1.nursing test banks A) B) C) D) E) Ans: 2. A) B) C) D) Ans: During data collection the nurse may val- idate data by which method? (Select all
... [Show More] that apply) Comparing cues to normal function Referring to textbooks, journals, and re- search reports Checking consistency of cues Clarifying the patient's statements Seeking consensus with colleagues about inferences A, B, C, D, E Feedback: These methods of validating data and in- ferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses. When making an inference from the cues obtained during an assessment, it is im- portant for the nurse to keep what in mind? Validate inferences with the patient Do not share inferences with the patient Document all inferences Avoid making any inferences A The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and in- ferences lead to the development of in- appropriate nursing diagnoses and pa- tient plans of care. While performing the nursing history the nurse notes that the patient states he is 3. A) B) C) D) Ans: 4. A) B) C) D) Ans: having very little pain, but is grimacing and holding his arm throughout the his- tory taking. This observation takes place during which phase of the nursing histo- ry? Preparatory Introductory Maintenance Concluding C Watching the patient to determine if non- verbal cues match their verbal communi- cation typically occurs during the main- tenance, or working, phase of the inter- view. The home care nurse is preparing to perform a nursing history on a newly as- signed adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate? "When I perform the nursing history I will need to ask your family to leave the room." "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." "I will perform a physical assessment while I am obtaining the nursing history." "I will leave a form with you to complete the nursing history information I need." B Nurses are responsible for completing nursing histories, and it usually takes ap- proximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical is performed separately. Family members can offer valuable information as long as the patient gives permission for them to remain present during the history taking. The RN is admitting a patient to a med- ical unit. The nurse delegates the mea- surement of the vital signs to unlicensed assistive personnel (UAP) while she col- lects data. After completing the admis- 5. sion process, the patient complains of a severe headache so the nurse re- assesses the vital signs to find the pa- tient's blood pressure extremely elevat- ed. Whose responsibility is the accuracy of the blood pressure measurement? The company that made the blood pres- sure equipment B) The nurse C) The UAP D) The charge nurse While the nurse may delegate duties to UAP, the professional RN is ultimately responsible for the completeness and accuracy of the information. Since this was part of the admission assessment it would be advisable for the nurse to have measured the vital signs herself. A novice nurse is using the assessment technique of auscultation. What assess- ment finding can the nurse obtain with this method? A) Size of the liver B) Presence of peristalsis C) D) 7. A) B) C) D) E) Ans: 8. A) B) C) Pupil reaction Skin temperature Peristalsis (bowel sounds) are assessed by auscultation with a stethoscope. The size of the liver is determined with per- cussion, inspection yields pupil size, and skin temperature is assessed through palpation. Which of the following are examples of objective data? Patient describing his pain Laboratory results Breath sounds Mother describing her child's asthma at- tack a patient's temperature B, C, E Objective data from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory results, re- ports from other healthcare team mem- bers), physical assessment (e.g., breath sounds, strength of extremities), and measurement devices (e.g., blood pres- sure, temperature) are collected to judge the patient's behavioral responses to nursing interventions. Which of the following would be consid- ered examples of subjective data? Se- lect all that apply. Comments made by the patient's family. Description of a symptom by a patient. D) E) Ans: 9. A) B) C) D) E) A mother telling a nurse what the baby looked like when he was very ill. A nursing assessment of the patient's vital signs. The physical exam notes made by the physician. A, B, C Subjective data are collected from many sources: the patient, family members or significant others, nursing staff, and oth- er healthcare team members. The nurse has identified a priority prob- lem on her unit. Which of the following statements is true regarding addressing a priority problem? Setting priorities involves skipping inter- ventions. Priorities are set at predetermined inter- vals throughout the shift. A priority problem requires a nursing in- tervention before another problem is ad- dressed. Priority of problems is established and continued according to the nursing plan of care. The physician is responsible for deter- mining priority of patient needs. A priority problem requires a nursing in- tervention before another problem is ad- dressed, but setting priorities does not entail skipping any interventions. Setting priorities affects only the order in which nursing interventions are performed. 10. A) B) C) D) 11. A) B) C) D) Ans: 12. A) B) During the interview component of the health assessment, the nurse conveys to the patient that the information is impor- tant by Nodding frequently during the interview Sitting at eye level with the patient Standing next to the patient while inter- viewing Limiting questions to those with yes or no answers When the patient responds to a ques- tion, convey interest by maintaining eye contact, occasionally nodding or verbally responding to his or her remarks. Before conducting a health assessment on a patient, the nurse should first Ask a family member to be present for the assessment Tell the patient the amount of time for the assessment Inform the patient of the procedure done in the assessment Introduce herself or himself to the patient D Introduce yourself to the patient, and explain the nature and purpose of the health assessment. A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a prior- ity? Assess the patient's diet Assess the patient's activity level C) D) 13. A) B) C) D) 14. A) B) C) D) Assess the patient's blood pressure Assess the patient's medication regimen While the diet, activity level, and med- ication regimen should be assessed, the priority intervention for the patient with an unstable blood pressure is to first measure the blood pressure. After assessment of a patient in an am- bulatory clinic, the nurse records the data on the computer. The nurse recog- nizes which of the following as objective data? Auscultation of the lungs Complaint of nausea Sensation of burning in her epigastric area Belief that demons are in her stomach Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, percep- tions, feelings, beliefs, attitudes, and sensations are sources of subjective data. When assessing the patient's pulse, the nurse is using the following assessment technique: Inspection Palpation Percussion Auscultation The pulsations of blood vessels; the outlines of organs such as the thyroid, spleen, or liver; the size, shape and mo- bility of masses; the temperature of the 15. A) B) C) D) 16. A) B) C) D) skin; vibration or movement of blood in a blood vessel; and tenderness or sen- sitivity of a body part are detected by palpation. During the introductory phase of inter- viewing for the purpose of obtaining in- formation for the nursing history, the nurse should Review literature pertinent to the pa- tient's attributes Assess his or her own feelings regarding similar clinical situations Inform the patient of the maintenance of confidentiality Implement supportive nursing interven- tions During the introductory phase, the nurse should inform the patient how the infor- mation will be used and that confidential- ity will be maintained. During the preparatory phase of inter- viewing for the purpose of obtaining in- formation for the nursing history, the nurse should Clarify the patient's health status Review as much information as possible Identify actual and potential nursing di- agnoses Develop the nursing plan of care The preparatory or preinteraction phase occurs when the nurse meets the pa- tient. The nurse should review as much information as possible about the pa- tient. 17. A) B) C) D) 18. A) B) C) D) 19. A) B) C) D) The purpose of obtaining a nursing his- tory is to Assist the physician to establish a med- ical diagnosis Minimize the time required to establish a nursing diagnosis Focus on objective physical data specific to the patient Identify actual and potential nursing di- agnoses The nursing history focuses on the pa- tient's account of the actual or potential health problems and their impact on his or her health status. Which of the following cultural groups may interpret touch by another as an invasion of privacy? Chinese American Spanish American European American African American Patients of Chinese heritage are very modest about having their bodies touched and may find it difficult to perform self-examinations for their own health promotion. A patient is a poor historian of his past medical history. Whom should the nurse consult about the patient's past history? Physician Old chart Social worker Family 20. A) B) C) D) 21. A) B) C) D) 22. Family members or significant others, if available, can provide information for a patient who is confused or incapacitated. The nurse observes the patient as he walks into the room. What information will this provide the nurse? Information regarding the patient's gait Information regarding the patient's per- sonality Information regarding the patient's psy- chosocial status Information on the rate of recovery from surgery Observation includes looking, watching, examining, scrutinizing, surveying, scan- ning, and appraising. What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5' 3" tall? Assess the HDL/LDL levels Obtain an electrocardiogram daily Assess blood pressure with a large cuff Begin patient teaching regarding a low fat diet When assessing an obese patient, a larger blood pressure cuff will likely be needed in order to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cho- lesterol levels and an ECG are ordered. Diet teaching may or may not be war- ranted depending on the cause of the obesity. A) B) C) D) 23. A) B) C) D) 24. A) B) C) D) 25. When assessing an infant, it is important to involve the Parents Siblings Physician Infant The assessment of a child often involves parental assistance. A patient describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a patient's description of pain in the right leg? Explanatory Subjective Objective Severe Cues may be signs (objective) or symp- toms (subjective). Pain is subjectively de- scribed by the patient. When collecting subjective and objective data for a database in a patient's home, it is important to Ask the patient to turn off the television Ask the social worker to verify the collect- ed data Collect a 24-hour diet recall Evaluate the care provided by the physi- cian Distractions such as a television should be minimized. A) B) C) D) 26. A) B) C) D) A nurse is asking questions about a pa- tient's sexual history. It is important for the nurse to Evaluate the patient's past history of sex- ual dysfunction Provide a time that enhances openness Collect data in a quiet, private environ- ment Pull the curtains in a semiprivate room An assessment is best performed in a quiet, private setting that lends itself to the discussion of sensitive, personal, and confidential information. An unconscious patient is brought to the emergency department. Which of the fol- lowing assessments should be imple- mented first? The patient's airway should be as- sessed. The nurse should determine the reason for admission. The nurse should review the patient's medications. The patient's past medical history is as- sessed. Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priori- ty. Often, the patient's difficulty involves airway, breathing, and circulatory prob- lems. A nurse practitioner has a private prac- tice in conjunction with a physician. She is providing psychiatric care to a woman 27. A) B) C) D) 28. C) D) 29. who has a past history of being abused by her husband. During the last visit, she stated that she was planning to leave her husband. On the next visit in 2 weeks, the nurse practitioner will assess her pa- tient's commitment to changing her life situation and her ability to feel empow- ered. What type of assessment is the nurse practitioner implementing? Complete Focus Time-lapsed Emergency Like the focus assessment, the time-lapsed reassessment determines the status of problems already identi- fied. Because of varying time intervals between reassessments, a complete re- view of all functional health patterns is carried out. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? General Time-lapse In focus assessments, the nurse deter- mines whether the problem still exists and whether the status of the problem has changed. In order for a hospital to meet crite- ria regarding nursing care established by the Joint Commission on Accredi- tation of Healthcare Organizations, the A) B) C) D) 30. A) B) C) D) 31. A) B) C) D) nurse must conduct which of the follow- ing types of assessment? Focus Psychosocial Physical Initial The Joint Commission on the Accredi- tation of Healthcare Organizations has mandated that each patient have a doc- umented nursing admission assessment that follows institutional policies. A patient has been discharged from an acute care facility. The first task a home health nurse must accomplish is Care of the patient's physical pain Establish the patient's database Evaluate the care provided previously Receive a report from the nursing staff An initial assessment is performed when the patient enters a healthcare facility, re- ceives care from a home health agency, or is seen for the first time in an outpa- tient clinic. The phase of the nursing process when the nurse gathers data about the patient to establish a plan of care is the Assessment Goals Interventions Evaluation The purpose of the nursing assessment is to gather data about the patient that 32. A) B) C) D) can be used in diagnosing, identifying outcomes, planning, and implementing care. What must the nurse do to identify actual or potential health problems? Evaluate care implemented Meet with significant others Call the physician Gather data from sources The first phase of the nursing process, called assessment, is the collection of data for nursing purposes. [Show Less]