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- Answers✔The nurse is preparing to examine a 6-year-old child. Which action is most
appropriate?
A. The thorax, abdomen, and genitalia are examined before the head.
B. Talking about the equipment being used is avoided because doing so may increase the childs
anxiety.
C. The nurse should keep in mind that a child at this age will have a sense of modesty.
D. The child is asked to undress from the waist up.
Ans: A. Objective
Exp: objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data is what the person
says about hm or herself during history taking. The terms REFLECTIVE and INTROSPECTIVE
are not used to describe data. - Answers✔After completing an initial assessment of a patient, the
nurse has charted that his reparations are eupneic and his pulse is 58 beats per minute. These
types of data would be:
A. Objective
B. Reflective
C. Subjective
D Introspective
Ans: C. Subjective
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Exp: subjective data are what the person says about him or herself during history taking.
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. The terms REFLECTIVE and
INTROSPECTIVE are not used to describe data. - Answers✔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
Ans: A. Data base
Exp: together with the patients record and laboratory studies, the objective and subjective data
form the data base. The other items are not part of the patients record, laboratory studies, or data.
- Answers✔The patients record, laboratory studies, objective data, and subjective data combine
to form the:
A. Data base
B. Admitting data
C. Financial statement
D. Discharge summary
Ans: C. Validate the data by asking a coworker to listen to the breath sounds
Exp: when unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she
asks an expert to listen. - Answers✔When listening to a patients breath sounds, the nurse is
unsure of a sound that is heard. The nurses next action should be to:
A. Immediately notify the patients 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. Asses again in 20 minutes to note weather the sound is still present
Ans: B. A set of rules
Exp: novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links. - Answers✔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
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B. A set of rules
C. Articles in journals
D. Advice from supervisors
Ans: A. Intuition
Exp: intuition is characterized by pattern recognition expert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct. -
Answers✔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
Ans: C. EBP emphasizes the use of best evidence with the clinicans experience
Exp: EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinicians experience, as well as patient preferences and values, when
making decisions about care and treatment. EBP is more than simply using the best practice
techniques to treat patients, and questioning tradition is important when no compelling and
supportive research evidence exists. - Answers✔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 clinicians experience
D. The patients own preference are not important with EBP
Ans: D. Individual with shortness of breath and respiratory distress
Exp: First-level priority problems are those that are emergent, life threatening, and immediate
(e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
vital signs.) - Answers✔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
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Ans: C. Abnormal laboratory values
Exp: Second-level priority problems are those that require prompt intervention to forestall further
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risk to safety or
security.) - Answers✔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
Ans: B. Clustering related cues
Exp: Clustering related cues helps the nurse see relationships among the data. - Answers✔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
Ans: A. Nursing
Exp: An accurate nursing diagnosis provides the basis for the selection of nursing interventions
to achieve outcomes for which the nurse is accountable. The other items do not contribute to the
development of appropriate nursing interventions. - Answers✔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
Ans: D. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
Exp: The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation. - Answers✔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