Ch. 1

Question 1

• 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.

Answer 1

A

Question 2

• 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.

Answer 2

C

Question 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.

Answer 3

A

Question 4

• 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.

Answer 4

C

Question 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 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.

Answer 5

B

Question 6

• 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.

Answer 6

A

Question 7

• 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.

Answer 7

C

Question 8

• 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

Answer 8

D

Question 9

• 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

Answer 9

C

Question 10

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

Answer 10

B

Question 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

Answer 11

A

Question 12

• 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

Answer 12

D

Question 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, sleep
B) Breathing, sleep, pain
C) Sleep, breathing, pain
D) Sleep, pain, breathing

Answer 13

A

Question 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

Answer 14

C

Question 15

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.

Answer 15

A

Question 16

• 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

Answer 16

D

Question 17

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.

Answer 17

D

Question 18

• 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.

Answer 18

D

Question 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 emphasis on the link between health and personal behavior.
D) the means to prevention is through treatment provided by primary health care
practitioners.

Answer 19

C

Question 20

• 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.

Answer 20

C

Question 21

• 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.

Answer 21

D

Question 22

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

Answer 22

C

Question 23

• 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

Answer 23

D

Question 24

• 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.

Answer 24

A

Question 25

• A patient is brought by ambulance to the emergency department with multiple
  traumas received in an automobile accident. He is alert and cooperative, but his injuries arequite severe. How would the nurse proceed with the data collection?

A) Collect history information first, then perform the physical examination and
institute life­saving measures.
B) Simultaneously ask history questions while performing the examination and
initiating life­saving measures.
C) Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
D) Perform life­saving measures and not ask any history questions until he i
transferred to the intensive care unit.

Answer 25

B

Question 26

• A 42­year­old Asian patient is being seen at the clinic for an initial examination.
  The nurse knows that it is important to include cultural information in his health assessment
  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.

Answer 26

D

Question 27

In the health promotion model, the focus of the health professional includes:

A) changing the patient’s perceptions of disease.
B) identifying biomedical model interventions.
C) identifying negative health acts of the consumer.
D) helping the consumer choose a healthier lifestyle.

Answer 27

D

Question 28

• The nurse is classifying nursing diagnoses. Which of these would be considered
  a risk diagnosis?

A) Identifying existing levels of wellness
B) Evaluating previous problems and goals
C) Identifying potential problems the individual may develop
D)
Focusing on strengths and reflecting an individual’s transition to higher levels of
wellness

Answer 28

C

Question 29

The nurse has implemented several planned interventions 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 individual’s condition and compare actual outcomes with expected
outcomes.
D) Interpret data and then identify clusters of cues and make inferences.

Answer 29

C

Question 30

• Which statement best describes a proficient nurse? A proficient nurse is one
  who:

A) has little experience with a specified population and uses rules to guide
performance.
B) has an intuitive grasp of a clinical situation and quickly identifies the accurate
solution.
C) sees actions in the context of daily plans for patients.
D) understands a patient situation as a whole rather than a list of tasks and sees long-
term goals for the patient.

Answer 30

D