Ch. 1 test bank

Question 1

1. After completing an initial assessment of a 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.

Answer 1

ANS: 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.

Question 2

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.

Answer 2

ANS: 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

Question 3

3. The patients 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

ANS: A

Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.

Question 4

4. When listening to a patients breath sounds, the nurse 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.

Answer 4

ANS: C
When unsure of a sound heard while listening to a patients 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.

Question 5

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.

Answer 5

ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.

Question 6

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.

Answer 6

ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.

Question 7

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 clinicians experience.
d. The patients own preferences are not important with EBP.

Answer 7

ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination
with the clinicians 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.

Question 8

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

Answer 8

ANS: 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).

Question 9

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

Answer 9

ANS: 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).

Question 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

Answer 10

ANS: B

Question 11

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

ANS: 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.

Question 12

12. The nursing process is a sequential method of problem solving that nurses use and includes
    which steps?

Answer 12

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
ANS: D
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.

Question 13

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

Answer 13

ANS: 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.

Question 14

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

ANS: C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process
calls for a nursing diagnosis.

Question 15

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.

Answer 15

ANS: 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.

Question 16

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

Answer 16

ANS: D
Data collection, including performing the health history, physical examination, and interview, is
the assessment step of the nursing process (see Figure 1-2).

Question 17

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 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.

Answer 17

ANS: 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.

Question 18

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 patients health state.
    d. Holistic health views the mind, body, and spirit as interdependent.

Answer 18

ANS: 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.

Question 19

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.

Answer 19

ANS: 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.

Question 20

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. 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.

Answer 20

ANS: D
Objective data are the patients 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.

Question 21

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 nurses primary responsibility for monitoring the patients d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly

Answer 21

ANS: 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, womens 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
persons health care.

Question 22

22. Which situation is most appropriate during which the nurse performs a focused or problemcentered
    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.

Answer 22

ANS: 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.

Question 23

23. 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 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 information changed.

Answer 23

ANS: A
A follow-up data base is used in all settings to follow up short-term or chronic health problems.
The other responses are not appropriate for the situation.

Question 24

Apatient is brought by ambulance to the emergency department with multiple traumas
received in an automobile 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 measures.
b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and coping d.
Perform life-saving measures and delay asking any history questions until the patient is transferred to unit.

Answer 24

ANS: B

Question 25

25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination.
    The nurse knows that including cultural information in his health assessment 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.

Answer 25

ANS: D
The inclusion of cultural considerations in the health assessment is of paramount importance to
gathering data that are accurate and meaningful and to intervening with culturally sensitive and
appropriate care.

Question 26

26. In the health promotion model, the focus of the health 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.

Answer 26

ANS: D
In the health promotion model, the focus of the health professional is on helping the consumer
choose a healthier lifestyle

Question 27

27. 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 individuals condition, and compare actual outcomes with expected outcomes.
    d. Interpret data, and then identify clusters of cues and make inferences.

Answer 27

ANS: C
Evaluation is the next step after the implementation phase of the nursing process. During this
step, the nurse evaluates the individuals condition and compares the actual outcomes with
expected outcomes