Practice Ch1

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

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

Question 3

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

ANS: A

Question 4

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.

Answer 4

ANS: C

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

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

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 clinician’s experience.
   d.
   The patient’s own preferences are not important with EBP.

Answer 7

ANS: C

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

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

Question 10

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

Question 12

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

Answer 12

ANS: D

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

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

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

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

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 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

ANS: D

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 patient’s health state.
    d.
    Holistic health views the mind, body, and spirit as interdependent.

Answer 18

ANS: D

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

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.
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.

Answer 20

ANS: D

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 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

Answer 21

ANS: C

Question 22

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.

Answer 22

ANS: D

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 may have changed.

Answer 23

ANS: A

Question 24

24. 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 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 patterns.
    d.
    Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care 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

Question 26

26. 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 26

ANS: D

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 individual’s condition, and compare actual outcomes with expected outcomes.
    d.
    Interpret data, and then identify clusters of cues and make inferences.

Answer 27

ANS: C

Question 28

28. 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 recognizes the long-term goals for the patient.

Answer 28

ANS: D

Question 29

29.	The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
a.
Inspiratory wheezes noted in left lower lobes
b.
Hypoactive bowel sounds
c.
Nonproductive cough
d.
Edema, +2, noted on left hand
e.
Patient reports dyspnea upon exertion
f.
Rate of respirations 16 breaths per minute

Answer 29

ANS: A, C, E, F