Ch. 1 Flashcards
- After completing an initial assessment on a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58. This type of data would be:
A) objective.
B) reflective.
C) subjective.
D) introspective.
A
- A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.” This type of data would be:
A) objective.
B) reflective.
C) subjective.
D) introspective.
C
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
- When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard. The nurse’s next action should be to:
A) notify the patient’s physician immediately.
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
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 to draw from, are more likely to make their decisions using:
A) intuition.
B) a set of rules.
C) articles in journals.
D) advice from supervisors.
B
- Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as:
A) intuition.
B) the nursing process.
C) clinical knowledge.
D) diagnostic reasoning.
A
- The nurse is reviewing information about evidencebased practice (EBP). Which
statement best reflects evidencebased practice?
A) EBP relies on tradition for support of best practices.
B) EBP is simply the use of best practice techniques for 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
- The nurse is conducting a class on priority setting for a group of new graduate
nurses. Which is an example of a firstlevel priority problem?
A) A patient with postoperative pain
B) A newly diagnosed diabetic who needs diabetic teaching
C) An individual with a small laceration on the sole of the foot
D) An individual with shortness of breath and respiratory distress
D
- When considering priority setting of problems, the nurse keeps in mind that
secondlevel priority problems include which of these aspects?
A) Low selfesteem
B) Lack of knowledge
C) Abnormal laboratory values
D) Severely abnormal vital signs
C
Which critical thinking skill helps the nurse to see relationships among the
data?
A) Validation
B) Clustering related cues
C) Identifying gaps in data
D) Distinguishing relevant from irrelevant
B
- 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
- The nursing process is a sequential method of problem solving that nurses use,
and includes which steps?
A) Assessment, treatment, planning, evaluation, discharge, followup
B) Admission, assessment, diagnosis, treatment, discharge planning
C) Admission, diagnosis, treatment, evaluation, discharge planning
D) Assessment, diagnosis, outcome identification, planning, implementation, evaluation
D
- 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, sleep
B) Breathing, sleep, pain
C) Sleep, breathing, pain
D) Sleep, pain, breathing
A
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
Barriers to incorporating evidencebased practice (EBP) include:
A) nurses’ lack of research skills in evaluating quality of research studies.
B) lack of significant research studies.
C) insufficient clinical skills of nurses.
D) inadequate physical assessment skills.
A
- What is the step of the nursing process that includes data collection by health
history, physical examination, and interview?
A) Planning
B) Diagnosis
C) Evaluation
D) Assessment
D
During a staff meeting, nurses discuss the problems with accessing research
studies in order to incorporate evidencebased clinical decision making into their practice. hich suggestion by the nurse manager would best help this problem?
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
- When reviewing concepts of health, the nurse recalls that 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
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 emphasis on the link between health and personal behavior.
D) the means to prevention is through treatment provided by primary health care
practitioners.
C
- The nurse is reviewing the components of the nursing process. Which statement
about nursing diagnoses is true?
A) They evaluate the etiology of disease.
B) They are a process based on the medical diagnosis.
C) They are clinical judgments about a person’s response to an actual or potential
health state.
D) They focus on the function and malfunction of a specific organ system in response to disease.
C
- 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 present on the right lower forearm.
D
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 followup data base to evaluate changes at appropriate intervals
B) An episodic data base because of the continuing, complex medical problems of thispatient
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 rapidly collect information and
make accurate diagnoses
C
- Which situation is most appropriate for the nurse to perform a focused or
problemcentered history?
A) A patient’s admission to a longterm care facility
B) A patient has sudden, severe shortness of breath
C) A patient’s admission to the hospital for surgery the following day
D) A patient in an outpatient clinic has cold and flulike symptoms
D
- A patient is at the clinic to have her blood pressure checked. She has been
coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
A) collect a followup 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 information may have changed.
A
