Answers
CHAPTER 1 Subjective Data
CRITICAL THINKING AND Definition: Information that is provided verbally by the
THE NURSING PROCESS
patient and referred to as symptoms.
Nursing Diagnosis
AUDIO CASE STUDY
Definition: Per NANDA International, a nursing diagnosis is
Jane and the Nursing Process a “clinical judgment concerning a human response to health
1. Assessment/data collection, diagnosis, planning, imple- conditions/life processes, or a vulnerability for that response,
mentation, and evaluation. by an individual, family, group or community. A nursing diag-
2. Jane was exhausted, failed a test, and was pulled in too nosis provides the basis for selection of nursing interventions
many directions. to achieve outcomes for which the nurse has accountability”
3. Jane’s resources included a good friend, sick time from (from www.nanda.org/glossary-of-terms).
work, and wasted time between classes that she could
better utilize. Your resources will be different, but they’re Evaluation
there!
Definition: Examination of outcomes and interventions to de-
VOCABULARY termine progress toward desired outcomes and effectiveness of
interventions.
Nursing Process
Definition: An organizing framework that links thinking with
Vigilance
nursing actions. Steps include assessment/data collection,
nursing diagnosis, planning, implementation, and evaluation. Definition: The act of being attentive, alert, and watchful.
Critical Thinking SUBJECTIVE AND OBJECTIVE DATA
Definition: The use of those cognitive (knowledge) skills or 1. Subjective (symptom)
strategies that increase the probability of a desirable outcome. 2. Subjective (symptom)
Also involves reflection, problem-solving, and related think- 3. Objective (sign)
ing skills. 4. Objective (sign)
5. Subjective (symptom)
6. Objective (sign)
Assessment 7. Subjective (symptom)
Definition: Gathering subjective and objective data to plan care. 8. Objective (sign)
9. Subjective (symptom)
10. Subjective (symptom)
Objective Data 11. Objective (sign)
Definition: Factual information obtained through physical as- 12. Objective (sign)
sessment and diagnostic tests. Objective data are observable 13. Subjective (symptom)
or knowable through the health care worker’s five senses. 14. Objective (sign)
Referred to as signs. 15. Objective (sign)
Med C
,2 Chapter 1 Answers
CRITICAL THINKING
This is just one possible way to complete a cognitive map.
Could it be low Am I diabetic? Frontal area "Sick" feeling Hard Tylenol helps Hunger makes
blood sugar? it worse
Patient's Where is it? Quality Aggravating and
perception alleviating factors
Food helps
Headache
Useful other Severity Timing
data
Sometimes feel Mother is 7–8 on 0–10 Lasts 1–2 hours Before meals Early in the
sick to stomach diabetic scale once starts morning
REVIEW QUESTIONS—CONTENT REVIEW signs; assessment is the first step in the nursing process.
(2, 3, 4) are all steps in the nursing process, for which
The correct answers are in boldface. the registered nurse is responsible; the licensed practical
1. (3) is a nursing diagnosis. (1, 2, 4) are medical diagnoses. nurse/licensed vocational nurse may assist the regis-
2. (1) is a medical diagnosis. (2, 3, 4) are nursing diagnoses. tered nurse with these.
3. (1) is correct. The nurse who keeps trying until the prob- 8. (1, 4, 5) can be observed through use of the five senses.
lem is solved is exhibiting perseverance. (2, 3, 4) are (2, 3) are subjective data that the patient must report.
incorrect. 9. (2) indicates that the patient is concerned about freedom
4. (3, 4, 5, 1, 2) is the correct order. from injury and harm. (1) relates to basic needs such as
5. (1) is the best definition. (2, 3, 4) do not define critical air, oxygen, and water. (3) relates to feeling loved. (4) is
thinking but are examples of good thinking. related to having positive self-esteem.
10. (4) is objective, realistic, and measurable with a time
REVIEW QUESTIONS—TEST PREPARATION frame. (1, 2, 3) are all good outcomes, but they relate to
airway clearance, nutrition, and strength, not directly to
The correct answers are in boldface.
swallowing.
6. (4) is correct. Evaluation determines whether goals are 11. (2) is correct. The three parts of a diagnosis include the
achieved and interventions effective. (2) is the role of the problem (from the NANDA International [NANDA-I]
physician. (1, 3) encompass data collection and imple- list), etiology (“related to”), and symptoms (“as evi-
mentation, which are earlier steps in the nursing process. denced by”). (1) does not include symptoms. (3) is a
7. (1) is correct. The licensed practical nurse/licensed voca- medical diagnosis. (4) is not a NANDA-I diagnosis,
tional nurse can collect data, which includes taking vital and the evidence is not related to dyspnea.
, Answers
CHAPTER 2 6. Health literacy: Degree to which a person has the capac-
ity to obtain, process, and understand basic health infor-
EVIDENCE-BASED PRACTICE mation and services to make the best-informed health
decisions.
AUDIO CASE STUDY
EVIDENCE-BASED PRACTICE
Marie and Evidence-Based Practice
1. proof
1. Thirdhand smoke is the dangerous toxins of smoke that 2. context
linger on hair, clothing, furniture, and other surfaces in 3. quality
an area after a cigarette is put out. Marie learned that 4. care
exposure to these toxins can be neurotoxic to children 5. randomized
and can trigger asthma attacks in sensitive people. 6. outcomes
2. Evidence-based practice is considered the gold standard 7. gold
of health care. 8. nursing
3. Step 1: Ask the burning question. Step 2: Search and 9. patient’s
collect the most relevant and best evidence available. 10. information
Step 3: Think critically. Appraise the evidence for
validity, relevance to the situation, and applicability. CRITICAL THINKING
Step 4: Measure the outcomes before and after instituting
the change. Step 5: Make it happen. Step 6: Evaluate the 1. By questioning the existing way of doing things to en-
practice decision or change. sure that the patient receives the best care possible.
4. Combination therapy with a nicotine patch and nicotine 2. A thorough search of the literature in the area of music
lozenges worked best, although bupropion (Zyban) and therapy.
nicotine lozenges worked well, too. A Cochrane Review 3. Cumulative Index to Nursing and Allied Health Litera-
found that advice and support from nursing staff can ture (CINAHL) Database, Joanna Briggs Institute
increase patients’ success in quitting smoking, especially evidence-based resources, Cochrane Reviews,
in a hospital setting. Medline/PubMed.
4. Measure patient outcomes before instituting the evi-
VOCABULARY dence-based change in practice so comparisons can
be made after implementation to determine if the
1. Evidence-based practice: A systematic process that uses intervention worked.
current evidence in making decisions about patient care. 5. Evaluate the results to determine whether the change
2. Evidence-informed practice: Consideration of patient fac- made a significant difference and if it was worthwhile
tors along with the use of evidence for shared decision- in terms of cost and time.
making between the health care provider and the patient.
3. Randomized controlled trials: True experimental studies REVIEW QUESTIONS—CONTENT REVIEW
in which as many factors as possible that could falsely
The correct answers are in boldface.
change the results are controlled.
4. Research: Scientific study, investigation, or experimenta- 1. (2) is Level I evidence. (1, 3, 4) are not examples of the
tion to establish facts and analyze their significance. best evidence.
5. Systematic review: A review of relevant research using 2. (1) is a nursing database. (2, 3, 4) are primarily medical
guidelines. databases.
1
, 2 Chapter 2 Answers
3. (3) is the website for the Joint Commission, where you 7. (1, 5) are Level I research. (2, 3, 4) are not systematic
can find the National Patient Safety Goals. (1, 2, 4) are reviews of randomized controlled trials.
incorrect. 8. (1, 3, 5, 6) because the evidence-based practice process
4. (2) is the definition of a randomized clinical trial. involves “ASKMME!”: ask, search, think, measure,
(1, 3, 4) are incorrect. make it happen, and evaluate. (2, 4) are not steps in the
5. (1) is correct. Evidence-based practice begins with a process.
burning question designed to solve a clinical problem. 9. (2, 3, 5) are correct, as they have been found to be best
(2, 3, 4) are incorrect. practice for oral care. (1, 4) do not remove plaque and
only freshen the mouth.
REVIEW QUESTIONS—TEST PREPARATION 10. (4) is correct. The search should be narrowed to include
the focus on the question. (1, 2, 3) do not focus on the
The correct answers are in boldface.
question being asked.
6. (2, 3, 4, 5, 6) are all independent nursing interventions
because no health care provider’s order is required. (1) is
a dependent function because it requires a health care
provider’s order.
CHAPTER 1 Subjective Data
CRITICAL THINKING AND Definition: Information that is provided verbally by the
THE NURSING PROCESS
patient and referred to as symptoms.
Nursing Diagnosis
AUDIO CASE STUDY
Definition: Per NANDA International, a nursing diagnosis is
Jane and the Nursing Process a “clinical judgment concerning a human response to health
1. Assessment/data collection, diagnosis, planning, imple- conditions/life processes, or a vulnerability for that response,
mentation, and evaluation. by an individual, family, group or community. A nursing diag-
2. Jane was exhausted, failed a test, and was pulled in too nosis provides the basis for selection of nursing interventions
many directions. to achieve outcomes for which the nurse has accountability”
3. Jane’s resources included a good friend, sick time from (from www.nanda.org/glossary-of-terms).
work, and wasted time between classes that she could
better utilize. Your resources will be different, but they’re Evaluation
there!
Definition: Examination of outcomes and interventions to de-
VOCABULARY termine progress toward desired outcomes and effectiveness of
interventions.
Nursing Process
Definition: An organizing framework that links thinking with
Vigilance
nursing actions. Steps include assessment/data collection,
nursing diagnosis, planning, implementation, and evaluation. Definition: The act of being attentive, alert, and watchful.
Critical Thinking SUBJECTIVE AND OBJECTIVE DATA
Definition: The use of those cognitive (knowledge) skills or 1. Subjective (symptom)
strategies that increase the probability of a desirable outcome. 2. Subjective (symptom)
Also involves reflection, problem-solving, and related think- 3. Objective (sign)
ing skills. 4. Objective (sign)
5. Subjective (symptom)
6. Objective (sign)
Assessment 7. Subjective (symptom)
Definition: Gathering subjective and objective data to plan care. 8. Objective (sign)
9. Subjective (symptom)
10. Subjective (symptom)
Objective Data 11. Objective (sign)
Definition: Factual information obtained through physical as- 12. Objective (sign)
sessment and diagnostic tests. Objective data are observable 13. Subjective (symptom)
or knowable through the health care worker’s five senses. 14. Objective (sign)
Referred to as signs. 15. Objective (sign)
Med C
,2 Chapter 1 Answers
CRITICAL THINKING
This is just one possible way to complete a cognitive map.
Could it be low Am I diabetic? Frontal area "Sick" feeling Hard Tylenol helps Hunger makes
blood sugar? it worse
Patient's Where is it? Quality Aggravating and
perception alleviating factors
Food helps
Headache
Useful other Severity Timing
data
Sometimes feel Mother is 7–8 on 0–10 Lasts 1–2 hours Before meals Early in the
sick to stomach diabetic scale once starts morning
REVIEW QUESTIONS—CONTENT REVIEW signs; assessment is the first step in the nursing process.
(2, 3, 4) are all steps in the nursing process, for which
The correct answers are in boldface. the registered nurse is responsible; the licensed practical
1. (3) is a nursing diagnosis. (1, 2, 4) are medical diagnoses. nurse/licensed vocational nurse may assist the regis-
2. (1) is a medical diagnosis. (2, 3, 4) are nursing diagnoses. tered nurse with these.
3. (1) is correct. The nurse who keeps trying until the prob- 8. (1, 4, 5) can be observed through use of the five senses.
lem is solved is exhibiting perseverance. (2, 3, 4) are (2, 3) are subjective data that the patient must report.
incorrect. 9. (2) indicates that the patient is concerned about freedom
4. (3, 4, 5, 1, 2) is the correct order. from injury and harm. (1) relates to basic needs such as
5. (1) is the best definition. (2, 3, 4) do not define critical air, oxygen, and water. (3) relates to feeling loved. (4) is
thinking but are examples of good thinking. related to having positive self-esteem.
10. (4) is objective, realistic, and measurable with a time
REVIEW QUESTIONS—TEST PREPARATION frame. (1, 2, 3) are all good outcomes, but they relate to
airway clearance, nutrition, and strength, not directly to
The correct answers are in boldface.
swallowing.
6. (4) is correct. Evaluation determines whether goals are 11. (2) is correct. The three parts of a diagnosis include the
achieved and interventions effective. (2) is the role of the problem (from the NANDA International [NANDA-I]
physician. (1, 3) encompass data collection and imple- list), etiology (“related to”), and symptoms (“as evi-
mentation, which are earlier steps in the nursing process. denced by”). (1) does not include symptoms. (3) is a
7. (1) is correct. The licensed practical nurse/licensed voca- medical diagnosis. (4) is not a NANDA-I diagnosis,
tional nurse can collect data, which includes taking vital and the evidence is not related to dyspnea.
, Answers
CHAPTER 2 6. Health literacy: Degree to which a person has the capac-
ity to obtain, process, and understand basic health infor-
EVIDENCE-BASED PRACTICE mation and services to make the best-informed health
decisions.
AUDIO CASE STUDY
EVIDENCE-BASED PRACTICE
Marie and Evidence-Based Practice
1. proof
1. Thirdhand smoke is the dangerous toxins of smoke that 2. context
linger on hair, clothing, furniture, and other surfaces in 3. quality
an area after a cigarette is put out. Marie learned that 4. care
exposure to these toxins can be neurotoxic to children 5. randomized
and can trigger asthma attacks in sensitive people. 6. outcomes
2. Evidence-based practice is considered the gold standard 7. gold
of health care. 8. nursing
3. Step 1: Ask the burning question. Step 2: Search and 9. patient’s
collect the most relevant and best evidence available. 10. information
Step 3: Think critically. Appraise the evidence for
validity, relevance to the situation, and applicability. CRITICAL THINKING
Step 4: Measure the outcomes before and after instituting
the change. Step 5: Make it happen. Step 6: Evaluate the 1. By questioning the existing way of doing things to en-
practice decision or change. sure that the patient receives the best care possible.
4. Combination therapy with a nicotine patch and nicotine 2. A thorough search of the literature in the area of music
lozenges worked best, although bupropion (Zyban) and therapy.
nicotine lozenges worked well, too. A Cochrane Review 3. Cumulative Index to Nursing and Allied Health Litera-
found that advice and support from nursing staff can ture (CINAHL) Database, Joanna Briggs Institute
increase patients’ success in quitting smoking, especially evidence-based resources, Cochrane Reviews,
in a hospital setting. Medline/PubMed.
4. Measure patient outcomes before instituting the evi-
VOCABULARY dence-based change in practice so comparisons can
be made after implementation to determine if the
1. Evidence-based practice: A systematic process that uses intervention worked.
current evidence in making decisions about patient care. 5. Evaluate the results to determine whether the change
2. Evidence-informed practice: Consideration of patient fac- made a significant difference and if it was worthwhile
tors along with the use of evidence for shared decision- in terms of cost and time.
making between the health care provider and the patient.
3. Randomized controlled trials: True experimental studies REVIEW QUESTIONS—CONTENT REVIEW
in which as many factors as possible that could falsely
The correct answers are in boldface.
change the results are controlled.
4. Research: Scientific study, investigation, or experimenta- 1. (2) is Level I evidence. (1, 3, 4) are not examples of the
tion to establish facts and analyze their significance. best evidence.
5. Systematic review: A review of relevant research using 2. (1) is a nursing database. (2, 3, 4) are primarily medical
guidelines. databases.
1
, 2 Chapter 2 Answers
3. (3) is the website for the Joint Commission, where you 7. (1, 5) are Level I research. (2, 3, 4) are not systematic
can find the National Patient Safety Goals. (1, 2, 4) are reviews of randomized controlled trials.
incorrect. 8. (1, 3, 5, 6) because the evidence-based practice process
4. (2) is the definition of a randomized clinical trial. involves “ASKMME!”: ask, search, think, measure,
(1, 3, 4) are incorrect. make it happen, and evaluate. (2, 4) are not steps in the
5. (1) is correct. Evidence-based practice begins with a process.
burning question designed to solve a clinical problem. 9. (2, 3, 5) are correct, as they have been found to be best
(2, 3, 4) are incorrect. practice for oral care. (1, 4) do not remove plaque and
only freshen the mouth.
REVIEW QUESTIONS—TEST PREPARATION 10. (4) is correct. The search should be narrowed to include
the focus on the question. (1, 2, 3) do not focus on the
The correct answers are in boldface.
question being asked.
6. (2, 3, 4, 5, 6) are all independent nursing interventions
because no health care provider’s order is required. (1) is
a dependent function because it requires a health care
provider’s order.
