NUTRITION EXAM 2: STUDY GUIDE (Latest solution guide, A+ Rated)
NUTRITION EXAM 2: STUDY GUIDE
CHAPTER 1
1.After completing an initial assessment of a
... [Show More] patient, the nurse has charted that his respirations
are eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
A
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data is what the
person says about him or herself during history taking. The terms reflective and
introspective are not used to describe data.
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types
of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
C
Subjective data are what the person says about him or herself during history taking.
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. The terms reflective and
introspective are not used to describe data.
3. The patient’s record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
A
Together with the patient’s record and laboratory studies, the objective and subjective
data form the data base. The other items are not part of the patient’s record, laboratory
studies, or data.
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.
The nurse’s next action should be to:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was
heard.
c. Validate the data by asking a coworker to
listen to the breath sounds.
d. Assess again in 20 minutes to note
whether the sound is still present.
C
When unsure of a sound heard while listening to a patient’s breath sounds, the nurse
validates the data to ensure accuracy. If the nurse has less experience in an area, then he
or she asks an expert to listen.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, without a background of skills and
experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
A
Intuition is characterized by pattern recognition—expert nurses learn to attend to a
pattern of assessment data and act without consciously labeling it. The other options are
not correct.
7. The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
a. EBP relies on tradition for support of best
practices.
b. EBP is simply the use of best practice
techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence
with the clinician’s experience.
d. The patient’s own preferences are not
important with EBP.
C
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinician’s experience, as well as patient preferences and values,
when making decisions about care and treatment. EBP is more than simply using the best
practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes
who needs diabetic teaching
c. Individual with a small laceration on the
sole of the foot
d. Individual with shortness of breath and
respiratory distress
D
First-level priority problems are those that are emergent, life threatening, and immediate
(e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring
abnormal vital signs) (see Table 1-1).
9. When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
C
Second-level priority problems are those that require prompt intervention to forestall
further deterioration (e.g., mental status change, acute pain, abnormal laboratory values,
risks to safety or security) (see Table 1-1).
10. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
B
Clustering related cues helps the nurse see relationships among the data.
11. The nurse knows that developing appropriate nursing interventions for a patient relies on
the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions
to achieve outcomes for which the nurse is accountable. The other items do not contribute
to the development of appropriate nursing interventions.
12. The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning,
evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis,
treatment, and discharge planning
c. Admission, diagnosis, treatment,
evaluation, and discharge planning
d. Assessment, diagnosis, outcome
identification, planning, implementation,
and evaluation
D
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
A
First-level priority problems are immediate priorities, remembering the ABCs (airway,
breathing, and circulation), followed by second-level problems, and then third-level
problems.
14. Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment
C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing
process calls for a nursing diagnosis.
15. Barriers to incorporating EBP include:
a. Nurses’ lack of research skills in
evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills.
A
As individuals, nurses lack research skills in evaluating the quality of research studies,
are isolated from other colleagues who are knowledgeable in research, and often lack the
time to visit the library to read research. The other responses are not considered barriers.
16. What step of the nursing process includes data collection by health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
D
Data collection, including performing the health history, physical examination, and
interview, is the assessment step of the nursing process (see Figure 1-2).
17. During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which suggestion
by the nurse manager would best help these problems?
a. Form a committee to conduct research
studies.
b. Post published research studies on the
unit’s bulletin boards.
c. Encourage the nurses to visit the library to
review studies.
d. Teach the nurses how to conduct
electronic searches for research studies.
D
Facilitating support for EBP would include teaching the nurses how to conduct electronic
searches; time to visit the library may not be available for many nurses. Actually
conducting research studies may be helpful in the long-run but not an immediate solution
to reviewing existing research.
18. When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external
environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient’s
health state.
d. Holistic health views the mind, body, and
spirit as interdependent.
D
Consideration of the whole person is the essence of holistic health, which views the mind,
body, and spirit as interdependent. The basis of disease originates from both the external
environment and from within the person. Both the individual human and the external
environment are open systems, continually changing and adapting, and each person is
responsible for his or her own personal health state.
19. The nurse recognizes that the concept of prevention in describing health is essential
because:
a. Disease can be prevented by treating the
external environment.
b. The majority of deaths among Americans
under age 65 years are not preventable.
c. Prevention places the emphasis on the link
between health and personal behavior.
d. The means to prevention is through
treatment provided by primary health care
practitioners.
C
A natural progression to prevention rounds out the present concept of health. Guidelines
to prevention place the emphasis on the link between health and personal behavior.
20. The nurse is performing a physical assessment on a newly admitted patient. An example
of objective information obtained during the physical assessment includes the:
a. Patient’s history of allergies.
b. Patient’s use of medications at home.
c. Last menstrual period 1 month ago.
d. 2 5 cm scar on the right lower forearm.
D
Objective data are the patient’s record, laboratory studies, and condition that the health
professional observes by inspecting, percussing, palpating, and auscultating during the
physical examination. The other responses reflect subjective data.
21. A visiting nurse is making an initial home visit for a patient who has many chronic
medical problems. Which type of data base is most appropriate to collect in this setting?
a. A follow-up data base to evaluate changes
at appropriate intervals
b. An episodic data base because of the
continuing, complex medical problems of
this patient
c. A complete health data base because of
the nurse’s primary responsibility for
monitoring the patient’s health
d. An emergency data base because of the
need to collect information and make
accurate diagnoses rapidly
C
The complete data base is collected in a primary care setting, such as a pediatric or family
practice clinic, independent or group private practice, college health service, women’s
health care agency, visiting nurse agency, or community health agency. In these settings,
the nurse is the first health professional to see the patient and has the primary
responsibility for monitoring the person’s health care.
22. Which situation is most appropriate during which the nurse performs a focused or
problem-centered history?
a. Patient is admitted to a long-term care
facility.
b. Patient has a sudden and severe shortness
of breath.
c. Patient is admitted to the hospital for
surgery the following day.
d. Patient in an outpatient clinic has cold and
influenza-like symptoms.
D
In a focused or problem-centered data base, the nurse collects a “mini” data base, which
is smaller in scope than the completed data base. This mini data base primarily concerns
one problem, one cue complex, or one body system [Show Less]