35
Part A
Admission assessment of a 4 year old with vomiting and diarrhea
The child should be assessed for his appearance (unwell), altered responsiveness,
decreased urine output, pallor or mottled skin and colder extremities. The child
should be categorized under dehydration grading to know the extent of dehydration
from no clinical symptom to clinical dehydration and shock (Lewis, 2013).
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?
Notify the concerned medical officer immediately about the patient’s allergy. Then
raise mplement computer alerts for particular drug allergy. Wear the patient with
medical bracelet indicating teh drug’s name. Then add the data to the PCEHR.
Question 36
Discharge care plan for Mrs. Marjorie, 83 year old who underwent hip
replacement.
Discharge plan for Mrs. Marjorie should include the entire course of care given to the
patient, medications to be taken with dose, frequency and route, physical activities
(mild/ moderate), diet restrictions along with follow-up instructions (Douglas, 2012).
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;
If the patient is found to be severe hypertensive, I will make the patient to lie down
on the bed. I will check BP of the patient every 15 minutes. I will inform to the
concerned staff nurse and then to the physician for further management. I will raise
the side rails of the bed to enable safety so as to prevent patient fall.
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Part B
List 2 likely causes of this high reading
This could be due to any previous history of cardiovascular, renal diseases or
hypertension. It could be due to decreased venous return due to ageing process.
Question 38
Health education for Jess, 19yrs male with asthma
Jess should be educated about the anatomy and physiology of the respiratory
system. He should be instructed about deep breathing and coughing and
diaphragmatic exercises, method of using inhalers and peak flow meter and the
importance of taking regular medications (Lewis, 2013).
Question 39
Milestone- 7 month old Zoe
I will explain her that mile stones can vary a little between children and it cant be
similar in all children, except in few variations were the milestone is greatly varied
causing developmental delay. The stages of development may vary to some extent
but not to a greater extent.
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
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Reference
Douglas, C. (2012). Potter and Perry’s Fundamentals of Nursing- Australian version.
(4th edition). Elsevier: St. Louis, Missouri
Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing:
Assessment and Management of Clinical Problems. (9th ed.). Missouri:
Mosby.
Park, K. (2017). Park’s Textbook of Prevention and Social Medicine. (24th ed.).
Jabalpur: m/s Banasardidas Bhanot.
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