1. After completing an initial assessment of a patient, the A nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute.
... [Show More] These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. 2. A patient tells the nurse that he is very nervous, is C nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. 3. The patients record, laboratory studies, objective A data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. 4. When listening to a patients breath sounds, the nurse C is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients 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. 5. The nurse is conducting a class for new graduate B nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a back- ground 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. 6. Expert nurses learn to attend to a pattern of assess- A ment 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. 7. The nurse is reviewing information about evi- C dence-based practice (EBP). Which statement best re- flects 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 clinicians experience. d. The patients own preferences are not important with EBP. 8. The nurse is conducting a class on priority setting for D 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 9. When considering priority setting of problems, the C nurse keeps in mind that second-level priority prob- lems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs 10. Which critical thinking skill helps the nurse see rela- B tionships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant 11. The nurse knows that developing appropriate nursing A interventions for a patient relies on the appropriate- ness of the diagnosis. a. Nursing b. Medical c. Admission d. Collaborative 12. The nursing process is a sequential method of prob- D lem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, dis- charge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and dis- charge planning d. Assessment, diagnosis, outcome identification, plan- ning, implementation, and evaluation 13. A newly admitted patient is in acute pain, has not been A 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 14. Which of these would be formulated by a nurse using C diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment 15. Barriers to incorporating EBP include: A 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. 16. What step of the nursing process includes data col- D lection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment 17. During a staff meeting, nurses discuss the problems D with accessing research studies to incorporate evi- dence-based clinical decision making into their prac- tice. 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 units 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. 18. When reviewing the concepts of health, the nurse D 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 patients health state. d. Holistic health views the mind, body, and spirit as interdependent. 19. The nurse recognizes that the concept of prevention C 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 provid- ed by primary health care practitioners. 20. The nurse is performing a physical assessment on D a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm. 21. A visiting nurse is making an initial home visit for C 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 appro- priate 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 nurs- es primary responsibility for monitoring the patients health d. An emergency data base because of the need to col- lect information and make accurate diagnoses rapidly 22. Which situation is most appropriate during which the D nurse performs a focused or problem-centered histo- ry? 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 influen- za-like symptoms. 23. A patient is at the clinic to have her blood pressure A checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history informa- tion may have changed. 24. A patient is brought by ambulance to the emergency B department with multiple traumas received in an au- tomobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life-saving mea- sures. b. Simultaneously ask history questions while perform- ing the examination and initiating life-saving mea- sures. c. Collect all information on the history form, including social support patterns, strengths, and coping pat- terns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit. 25. A 42-year-old patient of Asian descent is being seen at D the clinic for an initial examination. The nurse knows that including cultural information in his health as- sessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care. 26. In the health promotion model, the focus of the health D professional includes: a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle. 27. The nurse has implemented several planned interven- C tions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individuals condition, and compare actu- al outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences. [Show Less]