Health Assessment Chapter 5 Questions

Essential characteristics for the development of critical thinking skills include all the following except:

Following instructions

A nursing instructor is teaching about respiratory problems in the patient with chronic obstructive pulmonary disease (COPD). The instructor realizes that the student needs more teaching when the student states which of the following?

"Impaired gas exchange and ineffective breathing pattern can be interchanged."

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

"It's acceptable for a client to admitted for observation."

The nurse has clustered assessment data on a patient with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this patient?

Actual nursing diagnosis.

The RN may delegate which care component to a nursing assistant?

Ambulation assistance

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience.

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments.

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance

The nursing student learning about strengths and weaknesses of a patient understands that which of the following is considered to be an example of abnormal objective data?

Anxious appearance

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:

wellness diagnosis

A nurse proposes a nursing diagnosis for a client based on subjective and objective data. What step should the nurse perform before the diagnosis can be confirmed or ruled out?

Check for the presence of major and minor defining characteristics

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness diagnosis

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

discuss the plan with the patient

The nurse divides collected data into subjective and objective categories. What should the nurse do next in the critical thinking process?

identify abnormal data and strengths

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?

identifying abnormal or positive findings

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following?

too many or too few data