2110 Chapter 1

The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:

2 X 5 cm scar present 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 complete health data base because of the nurse's primary responsibility for monitoring the patient's health

Which situation is most appropriate for the nurse to perform a focuses or problem centred history?

A patient in an outpatient clinic has cold and flu like symptoms

When considering priority setting of problems, the nurse keeps in mind that second level problems include which of these aspects?

Abnormal laboratory values

What is the step of the nursing process that includes data collection by history, physical examination and interview?

Assessment

The nursing process is a sequential method of problem solving that nurses use, and includes which steps?

Assessment, diagnosis, outcome identification, planning, implementation, 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?

Breathing, pain, sleep

Which critical thinking skill helps the nurse to see relationship among the data?

Clustering

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:

Collect a follow up data base and the check her blood pressure

The patient's record, laboratory studies, objective data, and subjective data combine to form the:

Data base

Which of these would be formulated by a nursing using diagnostic reasoning?

Diagnostic hypotheses

The nurse is reviewing information about evidence based practice. Which statement best reflects evidence based practice?

EBP emphasizes the use of best practice with the clinicians experience.

The nurse has implemented several planning interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

Evaluate the individuals condition and compare actual outcomes with expected

A teenager who was stung by a bee during a soccer match is having trouble breathing.

First level priority problems

In the health promotion model, the focus of the health professional includes:

Helping the consumer choose a healthier lifestyle

When reviewing concepts of health, the nurse recalls that components of holistic health include which of these?

Holistic health views the mind, body and spirit as interdependent.

The nurse is classifying nursing diagnoses. Which of these would be considered a risk diagnosis?

Identifying potential problems the individual may develop

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of first level priority problem?

Individual with shortness of breath ad respiratory distress

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?

Inspiratory wheezes notes in the left lower lobes, Non productive cough, Patient reports dyspnea upon exertion, Rate of respirations 16 breaths per minute

Expert nurses learn to attend to a pattern f assessment data and toast without consciously labelling it. This is referred to as:

Intuition

Barriers to incorporate evidence based practice include:

Nurses lack of research skills in evaluating quality of research studies

The nurse knows the developing appropriate nursing interventions for a patient relies on the appropriateness of the _____ diagnosis

Nursing

After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

Objective

The recognizes that the concept of prevention in describing health is essential because:

Prevention places emphasis on the link between health and personal behaviour

A 42 year old asian patient is being seen at the clinic for an initial examination. The nurse knows that it is important to include information in his health assessment to:

Provide culturally sensitive and appropriate care.

An older adult with a urinary tract infection is also showing signs of confusion and agitation

Second level priority problems

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 to draw from, are more likely to make their decisions using:

Set of rules

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 the data collection?

Simultaneously ask history questions while performing the examination and initiating life saving measures.

A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:

Subjective

During a staff meeting, nurses discuss the problems with accessing research studies in order to incorporate evidence based clinical decision making into their practice. Which suggestion by the nurse manner would best help this problem?

Teach the nurses how to conduct electronic searches for research studies

The nurse is reviewing the components of the nursing process. Which statement about nursing diagnoses is true?

They are clinical judgements about a person's response to an actual or potential health state.

A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.

Third level priority problems

WHich statement best describes a proficient nurse? A proficient nurse is one who?

Understands a patients situation as a whole rather than a list of tasks and sees long term goals for the patient.

When listening to a patient's breath sounds, the nurse is unsure about a sound that is heard. The nurse's next action should be to:

Validate the data by asking a coworker to listen to the breath sounds