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.
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
Which situation is most appropriate during which the nurse
performs a focused or problem-centered history?
a. Patient is admitted to the hospital for surgery the following
day.
b. Patient in an outpatient clinic has cold and influenza-like
symptoms.
, 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.
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. Simultaneously ask history questions while performing
the examination and initiating life-saving measures.
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:
2
a. Provide culturally sensitive and appropriate care.
In the health promotion model, the focus of the health professional
includes:
a. Helping the consumer choose a healthier lifestyle.
The nurse has implemented several planned interventions to
address the nursing diagnosis of acute pain. Which would be the
next appropriate action?
a. Evaluate the individual’s condition, and compare actual
outcomes with expected outcomes.
Which statement best describes a proficient nurse? A proficient
nurse is one who:
a. Understands a patient situation as a whole rather than a
, list of tasks and recognizes the long-term goals for the
patient.
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 act without consciously labeling it. These responses are
referred to as:
a. Intuition.
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 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
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.
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.
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
Which situation is most appropriate during which the nurse
performs a focused or problem-centered history?
a. Patient is admitted to the hospital for surgery the following
day.
b. Patient in an outpatient clinic has cold and influenza-like
symptoms.
, 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.
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. Simultaneously ask history questions while performing
the examination and initiating life-saving measures.
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:
2
a. Provide culturally sensitive and appropriate care.
In the health promotion model, the focus of the health professional
includes:
a. Helping the consumer choose a healthier lifestyle.
The nurse has implemented several planned interventions to
address the nursing diagnosis of acute pain. Which would be the
next appropriate action?
a. Evaluate the individual’s condition, and compare actual
outcomes with expected outcomes.
Which statement best describes a proficient nurse? A proficient
nurse is one who:
a. Understands a patient situation as a whole rather than a
, list of tasks and recognizes the long-term goals for the
patient.
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 act without consciously labeling it. These responses are
referred to as:
a. Intuition.
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 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
1
