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Chapter 01: Evidence-Based Assessment
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.
A patient tells the nurse that he is very nervous, is nauseated, and
“feels hot.” These types of data would be:
a. Subjective.
The patient’s record, laboratory studies, objective data, and
subjective data combine to form the:
a. Data base.
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. Validate the data by asking a coworker to listen to the breath
sounds.
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. A set of rules.
Expert nurses learn to attend to a pattern of assessment data and
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act without consciously labeling it. These responses are referred
to as:
a. Intuition.
• The nurse is obtaining a history from a 30-year-old
male patient and is concerned about health promotion
activities. Which of these questions would be
appropriate to use to assess health promotion activities
for this patient?
• “Do you perform testicular self-examinations?”
• Which of these responses might the nurse expect
during a functional assessment of a patient whose
leg is in a cast?
• “I’m able to transfer myself from the
wheelchair to the bed without help.”
The nurse is reviewing information about evidence-based practice
(EBP). Which statement best reflects EBP?
a. EBP emphasizes the use of best evidence with the clinician’s
experience.
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?
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a. Individual with shortness of breath and respiratory distress
When considering priority setting of problems, the nurse keeps
in mind that second-level priority problems include which of
these aspects?
a. Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among
the data?
a. Clustering related cues
The nurse knows that developing appropriate nursing interventions
for a patient relies on the appropriateness of the diagnosis.
a. Nursing
The nursing process is a sequential method of problem solving that
nurses use and includes which steps?
a. Assessment, diagnosis, outcome identification, planning,
implementation, and evaluation
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
Which of these would be formulated by a nurse using diagnostic
reasoning?
a. Diagnostic hypothesis
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1
NUR 2407Health Assesment Answered test bank.
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