Week 3 Sherpath Flashcards
Which characteristics are reflective of critical thinkers?
Select all that apply.
Aware of their personal biases
Open-minded
Impulsive
Listen well
Emotionally reactive
Aware of their personal biases
Open-minded
Listen well
According to Paul and Elder, clinical thinking requires which components?
Select all that apply.
Emotion
Thought process
Reasoning
Intellectual standards
Intellectual traits
Thought process
Reasoning
Intellectual standards
Intellectual traits
Match the intellectual standard associated with the Paul and Elder Framework with the descriptive question.
Do I have a bias that needs to be addressed?
Does the answer make sense?
Can the thought be proven correct?
Are more details necessary?
Answer choices
Significance
Precision
Logic
Accuracy
Fairness
Depth
Do I have a bias that needs to be addressed?
Fairness
Does the answer make sense?
Logic
Can the thought be proven correct?
Accuracy
Are more details necessary?
Precision
Which description best corresponds to the term clinical judgment?
Used when discussing management scenarios or the reasoning process with nursing leadership
Requires recalling facts and recognizing patterns seen previously when caring for patients
Specific thought process used in nursing when analyzing, evaluating, and managing a patient
Similar to clinical reasoning but considered a broader term in nursing
Requires recalling facts and recognizing patterns seen previously when caring for patients
According to Alfaro-LeFevre, which factors can affect a nurse’s ability to think critically?
Select all that apply.
Life experience
Self-confidence
Gender
Nursing role
Moral development
Life experience
Self-confidence
Moral development
Which characteristic of both the nursing process and the Clinical Judgment Measurement Model refers to changes over time in response to patients’ individual needs?
Dynamic
Analytical
Organized
Adaptable
Dynamic
Which activities would best promote critical thinking in nursing?
Select all that apply.
Asking a peer to clarify their thoughts when discussing a specific nursing situation
Creating a critique map for a complicated patient to provide visual representation of nursing care plans
The newly graduated registered nurse identifying an experienced coworker to have as a mentor
Writing about a specific patient experience and lessons learned from the experience
The nurse manager deciding the staff meeting should be scheduled on an as-needed basis
Asking a peer to clarify their thoughts when discussing a specific nursing situation
The newly graduated registered nurse identifying an experienced coworker to have as a mentor
Writing about a specific patient experience and lessons learned from the experience
The nurse is caring for a patient who has been prescribed a blood transfusion after a traumatic injury. The nurse confirms it is the correct patient by reading his hospital wristband and verbally asking the patient his name and date of birth. The blood type is confirmed with a second nurse before initiation of the transfusion. This scenario is an example of which activity that enhances effective communication?
Situation, Background, Assessment, Recommendation (SBAR)
Time-out
Daily rounds
Concept map
Time-out
Match the factor that hinders critical thinking with the correct description.
Not gathering all the facts before reaching a conclusion
Having an expectation of a result without selecting specific evidence
Jumping to conclusions; not clearly thinking through presented information
Believing the presented information is factual without validating first
Answer choices
Lack of information
Illogical thinking
Confirmation bias
Tunnel vision
Erroneous assumption
Close-mindedness
Not gathering all the facts before reaching a conclusion
Lack of information
Having an expectation of a result without selecting specific evidence
Tunnel vision
Jumping to conclusions; not clearly thinking through presented information
Illogical thinking
Believing the presented information is factual without validating first
Erroneous assumption
The nurse is caring for a patient who is pregnant with her fifth child and considering terminating the pregnancy. The patient has asked the nurse for more information. For the past 2 years, the nurse has been unsuccessful in her own attempts to become pregnant. Which intellectual standard is the nurse most likely to have difficulty applying in this situation?
Humility
Empathy
Integrity
Perseverance
Empathy
Critical thinking is a conscious decision not to accept something at face value and instead attempt to analyze it from all perspectives. Which actions are considered part of the critical-thinking process?
Select all that apply.
Identifying the concern
Determining which information is most relevant
Gathering the input of others
Vetting the information presented
Quickly determining a resolution
Identifying the concern
Determining which information is most relevant
Gathering the input of others
Vetting the information presented
Match the intellectual standard with the scenario that represents it.
The nurse completely understands the complexities of the issue.
The nurse’s perspective has been confirmed as factual.
Others understand the nurse’s point of view.
The nurse focuses on the most important aspects of the situation.
Answer choices
Accuracy
Depth
Precision
Significance
Clarity
Breadth
The nurse completely understands the complexities of the issue.
Depth
The nurse’s perspective has been confirmed as factual.
Accuracy
Others understand the nurse’s point of view.
Clarity
The nurse focuses on the most important aspects of the situation.
Significance
According to Alfaro-LeFevre, which individual should be most adept at thinking critically?
A 40-year-old man who has only lived in a small town and never traveled outside of his state
A 22-year-old woman whose father was in the military, requiring her to live in Germany, England, California, Florida, and Missouri
A 36-year-old person with high self-esteem and self-confidence
A 19-year-old freshman in college who is majoring in communication
A 22-year-old woman whose father was in the military, requiring her to live in Germany, England, California, Florida, and Missouri
Which actions demonstrate a nurse using the Clinical Judgment Measurement Model (CJMM) and critical thinking when a patient reports increased pain at the surgical site?
Select all that apply.
Verifying that no pain medications were prescribed after surgery and calling the health care provider to inform them of the patient’s change in status to see if pain medications can be given
Determining whether pain medications were prescribed postoperatively, then compassionately relaying to the patient that no pain medications were prescribed for them
Using nonpharmaceutical treatment of focused deep breathing and imagery to help relieve the patient of pain after verifying that no pain medications were prescribed
Assessing the patient’s vital signs and verifying which pain medications were prescribed and when pain medication was last given to the patient
Assessing the surgical site to determine whether infection could be the cause of increased pain
Verifying that no pain medications were prescribed after surgery and calling the health care provider to inform them of the patient’s change in status to see if pain medications can be given
Using nonpharmaceutical treatment of focused deep breathing and imagery to help relieve the patient of pain after verifying that no pain medications were prescribed
Assessing the patient’s vital signs and verifying which pain medications were prescribed and when pain medication was last given to the patient
Assessing the surgical site to determine whether infection could be the cause of increased pain
Match the description of the nurse with the appropriate career stage.
A nurse with 3 years of experience, who just started working in the ICU
A nurse with 18 months of experience in the cardiac step-down unit
The charge nurse in the neonatal ICU
The neurosurgery unit staff educator nurse
Answer choices
Competent
Novice
Advanced beginner
Proficient
Expert
A nurse with 3 years of experience, who just started working in the ICU
Novice
A nurse with 18 months of experience in the cardiac step-down unit
Advanced beginner
The charge nurse in the neonatal ICU
Proficient
The neurosurgery unit staff educator nurse
Expert
An experienced nurse, who is precepting a new nurse, is caring for a critically ill patient and just placed a feeding tube as prescribed. After auscultation of air into the stomach to confirm tube placement, the preceptor initiates the tube feeding. The new nurse questions the starting of feeds without verifying nasogastric (NG) tube placement by x-ray, which is the new standard of care. The preceptor responds, “I have been a nurse for 20 years, and I have always verified placement by auscultation of air into the stomach.” This response is an example of which activity that can hinder critical thinking?
Bias
Erroneous assumption
Illogical thinking
Close-mindedness
Close-mindedness
The emergency department (ED) nurse is handing off care of a patient to the intensive care unit (ICU) nurse. The ED nurse is giving report using the Situation, Background, Assessment, Recommendation (SBAR) method. The ED nurse tells the ICU nurse that the patient is admitted for respiratory distress and is currently homeless. Which SBAR communication element does this scenario represent?
Situation
Background
Assessment
Recommendation
Background
Match the clinical reasoning process with its descriptor.
Recognizing the detail that is most important in the scenario
Identifying which tasks are most important and should be performed first
Identifying which tasks can be delegated
Recognizing that the action is necessary and professional
Answer choices
Right reason
Right expertise
Right patient
Right action
Right time
Right cue
Recognizing the detail that is most important in the scenario
Right cue
Identifying which tasks are most important and should be performed first
Right time
Identifying which tasks can be delegated
Right action
Recognizing that the action is necessary and professional
Right reason
Which nursing skill is essential to utilize throughout the nursing process?
Analysis
Observation
Critical thinking
Time management
Critical thinking
Place the steps of the nursing process in the order in which each should occur.
Evaluation
Implementation
Analysis
Planning
Assessment
Assessment
Analysis
Planning
Implementation
Evaluation
Match the nursing process characteristic to its description.
The nursing process incorporates the interprofessional team.
Nurses evaluate patient results to determine effectiveness.
Nurses use critical thinking for each step of the nursing process.
The nursing process helps ensure that patient care is well planned.
Answer Choices
Collaborative
Organized
Outcome-oriented
Analytical
The nursing process incorporates the interprofessional team.
Collaborative
Nurses evaluate patient results to determine effectiveness.
Outcome-oriented
Nurses use critical thinking for each step of the nursing process.
Analytical
The nursing process helps ensure that patient care is well planned.
Organized
Which component determines whether an assessment is primary or secondary?
Source of data
Types of data
Categories of data
Objectivity of the data
Source of data
Match the category of data with its description.
Obtained directly from patient
Blood pressure reading and weight
Direct quotes describing patient feelings
Obtained from other health care professionals or medical records
Answer Choices
Objective
Subjective
Secondary
Primary
Obtained directly from patient
Primary
Blood pressure reading and weight
Objective
Direct quotes describing patient feelings
Subjective
Obtained from other health care professionals or medical records
Secondary
Which examples reflect subjective data?
Select all that apply.
Signs
Feelings
Symptoms
Perceptions
Laboratory findings
Health history
Feelings
Symptoms
Perceptions
Health history
Which nursing concept is defined as an actual or potential problem or response to a problem?
Plan
Outcome
Diagnosis
Assessment
Diagnosis
Which aspects do nurses make judgments about when determining initial nursing diagnoses?
Select all that apply.
Vulnerabilities
Patient problems
Health promotion
Risk for problems
Evaluative measures
Vulnerabilities
Patient problems
Health promotion
Risk for problems
Which action reflects a primary task in the analysis step of the nursing process?
Initiating nursing actions
Forming diagnostic conclusions
Identifying realistic patient goals
Examining the effectiveness of interventions
Forming diagnostic conclusions
Which term describes how the nursing process changes over time in response to patients’ individual needs?
Dynamic
Analytical
Organized
Adaptable
Dynamic
Which statement defines collaborative interventions?
Involve independent nursing interventions
Establish the effectiveness of nursing actions
Require a prescription from the health care provider
Involve the expertise of health care team members
Involve the expertise of health care team members
Match the type of nursing intervention to the example.
Patient positioning
Foley catheter insertion
Respiratory therapy consult
Answer choices
Independent
Interdependent
Dependent
Patient positioning
Independent
Foley catheter insertion
Dependent
Respiratory therapy consult
Interdependent
Which function describes the primary purpose for documenting nursing interventions?
Implement policy.
Prove task completion.
Facilitate communication.
Ensure proper record-keeping.
Facilitate communication.
Which interventions reflect indirect nursing care?
Select all that apply.
Giving an injection
Helping a patient ambulate in the hall
Documenting medications administered
Collaborating to schedule occupational therapy
Working with a social worker to set up home care
Documenting medications administered
Collaborating to schedule occupational therapy
Working with a social worker to set up home care
During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur.
Review and revise the existing plan of care.
Reassess the patient.
Organize resources and care delivery.
Implement nursing interventions.
Anticipate and prevent complications.
Reassess the patient.
Review and revise the existing plan of care.
Organize resources and care delivery.
Anticipate and prevent complications.
Implement nursing interventions.
Which aspect would the nurse consider as a component of the evaluation step of the nursing process?
The patient being discharged from the hospital
The patient’s achievement of short- and long-term goals
The nurse’s completion of interventions in the plan of care
The nurse’s view on the patient’s desire to perform interventions
The patient’s achievement of short- and long-term goals
Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?
Select all that apply.
Recognizing errors
Gathering patient cues
Documenting patient progress
Comparing achieved effect with goals
Examining results according to clinical findings
Recognizing errors
Comparing achieved effect with goals
Examining results according to clinical findings
Which questions would the nurse ask when revising the plan of care because of unmet patient goals?
Select all that apply.
Were the original goals realistic?
What unanticipated events occurred?
Were the original goals collaborative?
What steps in the process can be handled differently?
What barriers did the patient encounter that prevented goal attainment?
Were the original goals realistic?
What unanticipated events occurred?
What steps in the process can be handled differently?
What barriers did the patient encounter that prevented goal attainment?
Which questions would the nurse ask when revising the plan of care because of unmet patient goals?
Select all that apply.
Were the original goals realistic?
What unanticipated events occurred?
Were the original goals collaborative?
What steps in the process can be handled differently?
What barriers did the patient encounter that prevented goal attainment?
Were the original goals realistic?
What unanticipated events occurred?
What steps in the process can be handled differently?
What barriers did the patient encounter that prevented goal attainment?
Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care?
Select all that apply.
It is organized.
It is outcome-oriented.
It necessitates observation skills.
It allows nurses to apply knowledge.
It requires nurses to think analytically.
It incorporates an interprofessional team.
It is organized.
It is outcome-oriented.
It allows nurses to apply knowledge.
It requires nurses to think analytically.
It incorporates an interprofessional team.
Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?
American Academy of Nursing
National Student Nurses Association
National League for Nursing
American Nurses Association
American Nurses Association
Which questions are critical for the nurse to ask during each step in the nursing process?
Select all that apply.
Were patient goals met?
Can interventions be universally applied?
Is collected data thorough and accurate?
Could interventions affect the patient negatively?
Are all underlying factors addressed in the plan of care?
Is collected data thorough and accurate?
Could interventions affect the patient negatively?
Are all underlying factors addressed in the plan of care?
Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?
Analysis
Evaluation
Assessment
Implementation
Assessment
Which type of data do the patient’s family members, friends, or other nurses provide?
Primary
Objective
Secondary
Comprehensive
Secondary
Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health?
General
Holistic
Focused
Universal
Holistic
Which nursing action occurs during the analysis step of the nursing process?
Initiating nursing interventions and treatments
Identifying realistic goals that are patient-focused
Clustering patient data to identify patient problems
Gathering patient data through a variety of sources
Clustering patient data to identify patient problems
Which phrase describes the primary purpose of nursing analysis and diagnosis?
Resolves patient confusion
Communicates patient problems
Articulates the nursing scope of practice
Describes the medical context of the patient problem
Communicates patient problems
Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process?
Select all that apply.
Provides a standardized nursing language
Outlines categories for patient information
Categorizes priorities based on importance
Identifies common labels for nursing diagnoses
Provides point-of-care documentation for clinical activity
Provides a standardized nursing language
Identifies common labels for nursing diagnoses
Provides point-of-care documentation for clinical activity
During which step of the nursing process would the nurse prioritize nursing diagnoses?
Planning
Analysis
Evaluation
Assessment
Planning
During which step of the nursing process would the nurse establish long-term goals with the patient?
Planning
Analysis
Evaluation
Implementation
Planning
Which part of the nursing process involves the nurse setting short-term goals for the patient?
Planning
Diagnosis
Evaluation
Assessment
planning
Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs?
Planning
Analysis
Evaluation
Implementation
Implementation
Which intervention reflects direct nursing care?
Giving an injection
Asking the health care provider to prescribe a special diet
Documenting nursing interventions
Working with a social worker to set up home care
Giving an injection
Which statements reflect the nurse’s role during the implementation step of the nursing process?
Select all that apply.
Be accountable for safe practice.
Consult with the health care provider.
Collaborate with support services.
Perform the steps of intervention accurately.
Understand why an intervention is planned.
Be accountable for safe practice.
Perform the steps of intervention accurately.
Understand why an intervention is planned.
Which step of the nursing process considers the effectiveness of nursing care?
Planning
Analysis
Evaluation
Implementation
Evaluation
Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care?
Planning
Evaluation
Assessment
Implementation
Evaluation
Which questions would the nurse ask to evaluate the effectiveness of nursing interventions?
Select all that apply.
Should the plan of care be discontinued?
Which nursing diagnosis covers this cluster of signs and symptoms?
Have new assessment data been identified that should be considered?
Did the patient meet the goals established during the implementation phase?
Does the plan of care need to be modified in response to patient changes?
Should the plan of care be discontinued?
Have new assessment data been identified that should be considered?
Does the plan of care need to be modified in response to patient changes?
Which data sources are examples of secondary data?
Select all that apply.
Patient chart
Laboratory test results
Statements made by the patient
Information from another health care provider
Statements made by a family member
Patient chart
Laboratory test results
Information from another health care provider
Statements made by a family member
Which assessment cues have a subjective classification?
Select all that apply.
Nausea
Headache
Lesions on leg
Facial grimacing
Blood pressure 110/78 mm Hg
Nausea
Headache
Match the type of patient cue organization model with its description.
Reveals patterns of patient data that are often overlooked
Begins with documentation of general health status
Concentrates solely on physical aspects of a patient’s condition
Answer choices
Head-to-Toe
Gordon’s Functional Health Patterns
Body Systems
Reveals patterns of patient data that are often overlooked
Gordon’s Functional Health Patterns
Begins with documentation of general health status
Head-to-Toe
Concentrates solely on physical aspects of a patient’s condition
Body Systems
Match the assessment strategy with its description.
Assesses patient’s body systematically
Collects demographic and medical data
Uses sight, hearing, and smell to gather data
Answer choices
Patient interview
Physical examination
Observation
Assesses patient’s body systematically
Physical examination
Collects demographic and medical data
Patient interview
Uses sight, hearing, and smell to gather data
Observation
Match the type of assessment with its description.
Thorough interview, health history, and physical examination
Assessment when there is a concern about the patient’s condition
Very focused survey with rapid decisions to address immediate concerns
Answer Choices
Emergency
Focused
Comprehensive
Thorough interview, health history, and physical examination
Comprehensive
Assessment when there is a concern about the patient’s condition
Focused
Very focused survey with rapid decisions to address immediate concerns
Emergency
Which examination room preparation is most important for the nurse to complete between patients in an outpatient clinic?
Sterilize all surfaces of the examination table.
Remove all garbage from the room.
Ensure that the barrier paper is neat and unsoiled.
Confirm the examination table surface is clean and has a fresh barrier in place.
Confirm the examination table surface is clean and has a fresh barrier in place.
Which actions would the nurse take to prepare the environment for the physical assessment?
Select all that apply.
Assess that equipment is working properly.
Wash hands on entering the patient room.
Open personal protective equipment (PPE) so it is ready to use when needed.
Obtain a translator when a communication barrier exists.
Explain when position changes will be needed during the assessment.
Assess that equipment is working properly.
Wash hands on entering the patient room.
Obtain a translator when a communication barrier exists.
Explain when position changes will be needed during the assessment.
Which aspect of creating a therapeutic environment reflects the nurse’s approval of a patient’s request for a family member to remain in the room during the patient interview and physical assessment?
Patient safety
Personal needs
Physical comfort
Emotional comfort
Emotional comfort
Which type of examination requires the nurse to alter the traditional sequence of assessment techniques (inspection, palpation, percussion, and auscultation)?
Cardiac
Abdominal
Respiratory
Integumentary
Abdominal
Which senses does the nurse use during inspection?
Select all that apply.
Sight
Taste
Smell
Touch
Hearing
sight
smell
hearing
Which term describes subjective indications of a disease or a change in condition as perceived by the patient?
Signs
Symptoms
Conditions
Assessments
symptoms
Which concept describes the process in which the nurse collects information related to a patient problem by speaking with the patient?
Focused assessment
Objective data collection
Subjective data collection
Comprehensive assessment
Subjective data collection
Which model of data organization uses a holistic approach to the patient and potentially reveals data patterns the nurse might otherwise overlook?
Medical
Head-to-Toe
Body Systems
Gordon’s Functional Health Patterns
Gordon’s Functional Health Patterns
Which assessment would the nurse perform during the patient’s initial visit to a new health care provider?
Brief
Focused
Emergency
Comprehensive
Comprehensive
Which environmental strategies would the nurse implement to maximize a patient’s comfort during an interview and physical examination?
Select all that apply.
Dim room lighting.
Reduce extra noise.
Increase visual stimuli.
Remove distracting items.
Manage room temperature.
Reduce extra noise.
Remove distracting items.
Manage room temperature.
Which actions would the nurse take when greeting the patient?
Select all that apply.
Introduce self.
Call the patient by name.
Start the physical assessment.
Explain the reason for the interview.
Educate the patient on hand hygiene.
Introduce self.
Call the patient by name.
Explain the reason for the interview.
Which actions would the nurse take after completing the interview and physical examination?
Select all that apply.
Document collected data.
Discuss what to expect next.
Encourage the patient to ask questions.
Place the call bell on the bedside table.
Assist the patient to a comfortable position.
Document collected data.
Discuss what to expect next.
Encourage the patient to ask questions.
Assist the patient to a comfortable position.
Place the assessment techniques in the order performed for assessing the abdomen.
Inspection
Percussion
Palpation
Auscultation
Inspection
Auscultation
Palpation
Percussion
Which factors would the nurse consider before performing an inspection during a physical examination?
Select all that apply.
Ample lighting
Available assistance
Time available for the examination
Cleaning of the patient’s hands
Adequate exposure of anatomic surfaces
Ample lighting
Available assistance
Time available for the examination
Adequate exposure of anatomic surfaces
Which types of abnormalities can the nurse identify when percussing the abdomen?
Select all that apply.
Gas
Fluid
Masses
Organs
Wounds
Gas
Fluid
Masses
Which techniques would the nurse utilize when assessing the integumentary system?
Select all that apply.
Palpation
Inspection
Percussion
Auscultation
Evaluation
Palpation
Inspection
Match the skin assessment term to the appropriate description.
Redness
Yellow hue
Lack of color
Blue discoloration
Answer choice
Cyanosis
Pallor
Erythema
Jaundice
Redness
Erythema
Yellow hue
Jaundice
Lack of color
Pallor
Blue discoloration
Cyanosis
The nurse associates abnormalities of the skin, hair, or nails with potential disorders of which systems?
Select all that apply.
Cardiac
Sensory
Neurologic
Respiratory
Hematologic
Cardiac
Respiratory
Hematologic
Match the type of health history content being gathered by the nurse to the appropriate question.
Have you ever had any allergic skin reactions to food, drugs, or plants?
Have you observed changes in the consistency, color, or texture of your nails?
Has anyone in your family ever had skin cancer?
Answer choices
Personal medical history
Family medical history
Current health
Have you ever had any allergic skin reactions to food, drugs, or plants?
Personal medical history
Have you observed changes in the consistency, color, or texture of your nails?
Current health
Has anyone in your family ever had skin cancer?
Family medical history
Which techniques would the nurse use when assessing a patient’s head, eyes, ears, nose, and throat?
Select all that apply.
Palpation
Inspection
Evaluation
Percussion
Auscultation
Palpation
Inspection
Auscultation
Which instrument would the nurse use to assess the pupillary reflexes?
Penlight
Otoscope
Reflex hammer
Tongue blade
Penlight
Which anatomic structure would the nurse auscultate during the examination of the throat?
Jugular veins
Thyroid glands
Carotid arteries
Subclavian arteries
Carotid arteries
Which question would the nurse ask to gather health history information about the patient’s head and neck?
Do you have a history of vertigo?
Do you have a history of tonsillitis?
Have you ever experienced dizziness?
Have you experienced pain or discharge around your eyes?
Have you ever experienced dizziness?
Which assessment techniques would the nurse use during examination of the respiratory system?
Select all that apply.
Palpation
Inspection
Evaluation
Percussion
Auscultation
Palpation
Inspection
Auscultation
Which characteristics would the nurse assess while inspecting the chest during the respiratory system examination?
Select all that apply.
Shape
Symmetry
Tenderness
Skin temperature
Breathing pattern
Shape
Symmetry
Breathing pattern
Which assessment finding would the nurse expect when auscultating the lungs of a healthy adult?
High-pitched, loud bronchovesicular sounds
Low-pitched, soft sounds heard over the trachea
Pursed-lip breathing by the patient during expiration
High-pitched, loud sounds heard over the main stem bronchus
High-pitched, loud sounds heard over the main stem bronchus
Which physical assessment techniques would the nurse use during examination of the cardiac and peripheral vascular systems?
Select all that apply.
Palpation
Inspection
Interview
Percussion
Auscultation
Palpation
Inspection
Auscultation
Which signs would the nurse associate with arterial insufficiency?
Select all that apply.
Pallor
Edema
Paralysis
Numbness
Pulselessness
Pallor
Paralysis
Numbness
Pulselessness
Which region would the nurse palpate to assess for aortic vibrations?
Epigastric area
Midaxillary area
Midthoracic area
Periumbilical area
Epigastric area
When collecting information about the patient’s current health status related to the cardiovascular system, which questions would the nurse ask?
Select all that apply.
Have you recently gained or lost weight?
Are you experiencing chest pain?
Do you have edema or swelling in your ankles?
Have you ever had loss of consciousness or fainted?
Have you been hospitalized for a cardiac event?
Have you recently gained or lost weight?
Are you experiencing chest pain?
Do you have edema or swelling in your ankles?
Which components does the nurse assess during the musculoskeletal examination?
Select all that apply.
Mobility
Bone disease
Tendon injury
Cartilage disorder
Exercise level
Mobility
Bone disease
Tendon injury
Exercise level
Which assessment techniques would the nurse use when assessing the musculoskeletal system?
Select all that apply.
Palpation
Inspection
Percussion
Observation
Auscultation
Palpation
Inspection
In which areas would the nurse use a reflex hammer to assess for deep tendon reflexes?
Select all that apply.
Patellae
Biceps
Triceps
Phalanges
Achilles tendon
Patellae
Biceps
Triceps
Achilles tendon
Which finding indicates a problem associated with bone loss, such as osteoporosis?
Gross disfigurement
Abnormal reflexes
Postural abnormalities
Decreased pulse strength
Postural abnormalities
Which components are included in the neurologic system?
Select all that apply.
Skull
Brain
Nerves
Spinal cord
Carotid artery
Brain
Nerves
Spinal cord
Match the type of neurologic examination to the appropriate description.
Eye movements and pupillary reflex
Sharp/dull discrimination or light touch
Strength, coordination, and gait
Level of consciousness and orientation
Answer choices
Cranial nerves
Motor function
Sensation
Mental status
Eye movements and pupillary reflex
Cranial nerves
Sharp/dull discrimination or light touch
Sensation
Strength, coordination, and gait
Motor function
Level of consciousness and orientation
Mental status
Which component of the focused neurologic examination addresses emotional state?
Sensation
Mental status
Motor function
Cranial nerves
Mental status
Which patient position enables the nurse to perform an examination of the gastrointestinal system?
Sims
Prone
Supine
Fowler
Supine
Place the components of the gastrointestinal examination in the correct order.
Auscultation
Inspection
Palpation
Percussion
Inspection
Auscultation
Palpation
Percussion
Which unexpected findings from the abdominal assessment would the nurse document in the electronic health record and report to the health care provider?
Select all that apply.
Flat abdomen
Visible protrusions
Rebound tenderness
Hyperactive bowel sounds
Bowel sounds in all quadrants
Visible protrusions
Rebound tenderness
Hyperactive bowel sounds
Which priority action would the nurse take before beginning an examination of the breasts and genitals?
Ensure proper positioning of the patient.
Provide a quiet, calm environment.
Ensure respect for the patient’s privacy.
Provide education regarding self-examinations
Ensure respect for the patient’s privacy.
In which position would the nurse place the female patient to examine the female genitalia?
Sims
Supine
Fowler
Lithotomy
Lithotomy
Which member of the health care team can perform internal vaginal and prostate examinations?
Registered nurse
Health care provider
Patient care technician
Certified nursing assistant
Health care provider
In which order would the nurse perform an assessment of the integumentary system.
Review the patient’s medical records for preexisting issues with skin, hair, or nails.
Complete physical examination of the skin, hair, and nails.
Interview the patient to complete the general survey, health history, and review of systems.
Review the patient’s medical records for preexisting issues with skin, hair, or nails.
Interview the patient to complete the general survey, health history, and review of systems.
Complete physical examination of the skin, hair, and nails.
Which components would the nurse assess during palpation of the skin?
Select all that apply.
Clubbing
Swelling
Skin texture
Discoloration
Skin temperature
Swelling
Skin texture
Skin temperature
When the nurse identifies clubbing of a patient’s nails, which type of medical condition would the nurse suspect as the cause?
Cardiac
Neurologic
Gastrointestinal
Musculoskeletal
Cardiac
Which part of the eye would the nurse palpate gently to assess for nodules or pain?
Lens
Eyelid
Cornea
Orbital bone
Eyelid
Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness?
Nostrils
Mucosa
Sinuses
Septum
Sinuses
When examining the head and its associated structures, which unexpected findings would the nurse document?
Select all that apply.
Lumps
Edema
Lesions
Symmetry
Discoloration
When examining the head and its associated structures, which unexpected findings would the nurse document?
Select all that apply.
Lumps
Edema
Lesions
Discoloration
Which techniques would the nurse utilize to auscultate the patient’s chest during the respiratory assessment?
Select all that apply.
Listen for a full respiratory cycle.
Use a systematic pattern.
Assess at least two lobes.
Feel for depth of breathing.
Listen for unexpected sounds.
Listen for a full respiratory cycle.
Use a systematic pattern.
Listen for unexpected sounds
Which aspects does the nurse assess while palpating the chest during the respiratory system assessment?
Select all that apply.
Respiratory rate
Masses
Skin moisture
Front-to-back diameter
Breathing effort
Masses
Skin moisture
Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment?
Lung capacity
Lung shape
Respiratory rate
Depth of respirations
Depth of respirations
Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems?
Respiratory
Genitourinary
Gastrointestinal
Musculoskeletal
Respiratory
Which actions would the nurse implement during auscultation of the cardiovascular system?
Select all that apply.
Listen at all three valves
Evaluate for symmetry
Assess rate and rhythm
Feel for quality of pulses
Use both sides of stethoscope
Assess rate and rhythm
Use both sides of stethoscope
Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities?
Apical pulse
Peripheral pulses
Peripheral perfusion
Heart rhythm
Peripheral perfusion
Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview?
Review of health records
Organization of equipment
Analysis of the review of systems
Completion of the physical examination
Review of health records
Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination?
Select all that apply.
Masses
Crepitus
Tenderness
Deep tendon reflexes
Postural abnormalities
Masses
Crepitus
Tenderness
Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider?
Select all that apply.
Pain
Lesions
Absence of crepitus
Abnormal posture or gait
Presence of deep tendon reflexes
Pain
Lesions
Abnormal posture or gait
Which assessment technique would the nurse use during the neurologic assessment?
Inspection
Reflexology
Percussion
Auscultation
Inspection
Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body?
Motor nerve
Cranial nerve
Sensory nerve
Accessory nerve
Sensory nerve
Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes?
Motor nerve
Cranial nerve
Sensory nerve
Accessory nerve
Cranial nerve
Which assessment techniques would the nurse use during the abdominal assessment?
Select all that apply.
Palpation
inspection
Percussion
Observation
Auscultation
Palpation
inspection
Auscultation
The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems?
Select all that apply.
Urinary
Digestive
Endocrine
Circulatory
Reproductive
Urinary
Digestive
Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope?
Wheezes
Blood flow
Bowel sounds
Breath sounds
Bowel sounds
Which findings would the nurse recognize as abnormal during assessment of the male genitalia?
Select all that apply.
Rashes
Lesions
Masses
Dimpling
Discharge
Rashes
Lesions
Masses
Discharge
Which technique would the nurse use to palpate the breast tissue?
Both hands
Palm of one hand
Two to three fingers
Thumb and forefinger
Two to three fingers
During the breast and genital examination, which findings would the nurse document and report to the health care provider?
Select all that apply.
Lesions on the genitalia
Presence of hemorrhoids
Unusual odor or discharge
Excoriation of the breast tissue
Symmetry of the breast tissue
Lesions on the genitalia
Presence of hemorrhoids
Unusual odor or discharge
Excoriation of the breast tissue
Which functions does the nurse complete during the second step of the Clinical Judgment Measurement Model?
Select all that apply.
Relate findings to potential disease processes.
Examine subjective and objective patient cues.
Interpret cues collected during the evaluation phase.
Correlate patient cues to conditions by clustering data.
Link cues from step one (Assessment) to step two (Recognize Cues).
Relate findings to potential disease processes.
Examine subjective and objective patient cues.
Correlate patient cues to conditions by clustering data.
Which questions help the nurse to cluster and analyze patient data during the second step of the Clinical Judgment Measurement Model?
Select all that apply.
Which patient findings fit together?
Which conditions present with cues like the patient’s cues?
What other information can help evaluate patient outcomes?
Are there any findings or patient cues that seem contradictory?
Which patient conditions are expected based on the medical diagnosis?
Which patient findings fit together?
Which conditions present with cues like the patient’s cues?
Are there any findings or patient cues that seem contradictory?
Which patient conditions are expected based on the medical diagnosis?
Which outcome results from analysis of patient assessment data during the second step of the Clinical Judgment Measurement Model?
A prioritized list of patient needs
A single nursing diagnostic statement
Nursing interventions to achieve patient goals
Grouping of patient cues according to similarities
Grouping of patient cues according to similarities
Which labels describe a hypothesis?
Select all that apply.
Patient problem
Objective patient cue
Subjective patient cue
Diagnosed medical condition
Ailment the patient is at risk for developing
Patient problem
Diagnosed medical condition
Ailment the patient is at risk for developing
Place in order the actions the nurse takes when applying the Clinical Judgment Measurement Model to nursing practice.
Recognize cues
Form hypotheses
Link cues
Cluster cues
Recognize cues
Cluster cues
Link cues
Form hypotheses
Which statement describes how nurses apply the International Classification for Nursing Practice (ICNP) terminology to the second step of the Clinical Judgment Measurement Model?
Collect patient cues.
Determine outcomes.
Prioritize hypotheses.
Select nursing diagnoses.
Select nursing diagnoses.
Which action is essential for the nurse to complete during step two of applying the Clinical Judgment Measurement Model to nursing practice?
Recognize patient cues.
Consider environmental factors.
Cluster subjective and objective data.
Generate solutions based on patient needs.
Cluster subjective and objective data.
When analyzing patient cues during the second step of the Clinical Judgment Measurement Model, which strategy provides meaning to cues and insight into the patient’s unique circumstances?
Developing a nursing diagnosis
Clustering similar data into groups
Conducting a complete head-to-toe assessment
Asking questions to identify patterns among collected cues
Asking questions to identify patterns among collected cues
Which concepts does the nurse apply when clustering patient data?
Select all that apply.
Anticipated findings
Potential disease processes
Prior patient care experiences
Stages of growth and development
Process for prioritization of hypotheses
Anticipated findings
Potential disease processes
Prior patient care experiences
Stages of growth and development
Which types of factors influence the development of a hypothesis?
Select all that apply.
Risk
Social
Indirect
Cultural
Supportive
Risk
Social
Cultural
The nurse clustered the following patient cues during the assessment: Sharp pain in lower right abdomen, patient pain rating 9 on a 0-to-10 pain scale, and facial grimacing. Which hypothesis based on International Classification for Nursing Practice (ICNP) terminology can the nurse select when clustering the data?
Acute Pain
Constipation
Abdominal Pain
Risk for Vomiting
Abdominal Pain
Which statement describes why nurses identify supporting data for a hypothesis?
Supporting data validates the patient’s plan of care.
Identification of supporting data allows the nurse to individualize the plan of care.
Documentation of supporting data allows the nurse to prioritize hypotheses.
Supporting data provides consistency when planning care for patients experiencing similar conditions.
Identification of supporting data allows the nurse to individualize the plan of care.
