Examination 6th Edition Estes
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,Estes: Health Assessment & Physical Examination, 6e 1
Test Bank Chapter 1
Chapter 1: Critical Thinking and Clinical Reasoning in Nursing
MULTIPLE CHOICE
1. A client hears the nurse instructing a nursing peer to use critical thinking when planning a
difficult dressing change. The client states, “Are you asking her to be critical of my current
dressing? Is something wrong?” Which statement is best for the nurse to educate and reassure the
client regarding that unfamiliar phrase?
1. “I was not being critical, just teaching a new technique.”
2. “Critical thinking is a skill of using logic and reasoning to identify approaches to clinical or
practice problems.”
3. “Critical thinking is how we apply practice-based nursing principles to your dressing change.”
4. “The dressing is fine; we just feel it could be done differently.”
ANS:
2. During a nursing health history, information regarding recreational drug usage is needed. The
nurse documents this statement: “The client reports the use of one marijuana product every
weekend.” That statement best demonstrates which Universal Intellectual Standard (UIS) of
critical thinking?
1. Clarity
2. Accuracy
3. Precision
4. Depth
ANS:
3. Which statement best defines the American Nurses Association (ANA) Scope and Standards
of Practice?
1. A set of tenets upon which the entire health assessment and physical examination of the client
are conducted.
2. A set of legal boundaries that differentiate specific nursing and physician roles.
3. A process that allows the nurse to combine knowledge and assessment to prioritize and deliver
safe client care.
4. A parameter that defines the number of clients a nurse can safely manage during a working
shift.
ANS:
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4. The nurse is performing the health history interview for a new client. Which statement is true
in relation to proper collection of that information?
1. The health history is a means of gathering objective data.
2. The nurse may gather information from any available source.
3. Health history data must be obtained from the client to ensure reliability.
4. Because of consistency in health-care documentation, data from previous medical records can
be used without need of additional verification.
ANS:
5. A nurse contacts the physician and relays some pertinent background information on a client’s
reason for hospitalization, recent vital signs, and changes in lab work. What information should
follow next in the nurse’s communication with the physician if using the SBAR technique?
1. Client name, age, admitting diagnosis
2. Full name and credentials of the nurse
3. Action recommended by the nurse
4. Nurse’s assessment of the situation
ANS:
6. The nurse is completing standard three of the Nursing Process. Which statement demonstrates
additional information is needed to properly meet that standard?
1. The client met their goal of 5 pounds of weight loss within a 3-week period.
2. The client will stop using tobacco products within 3 months.
3. The client has been instructed on the need to reduce salt in their diet.
4. The client will use a cane correctly to avoid falling.
ANS:
7. The nurse is using the NCJMM to determine which information is the most important and
immediately concerning. On which step of the Nursing Process is the nurse expanding?
1. Assessment
2. Planning
3. Implementing
4. Evaluating
ANS:
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8. The nurse is using the gold standard of techniques for passing client-specific information to
another member of the health care team. Which statement best describes that technique?
1. It is a verbal communication technique to review the day’s progress for an individual client.
2. It is a written informational tool that contains only information related to the current need.
3. It is a verbal communication technique to address a situation requiring immediate attention.
4. It is a written tool that meets the patient’s protection and privacy rights when used in an email.
ANS:
9. While completing a health history with a client, the nurse notices that information being
shared by the client is not consistent. During which step of the Nursing Process will the nurse
seek to validate or add data for interpretation?
1. Outcomes Identification
2. Assessment
3. Evaluation
4. Diagnosis
ANS:
10. To accurately interpret information gathered from a client requires the nurse to decode
hidden messages and clarify and categorize information. Which professional clinical skill is
demonstrated when performing those specific activities?
1. Clinical Reasoning
2. Nursing Process
3. Critical Thinking
4. Clinical Judgment
ANS:
11. The ANA Standards of Nursing Practice outlines six actions for the registered nurse to follow
during health assessment and physical examination of a client. Which activity demonstrates
adhering to the standard of Outcomes Identification?
1. The nurse documents that the client has met their goal to walk 50 feet without assistance.
2. The nurse collects information related to the distance that a client can walk without assistance.
3. The nurse coordinates with physical therapy to document 50 feet in the hallway for the client
to measure progress towards walking that distance without assistance.
4. The nurse discusses with the client a safe distance for walking without assistance.
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ANS:
12. Which statement in the nurse’s documentation shows completion of the second step of the
Nursing Process?
1. The client is awake and alert.
2. The client is at risk of falling.
3. The client’s pain level is reduced after their medication.
4. The client will be served small, frequent meals.
ANS:
13. A nurse is teaching a nursing student the proper steps to take when communicating with
physicians. Which order is correct if the nurse is teaching use of the gold standard tool for verbal
communication?
1. Recommendation, Assessment, Background, Situation
2. Background, Assessment, Situation, Recommendation
3. Assessment, Background, Recommendation, Situation
4. Situation, Background, Assessment, Recommendation
ANS:
14. Upon observation of diffuse tan skin discolorations, the nurse teaches the client that the use
of sunscreen helps to protect from the harmful effects of sun. Which two standards from the
ANA Standards of Professional Nursing Practice are being demonstrated in this scenario?
1. Planning and Diagnosis
2. Assessment and Evaluation
3. Diagnosis and Implementation
4. Evaluation and Planning
ANS:
15. Institutions may have their own method for charting, each with advantages and
disadvantages. Which commonly used written documentation method is most seen in both
academic and clinical settings for recording client progress?
1. Focus charting
2. PIO: Problem/diagnosis, intervention, outcome
3. CBE: Charting by exception
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4. SOAP: Subjective, objective, analysis, plan
ANS:
16. During a hand-off, the nurse transfers client-specific information to another team of
caregivers. According to the Joint Commission, what is the purpose of the hand-off?
1. A hand-off ensures continuity and safety of the client’s care.
2. A hand-off enhances trust in the next team of caregivers.
3. A hand-off serves to confirm that all tasks are completed prior to the change in care team.
4. A hand-off’s purpose is to prevent medical errors.
ANS:
17. The nurse is using Maslow’s Hierarchy of Needs to aid in planning a client’s care. The client
has just been admitted for observation after a lengthy stay in the emergency room. Which action
demonstrates correct use of that prioritization element of Planning?
1. Acknowledge the client’s position as a hospital administrator; then provide water at the
bedside.
2. Teach the family that they are always allowed to be present; then darken the room for sleep.
3. Provide the client with a meal from nutrition services; then invite family to enter the room.
4. Secure the client’s valuables; then provide a meal from nutrition services.
ANS:
18. During a clinical experience, the student nurse is learning the six steps involved in
completion of the Nursing Process from the nurse. The nurse recognizes that the student
incorrectly documented which action as one of those six steps?
1. Planning
2. Recognize cues
3. Evaluation
4. Diagnosis
ANS:
19. Which statement best describes the relationship between the six steps of the Nursing Process
and the six cognitive skills of the NCJMM?
1. The NCJMM illustrates the Nursing Process to better define the assessment skills needed to
complete a client history.
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2. The NCJMM augments the Nursing Process to allow usage by the entire health-care team.
3. The NCJMM replaces the Nursing Process to define the specific skills related to physical
assessment of a client.
4. The NCJMM aligns with the Nursing Process to expand and highlight cognitive skills needed
to make appropriate clinical judgments.
ANS:
20. The nurse is completing an admission health history on a client who does not make eye
contact, offers only brief answers to questions, and shifts uncomfortably in the chair. The nurse
will use which element of critical thinking to correctly categorize the client’s behaviors?
1. Interpretation
2. Inference
3. Explanation
4. Evaluation
ANS:
21. The nurse is teaching a student nurse to properly formulate a nursing diagnosis. Which
statement is the nurse’s best choice to use in that education?
1. A nursing diagnosis helps to guide the client’s medication needs.
2. A nursing diagnosis is a clinical judgment of a human response to health-care situations.
3. A nursing diagnosis is a key piece of information needed for insurance billing.
4. A nursing diagnosis guides the health and physical assessment.
ANS:
22. The nurse is progressing through the Nursing Process and seeking to properly formulate a
nursing diagnosis. Using the data collected during the client assessment, in which order will the
nurse perform the required steps?
1. Collect, Interpret, Cluster, Name
2. Cluster, Interpret, Name, Collect
3. Interpret, Name, Cluster, Collect
4. Name, Cluster, Collect, Interpret
ANS:
23. The experienced nurse is reflecting on critical thinking skills that were used for the initial
portion of a client’s health history. After determining which skills were most effective,
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adjustments are made for the remaining portion of the interview. What is the nurse
demonstrating?
1. Evaluation
2. Self-regulation
3. Analysis
4. Inference
ANS:
24. The nurse is collecting a client’s dietary history and documents the following statement:
“The client consumes excessive amounts of caffeine.” Which statement would best edit that
documentation to meet the UIS for Critical Thinking?
1. The client consumes two 16-oz. energy drinks, two 8-oz. coffees, and two chocolate donuts
each morning.
2. The client stops at a convenience store each morning for products that contain high amounts of
caffeine.
3. The client admits to excessive consumption of caffeine.
4. The client states that morning coffee is part of their daily routine.
ANS:
25. The nurse examines answers to questions obtained during a client history and notices that the
client denied any surgical history. On physical assessment the client was observed to have a
well-healed abdominal scar. The nurse uses which critical thinking element to reflect on the
reason for that discrepancy?
1. Explanation
2. Evaluation
3. Analysis
4. Inference
ANS:
26. The nurse is completing a health history with a new client. The client asks the nurse the
reason for the many questions, stating, “Why did you ask about my family? Most of this is not
related to why I came here today, and my doctor already knows.” What is the nurse’s best
response to the client’s stated concern?
1. “The hospital requires that all the blanks be filled in, so thank you for your patience.”
2. “The doctor does not fill this out for us, so thank you for your continued cooperation.”
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3. “I am collecting this to share with the team to positively impact your health status, so thank
you for your help.”
4. “The insurance company requires all the blanks be filled in, so thank you for your
cooperation.”
ANS:
27. When formulating a nursing diagnosis, what must the nurse consider most for interpreting
data collected during the health history and physical assessment?
1. The source of specific information
2. The provision of privacy in the room
3. The client’s abnormal lab values
4. The standards of that specific client’s population
ANS:
28. The nurse has identified all data from a health history and clustered them into a NANDA-I
domain. What is the nurse’s next and final step to complete formulation of the nursing diagnosis?
1. Assessment
2. Naming
3. Analyzing
4. Collecting
ANS:
29. The nurse is reviewing planned documentation by the student nurse related to the nursing
diagnosis. The nurse recognizes that one of the NANDA-I domains as noted in the student’s
work is incorrect. What needs to be edited by the student nurse prior to entering in the client’s
record?
1. Grief counseling
2. Stress tolerance
3. Self-perception
4. Life principles
ANS:
30. To complete formal and concise charting, the nurse is seeking to categorize a client’s nursing
diagnosis. What is the proper category for assessment information concerning a client’s family’s
vulnerability to a community-acquired disease?
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