Health Assessment answered test bank Q&A

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. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be: a. Subjective. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. 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. Validate the data by asking a coworker to listen to the breath sounds. 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. A set of rules. 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. 7. 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. 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. Individual with shortness of breath and respiratory distress 9. 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 10. Which critical thinking skill helps the nurse see relationships among the data? a. Clustering related cues 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a. Nursing 12. 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 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 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Diagnostic hypothesis 1 15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies. 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a. Assessment 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. Teach the nurses how to conduct electronic searches for research studies. 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Holistic health views the mind, body, and spirit as interdependent. 19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Prevention places the emphasis on the link between health and personal behavior. 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. 2  5 cm scar on the right lower forearm. 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 22. 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. 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. 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. Simultaneously ask history questions while performing the examination and initiating life-saving measures. 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: 2 a. Provide culturally sensitive and appropriate care. 26. In the health promotion model, the focus of the health professional includes: a. Helping the consumer choose a healthier lifestyle. 27. 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. 28. 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. 29. 30. 31. MULTIPLE RESPONSE 32. 1. 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. Nonproductive cough c. Patient reports dyspnea upon exertion d. Rate of respirations 16 breaths per minute 2. 3. MATCHING 4. Put the following patient situations in order according to the level of priority. a. .A teenager who was stung by a bee during a soccer match is having trouble breathing. b. An older adult with a urinary tract infection is also showing signs of confusion and agitation. c. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer 5. 6. 7. 8. Chapter 04: The Complete Health History 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide a database of subjective information about the patient’s past and current health 2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient: a. Provided consistent information and therefore is reliable. 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care? 3 a. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours. 4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response? a. “Can you point to where it hurts?” 5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement? a. “How would you say the pain affects your ability to do your daily activities?” 6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. 7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. Grav 6, Term 4, (S)Ab-2, Living 4 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? a. “Describe what happens to you when you take penicillin.” 9. The nurse is taking a family history. Important diseases or problems about which t