HA EXAM FINAL QUESTIONS AND ANSWERS
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.
b. Reflective.
c. Subjective.
d. Introspective. - Answer -a. Objective.
A patient tells the nurse that he is very nervous, is nauseated, and ―feels hot.‖ These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - Answer -c. Subjective.
The patient's record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - Answer -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. Immediately notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present. - Answer -c.
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. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. - Answer -b. 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.
b. The nursing process.
c. Clinical knowledge.
,d. Diagnostic reasoning. - Answer -a. Intuition.
The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patient's own preferences are not important with EBP. - Answer -c. 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?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress - Answer -d. 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. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs - Answer -c. Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant - Answer -b. Clustering related cues
The nurse knows that developing appropriate nursing interventions for a patient relies
on the appropriateness of the_____ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative - Answer -a. Nursing
The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation - Answer -d. 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
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing - Answer -a. Breathing, pain, and sleep
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment - Answer -c. Diagnostic hypothesis
Barriers to incorporating EBP include:
a. Nurses' lack of research skills in evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills. - Answer -a. Nurses' lack of research skills in
evaluating the quality of research studies.
What step of the nursing process includes data collection by health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment - Answer -d. Assessment
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. Form a committee to conduct research studies.
b. Post published research studies on the unit's bulletin boards.
c. Encourage the nurses to visit the library to review studies.
d. Teach the nurses how to conduct electronic searches for research studies. - Answer
-d. Teach the nurses how to conduct electronic searches for research studies.
When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient's health state.
d. Holistic health views the mind, body, and spirit as interdependent. - Answer -d.
Holistic health views the mind, body, and spirit as interdependent.
, The nurse recognizes that the concept of prevention in describing health is essential
because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Prevention places the emphasis on the link between health and personal behavior.
d. The means to prevention is through treatment provided by primary health care
practitioners. - Answer -c. Prevention places the emphasis on the link between health
and personal behavior.
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. Patient's history of allergies.
b. Patient's use of medications at home.
c. Last menstrual period 1 month ago.
d. 2 5 cm scar on the right lower forearm. - Answer -d. 2 5 cm scar on the right lower
forearm.
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 - Answer -c. A complete health data base because of the
nurse's primary responsibility for monitoring the patient's health
Which situation is most appropriate during which the nurse performs a focused or
problem- centered history?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital for surgery the following day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms. - Answer -d.
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.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was documented
2 months ago.
d. Obtain a complete health history before checking - Answer -a. Collect a follow-up
data base and then check her blood pressure.
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.
b. Reflective.
c. Subjective.
d. Introspective. - Answer -a. Objective.
A patient tells the nurse that he is very nervous, is nauseated, and ―feels hot.‖ These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - Answer -c. Subjective.
The patient's record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - Answer -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. Immediately notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present. - Answer -c.
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. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. - Answer -b. 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.
b. The nursing process.
c. Clinical knowledge.
,d. Diagnostic reasoning. - Answer -a. Intuition.
The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. The patient's own preferences are not important with EBP. - Answer -c. 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?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress - Answer -d. 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. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs - Answer -c. Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant - Answer -b. Clustering related cues
The nurse knows that developing appropriate nursing interventions for a patient relies
on the appropriateness of the_____ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative - Answer -a. Nursing
The nursing process is a sequential method of problem solving that nurses use and
includes which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation - Answer -d. 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
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing - Answer -a. Breathing, pain, and sleep
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment - Answer -c. Diagnostic hypothesis
Barriers to incorporating EBP include:
a. Nurses' lack of research skills in evaluating the quality of research studies.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills. - Answer -a. Nurses' lack of research skills in
evaluating the quality of research studies.
What step of the nursing process includes data collection by health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment - Answer -d. Assessment
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. Form a committee to conduct research studies.
b. Post published research studies on the unit's bulletin boards.
c. Encourage the nurses to visit the library to review studies.
d. Teach the nurses how to conduct electronic searches for research studies. - Answer
-d. Teach the nurses how to conduct electronic searches for research studies.
When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient's health state.
d. Holistic health views the mind, body, and spirit as interdependent. - Answer -d.
Holistic health views the mind, body, and spirit as interdependent.
, The nurse recognizes that the concept of prevention in describing health is essential
because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Prevention places the emphasis on the link between health and personal behavior.
d. The means to prevention is through treatment provided by primary health care
practitioners. - Answer -c. Prevention places the emphasis on the link between health
and personal behavior.
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. Patient's history of allergies.
b. Patient's use of medications at home.
c. Last menstrual period 1 month ago.
d. 2 5 cm scar on the right lower forearm. - Answer -d. 2 5 cm scar on the right lower
forearm.
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 - Answer -c. A complete health data base because of the
nurse's primary responsibility for monitoring the patient's health
Which situation is most appropriate during which the nurse performs a focused or
problem- centered history?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital for surgery the following day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms. - Answer -d.
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.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was documented
2 months ago.
d. Obtain a complete health history before checking - Answer -a. Collect a follow-up
data base and then check her blood pressure.
