health assessment chapter one - evidence based practice

Which question posed by the nurse is most appropriate to determine the next step in treatment for the patient who presents to the urgent care with a cough and is febrile?

"How long have you had the cough?" The most important question for the nurse to ask is about the duration of the cough. A new onset cough with fever would indicate a possible infection, whereas a chronic productive cough could be related to chronic lung problems. The answer to this question will guide treatment. The patient has a fever, so the nurse does not need to ask about feeling warm. Treatment of the cough and prior illnesses are important but do not guide treatment.

Diagnostic reasoning is performed in which order?

1. Attend to the initially available cues. 2.Formulate the tentative diagnostic hypothesis. 3.Gather data relative to the tentative hypothesis. 4.Evaluate each hypothesis with the newly collected data Diagnostic reasoning is the process of analyzing the data obtained during the assessment and drawing conclusions to identify the illness. The nurse would first attend to cues such as signs or symptoms or a piece of laboratory data. Then the nurse would formulate a diagnostic hypothesis for a cue or set of cues that is necessary for further investigation. Then the nurse must gather data and organize the data into meaningful clusters relative to tentative hypotheses. Finally, the nurse must evaluate each hypothesis with the newly collected data and arrive at a final diagnosis.

The nurse is caring for a patient who is hypertensive with acute abdominal pain and an increased heart rate and urinary frequency. The patient is anxious and hallucinating. Which of these conditions can be categorized as second-level priority problems? Select all that apply. Altered vital signs Respiratory problems Acute pain Urinary frequency Change in mental status Abnormal electrolyte levels

Acute pain Urinary frequency Change in mental status Abnormal electrolyte levels Acute pain, urinary frequency, changes in mental status, and abnormal electrolyte levels are categorized as second-level priority problems, because they do not require immediate attention. These conditions are not life-threatening and do not cause an immediate health crisis. Altered vital signs and respiratory problems may be life-threatening conditions. Therefore these conditions are considered first-priority problems.

A nursing student is completing an assessment on a patient with a diagnosis of human immunodeficiency virus (HIV) with a holistic approach in mind. Which action by the student indicates a need for further teachings?

Assuming the patient will not adhere to the treatment While assessing a patient, the student should not make any assumptions or take any information for granted. If the student makes this assumption, further teaching is required. The student would evaluate the patient's support system to meet the needs and provide shelter to the patient. The student would determine the coping abilities of the patient to ensure that the patient is not at risk for psychological illness. To assess whether the patient has depression, the student would assess the patient for feelings of despair.

The nurse caring for a patient with coronary artery disease finds the patient is nonresponsive and without a pulse. Which nursing intervention is best in this situation?

Beginning CPR with chest compression CPR with chest compressions is an emergency procedure in which the heart is manually pumped to ensure blood circulation. Calcium supplements are not effective to resuscitate a patient in cardiac arrest. While providing CPR, the nurse would avoid blood transfusion because it increases the circulatory load and may worsen the patient's condition. The nurse can monitor the patient's vital signs and ankle brachial index after restoring respiration and blood circulation in the patient.

Which patient requires a database different from the one created by the nurse? A. overdose- emergency database B. severe skin lesions- problem centered database C. cough 2 days after surger - follow up database D. chronic liver disease - complete database

C. patient C Patient C has undergone surgery and is experiencing a congested cough, so the nurse would establish a focused database, not a follow-up database, about the patient's respiratory problems. Patient A consumed an overdose of sleeping pills, so it is correct to establish an emergency database for the patient. Patient B has a skin rash, so the nurse would collect problem-centered data that provide information about the reason, such as food or medicine allergy, for the rash. Patient D has chronic liver disease, so the nurse would establish a complete database to find the patient's perception of the illness, support system, and coping abilities.

A nursing student reads the case studies of different patients and separates the subjective data and objective data as part of an assignment. Which patient entry indicates a correct understanding of data collection by the nursing student?

C. the patient has bronchitis and Uti. the pt complains of burning during urination subjective- burning sensation during urination objective- bronchitis and UTI Information given by the patient during data collection is considered subjective data. The data obtained by the nurse during physical examination by inspecting, percussing, palpating, and auscultating the patient is known as objective data, as are any data obtained from laboratory findings, medical history, and diagnostic reports. The data collection for Patient C is correct because it separates subjective data (burning sensation during urination) from objective data (bronchitis and urinary tract infection) that is diagnosed from laboratory results and diagnostic reports.

Which nursing action is the priority for a patient in the urgent care setting who reports having "crushing" chest pain?

Emergency assessment to initiate lifesaving measures The nurse's priority in this case is to perform an emergency assessment and initiate lifesaving measures, because the patient's life may be at risk. The nurse cannot perform a comprehensive assessment at this time, because the patient may need prompt treatment. It may not be feasible to perform a problem-focused assessment, because the patient is in distress. The nurse needs to first initiate lifesaving measures and then call for an ambulance so that the patient is not at immediate risk.

Which nursing intervention would be completed first for a patient who reports missing a dialysis appointment and presents with bilateral pitting edema of the extremities and an 8-lb (3.62-kg) weight gain over the past 3 days?

Ensure that the patient undergoes dialysis The nurse must ensure that the patient undergoes dialysis. The missed dialysis appointment has led to water retention and edema on both feet. The nurse need not review the patient's diet or evaluate the patient's water intake, because the weight gain is a result of water retention after delayed dialysis. The nurse may speak to the patient or the caregiver about the importance of regular dialysis after the patient has stabilized.

The nurse is developing a holistic wellness program for a group of young adults at a college campus. Based on this model, which information would the nurse include when performing a focused assessment? Select all that apply. Exercise Role in family Level of stress Family history Military service

Exercise Role in family Level of stress In a holistic model, the nurse would focus on lifestyle behaviors including exercise, family and social roles, and level of stress the person is experiencing. Family history and military service would be considered demographic data.

While preparing a complete database for a 35-year-old female patient with diabetes, the nurse determines that the patient is following appropriate health-promotion techniques. Which findings support the nurse's conclusion? Select all that apply. Has dental visits twice a year Walks 2 miles 3 times a week Uses sunscreen when going outside Has a pedicure and foot checks once a year Does a breast self-examination twice a year

Has dental visits twice a year Walks 2 miles 3 times a week Uses sunscreen when going outside When preparing a complete database, the nurse would check various health-promotion techniques followed by the patient; this helps identify and reinforce positive behaviors in the patient. To have good oral health, the patient should follow good oral care and visit the dentist twice a year. Walking 2 miles 3 times a week helps the patient remain fit and healthy. Sunscreen protects the skin from radiation and prevents skin cancer. A diabetic patient may experience skin integrity issues on his or her feet because of reduced blood flow, so the patient should do pedicures and foot checks once a week rather than once a year. A female patient should perform a breast self-examination once a month, rather than twice a year, to detect breast cancer.

During an assessment, the nurse evaluates the patient's perception of illness, activities of daily living, and health maintenance behaviors to establish a complete database. Which additional information would the nurse collect from the patient? Select all that apply. Health goals Financial assets Coping patterns Functional ability Partner intimacy

Health goals, coping patterns, functional ability, partner intimacy To establish a complete database, the nurse would obtain a complete health history and conduct a full physical examination of the patient. Therefore the nurse would gather information about the patient's perception of illness, activities of daily living, and health maintenance behaviors. In addition to this information, the nurse would also collect data about the patient's health goals, coping patterns, functional ability, and partner intimacy, because this information helps the health care team plan appropriate treatment and care for the patient. A complete database does not include data regarding the patient's financial assets.

Which information would be most appropriate for the nurse to obtain when obtaining a complete database? Select all that apply. Smokes 1 pack per day Current medication list Obtains screening tests Ambulates independently Onset of current symptoms

Smokes 1 pack per day Current medication list Obtains screening tests The complete database would include strengths or assets such as health maintenance behaviors, including smoking, current medications, and obtaining screening tests. In an acute care setting, the nurse would obtain functional ability such as independent ambulation and onset of current symptoms.

A nurse manager is presenting to management. Which information would the nurse manager include in a presentation about the importance of incorporating evidence-based practice (EBP) at the bedside?

Using EBP provides improved patient outcomes. It allows the nurse to manage the care of more complex patients, and it decreases the length of stay because of improved outcomes. It does not affect staffing.

The nurse is preparing a care plan for a patient with a complex cardiovascular disorder. Which actions would the nurse consider to provide effective care for the patient? Select all that apply. 1. Document data immediately after observing the patient. 2. Work with the patient to facilitate outcome achievement. 3. Discuss patient data with the interdisciplinary team members. 4. Recognize the document as an assistive tool and not a legal document. 5. Set small, achievable goals to be accomplished in a given time frame

Work with the patient to facilitate outcome achievement. Discuss patient data with the interdisciplinary team members. Set small, achievable goals to be accomplished in a given time frame Once the problem is established, the nurse will work with the patient to facilitate outcome achievement. While evaluating and recording the care plan, the nurse would discuss the care plan with the interdisciplinary team members to ensure that the treatment provided is safe and effective. Setting small goals will assist in achieving measurable outcomes. The nurse would document data while providing care rather than after completing treatment, because there is a chance of error if data are documented at the end. This is a legal document, and accurate reporting is important for evaluation, insurance reimbursement, and research.

Which intervention would the nurse assign as the highest priority for a diabetic patient who presents to the emergency department with shortness of breath and decreased alertness?

assist with breathing The nurse would give high priority to first-level priority problems that are emergent and life-threatening. First-level priority problems include airway problems, breathing problems, cardiac/circulation problems, and stabilizing vital signs. Therefore in this case the nurse must first assist the patient with breathing. Second-level priority problems are those that need immediate attention to prevent further deterioration. The nurse must monitor the patient's alertness and assess blood sugar level. The blood sugar level and alertness may be related. The third-level priority is to teach the family to monitor the patient's blood sugar levels at regular intervals at home.

Which type of database would the nurse establish for a patient with a new diagnosis when reviewing patient history, coping skills, support systems, and lifestyle, followed by conducting a physical assessment?

complete

Upon reviewing a laboratory report, the nurse finds that the patient has hyperlipidemia and hypercholesterolemia. During which phase of the nursing process will the nurse use this data?

diagnosis During the nursing diagnosis phase, the nurse analyzes, interprets, and documents the patient's illness by comparing the patient's laboratory findings with normal levels. In this case the nurse interprets and documents that the patient has hyperlipidemia and hypercholesterolemia after reviewing the laboratory reports. Therefore the diagnosis phase includes these nursing actions. In the planning phase, the nurse establishes the priority interventions that would help provide effective care to the patient. In the evaluation phase, the nurse evaluates the outcomes based on the treatment provided to the patient. In the implementation phase, the nurse administers medication to the patient as prescribed by the health care provider.

Which questions would the nurse ask during a follow-up database to determine compliance for the patient with new-onset type 1 diabetes mellitus? Select all that apply. 1"When did you eat your last meal or snack?" 2"Can you tell me what you eat on a normal day?" 3"How often do you perform blood glucose monitoring?" 4"Do you have any family members with diabetes mellitus?" 5"Will you show me how you self-administer your insulin?"

eat in a normal day, how often perform blood glucose, show me how you self admin insulin Information that is needed to determine compliance would be overall diet, frequency of blood glucose monitoring, and self-administration of insulin. Asking when they ate last would be important to know when obtaining a single blood glucose reading. Family history would be obtained at the initial appointment, not at a follow-up visit.

Which database would the nurse establish for a patient who has accidentally consumed a pesticide?

emergency During an emergency condition such as poisoning, the patient requires immediate and effective treatment. The nurse would establish an emergency database by evaluating vital signs, airway, and level of consciousness simultaneously. The nurse would also obtain information regarding the quantity of pesticide consumed by the patient. A complete database would be collected only after an emergency when the patient is stabilized. This database describes the current and past health status of the patient

Which database would the nurse complete for a patient who reports slight pain in the left ear for the past 2 days?

focused The nurse gathers data to complete a focused or problem-centered database. The history and examination focus primarily on the ears. A complete or total health database includes a full history and full physical examination. This examination forms the baseline for all future assessments. A follow-up database contains information that helps evaluate previously identified problems. The nurse often obtains information for a follow-up database during the patient's consecutive visits to the health care facility after a surgery. An emergency database is an urgent, rapid collection of crucial information that is compiled concurrently with lifesaving measures. This type of information is collected when the diagnosis must be swift and sure, as in the case of a motor vehicle accident victim.

The nurse is caring for a patient who was in a car accident and has a knee ligament injury. The health care provider has prescribed a knee brace. After 2 weeks, the nurse assesses the patient and documents that the patient has a wider range of motion and less pain in the knee. Which type of database did the nurse establish in this situation?

follow up To establish a follow-up database, the nurse evaluates the problems identified in the patient at regular intervals, which helps determine the effectiveness of the treatment. Therefore by examining the patient's knee 2 weeks after the knee brace is prescribed, the nurse is establishing a follow-up database. A complete database documents the patient's current and past health conditions and includes a complete health history and physical examinations of the patient. The nurse would establish an emergency database in assessing a patient who needs urgent, rapid collection of crucial information; the emergency database is often compiled concurrently with lifesaving measures. A problem-centered database is limited to a short-term problem and contains data regarding one problem, one cue complex, or one body system.

A patient who complains of frequent urination and thirst is found to have lower limb edema and seborrheic dermatitis. Laboratory results include a fasting blood glucose level of 140 mg/dL. Which data obtained during the assessment are categorized as subjective data?

frequent urination Subjective data are the signs and symptoms reported by the patient during the assessment. In this case the patient complains of frequent urination and thirst, so these two symptoms can be considered subjective data. The signs and symptoms observed by the nurse and the data obtained from laboratory reports are known as objective data. Therefore blood glucose levels, lower limb edema, and seborrheic dermatitis are considered objective data.

Which assessment data would the nurse cluster together to determine the priority care for a patient with new-onset type 1 diabetes mellitus (DM)? Select all that apply. 1 Nasal congestion 2Frequent urination 3 Lower extremity edema 4 No knowledge of type 1 DM 5 Blood glucose level 425 mg/dL

frequent urination, no knowledge, blood glucose level of 425 Assessment data that would guide care for a patient with new-onset type 1 DM would be frequent urination, no knowledge of the disease process, and an elevated blood glucose level. The nasal congestion and lower extremity edema are unrelated to the new diagnosis.

In which case would a nurse establish a complete database of a patient? Select all that apply. 1During an initial home visit 2During a preoperative interview 3In an emergency department 4In a primary health care setting 5In a community health care setting

initial home visit, primary health care, community heath care setting While assessing a patient during an initial home visit, in a primary health care setting, and in a community health care setting, the nurse would review the patient's medical history and laboratory and diagnostic reports. Along with this information, the nurse would evaluate the patient's coping skills, support system, and lifestyle modifications. This information would help the nurse establish a complete database. This is an elaborate and time-consuming procedure. A focused assessment would be appropriate for a preoperative interview because this is done just before a surgical procedure. The nurse would obtain information critical to the pending surgical procedure such as drug allergies, health history, and NPO status. In an emergency department the patient may have serious complications suddenly and require immediate and effective treatment; therefore while caring for such patients, the nurse would establish an emergency database.

Upon entering a patient's room, the nurse notices the patient has a low oxygen saturation, and the patient reports a history of asthma and feeling short of breath within the past 5 minutes. Which finding would be documented under objective data?

low oxygen saturation The nurse observes the patient has a low oxygen saturation, so this is objective data. Subjective data are what the patient reports, which include having a history of asthma, stating the symptoms began 5 minutes ago, and feeling short of breath.

Which condition would the nurse consider a third-level priority problem in a patient with a diagnosis of coronary artery disease who is hypertensive and who has chest pain, lower limb edema, and difficulty breathing?

lower limb edema

A patient who lives alone has chronic obstructive pulmonary disease and reports difficulty breathing and pain with movement due to arthritis. Which assessment finding would be considered a second-level priority problem?

pain level Second-level priority problems include pain, mental status changes, abnormal labs and elimination problem. Mobility and living situation are third-level problems. Difficulty breathing is a first-level problem.

Which type of database would the nurse establish when caring for a patient with a skin infection and assessing the patient for fever and pain related specifically to the skin lesions?

problem centered Depending on the patient's condition and the data obtained during the assessment, the nurse would establish a specific type of database to provide effective treatment for the patient. In this case the nurse is collecting data regarding the cause, signs, and symptoms specific to a skin infection, so he or she would establish a problem-centered database focused on one issue. The nurse would collect a complete health history and would conduct a complete physical examination of the patient to establish a complete database. To establish a follow-up database, the nurse would evaluate the effectiveness of the treatment. The nurse would establish an emergency database to provide immediate treatment for acutely serious conditions such as drug overdose.

The nurse obtains the following data from a patient assessment: lung sounds are coarse throughout, regular heart rhythm, denies pain, ambulates with minimal assistance, and reports a productive cough. Which would the nurse document under objective data? Select all that apply.

regular heart rhythm, lung sounds course throughout, ambulates with min assistance Objective data is data observed by the nurse. This includes the heart rhythm, lung sounds, and ambulation ability. The pain level and productive cough were reported by the patient and are considered subjective data.

The nurse is performing a screening examination for a patient using the Guide to Clinical Preventive Services. Which questions would the nurse include in the assessment? Select all that apply. 1"How old are you?" 2"Are you sexually active?" 3"Do you use alcohol or drugs?" 4"Any heart disease in your family?" 5 "What is your height and weight?"

sexually active, drugs/alcohol, height/weight According to the guide for examination, the nurse would ask about sexual activity and practices, use of alcohol and drugs, and height and weight. The patient's age is demographic information, and the presence of heart disease is family history.