Unit 3.1: Nursing Assessment Frameworks

• Topic 01

  Activities of Daily Living — Roper–Logan–Tierney Model

  45 questions
• Topic 02

  Holistic Assessment

  30 questions
• Topic 03

  Admission Assessment and Baseline Observations

  45 questions
• Topic 04

  Risk Assessment Tools

  45 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A patient with known anxiety disorder reports that their anxiety is 10/10 during the holistic assessment. The nurse observes that the patient is calm in appearance, speaking clearly, and engaging well with questions. A student nurse suggests documenting 'patient appears calm — subjective report inconsistent with objective findings'. Why is this documentation approach problematic?

   • A
     The student nurse is correct; appearing calm while reporting severe anxiety indicates the patient may not have capacity to self-report reliably
   • B
     The student nurse is correct; when objective and subjective findings conflict, the objective finding should be documented as the primary assessment
   • C
     The documentation is acceptable provided the nurse also refers to the psychological domain specialist team
   • D
     It privileges objective observation over subjective self-report, which is clinically unsafe in anxiety assessment; the nurse's observation of calm behaviour does not invalidate the patient's experience of severe internal anxiety
     Correct answer
   Explanation

   Anxiety is a predominantly internal subjective experience; external appearance of calm does not reflect the severity of internal distress. Many individuals with anxiety disorders present outwardly composed while experiencing severe symptoms (sometimes described as 'high-functioning anxiety'). Dismissing the patient's self-report as inconsistent risks failing to provide appropriate psychological support. Under NMC Code Section 2, nurses must listen to patients and respond to their preferences and concerns, not discount them because the nurse's observation does not match the report.

2. Under NICE NG89, within how many hours of admission must VTE risk assessment be completed?

   • A
     6 hours
   • B
     72 hours
   • C
     4 hours
   • D
     14 hours
     Correct answer
   Explanation

   NICE Guideline NG89 (Venous thromboembolism in over 16s: reducing the risk of hospital-acquired DVT or PE, 2018, updated 2023) requires VTE risk assessment to be completed within 14 hours of hospital admission for all adult patients. This tight timeframe reflects the risk that VTE can develop within hours of immobility, particularly in post-operative or acutely ill patients.

3. A patient with chronic heart failure is admitted for the fourth time in six months. Holistic assessment reveals: physical domain — fluid overload and weight gain of 3 kg; psychological domain — low mood and poor understanding of fluid restriction; social domain — lives alone, no carer, reduced mobility limiting shopping; spiritual/cultural domain — fatalistic about prognosis. How should the nurse use all four domain findings to develop a comprehensive care plan?

   • A
     Prioritise the psychological domain over the physical because non-adherence to fluid restriction is the root cause of the readmission
   • B
     Prioritise the spiritual/cultural domain because the patient's fatalism represents a safeguarding concern requiring an urgent mental health review
   • C
     Develop separate care plans for each domain and ask the patient to choose which one they want the nursing team to action first
   • D
     Address fluid overload immediately (physical), provide structured education about fluid restriction matched to the patient's health literacy (psychological), arrange a social needs assessment and consider meal delivery services (social), and explore the patient's end-of-life wishes sensitively given their fatalism and recurrent admissions (spiritual/cultural)
     Correct answer
   Explanation

   This scenario illustrates the interdependence of all four holistic assessment domains. The physical problem (fluid overload) is the presenting emergency. The psychological finding (low health literacy and low mood) explains why self-management has failed. The social finding (isolation, limited access to appropriate food) explains why adherence to dietary restrictions is difficult despite motivation. The spiritual finding (fatalism about prognosis) signals an unmet need for advance care planning. All four domains must inform the care plan; addressing only the physical domain will result in a fifth admission.