Nursing Health Assessment A Best Practice Approach 3rd Edition – Test Bank

Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen

Test Bank

Chapter 1. Nurse’s Role in Health Assessment

1. After completing an initial assessment of a patient, the nurse has charted that lurespirations are eupneic and his pulse is 58 beats per minute. These types of data would be

1. Objective

Reflective

Subjective

retrospective

ANS A

Objective data are what the health professional observes by inspecting, percussing, palpating, anduin the psical examination Subjective data is what the person him or herself during history taking The tentandrecte noted to describe data.

DIF: Cegative Level: Understanding Comprehension) REF:2

MSC: Cheat Needs Safe and Effective Care Event Management of Care

2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be

Objective

Reflective

Subjective

Introspective

ANS: C

Subjective data are what the person says about him or herself during history taking Objective data ace what the health professional observes by inspecting, percing, palpating, and sungduring the physical examination. The teadandrospective are not used

to describe data

DIF: Cestive Level: Understanding (Compression) REF:2

MSC: Cheat Needs Safe and Effective Care Event Management of Care

3. The patients record, laboratory studies, objective data, and subjective dat combine to for the

Database

Adming data

Discharge summary

ANS A

Together with the patients record and laboratory studies, the objective and subjective data fo the database. The other items are not part of the patients record,story shades, odat

DOF: Cocutive Level Remembering Knowled)

REF:2

MSC: Client Needs: Sade and Effective Care Environment: Management of Care

4. When listening to a patients breath sounds, the nurses of sound that is beard. The punes nest action should be

Immediately notify the patients physicia

b Document the sound exactly as it was heted

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

4 Assess again in 20 minutes to note whether the sound is still present

ANS: C

When unsure of a sound beard while listening to a patients breath sounds, the arealidate the data to ease accuracy. If there has less experience in an area, then he or she asks an expest

DEF: Cognitive Level Analyzing (Analysis) REF: d. 2

MSC: Client Needs: Sade and Effective Care Eastonment Management of Care

5. The nurse in conducting a class for new graduates. During the teaching session, the nurse should keep in mind that notices, without background of skills and experience thom which to draw, are more likely to make their decisions using

Intuition

A set of rules

Articles in joumals.

ANS: B

Advice from supervis

Novice as operate from a set of defined, structured rules. The expect practitioner uses

intuitive links.

DEF: Cogusive Level: Understanding (Comprehension) REF:3

MSC: Chent Need

6. Expertes learn to attend to a pattern of assesment data and act without consciously labeling it. These responses are referred to as

Clinical knowledge

ANS: A

Diagnostic reasoning

ution is characterized by pamers rесоваловекресtele to attend top of assessment data and act without consciously labeling it. The other options are not correct.

DIF: Cognitive Level Understanding (Compression) REF:

MSC: Chent Needs: General

7. There is everwing information about evidence-based practice (EBP), Which statement

best reflects EBP!

EBP relies on traditiofuppof best practices.

EBP is simply the ne of best practice techniques for the treatment of patients.

ESP emphasizes the use of best evidence with the clinicians εxρετίστοι

4 The patients own preferences are not important with EBP.

ANS: C

EBP is a systematic approach to practice that emphasizes the use of best evidence in com 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 test patients, and questioning traditionismportant when no compelling and supportive research evidence exists

DIF: Comitive Level: Azelving (Application) REF:5

MSC: Cheat Needs Safe and Effective Care Event Management of Care

8. The nurse is conducting a class on priority setting for a group of new graduste mures. Which is an example of a first-level priority problem?

Patient with postoperative pi

Newly diagnosed patient with diabetes who needs diabetic teaching

Individual with a small laceration on the sole of the foot

Individual with shortness of breath and respiratory distress

ANS: D

First-level priority problems are those that are andmediate (eg eutablishing a sirway, supporting boathing, maintaining circulation, monitoring abnormal vital sign) (see Table 1-1)

DIF: Cogutive Level: Understanding (ComprehensioREF

MSC: Client Needs: Safe and Effective Care Enviroment Management of Care

9. When considering priority setting of problems, the muse keeps in mind that second-level priority problems include which of these aspects?

Low self-esteem

Lack of knowledge

Absomal laboratory values

ANS: C

Severely abnormalities

Second-level pricity problems are those that require prompt intervention to forestall further deterioration (eg, mental status change, acute poin, anormal laboratory values risks to safety

or security) (see Table 1-1) DIF: Cogative Level: Understanding (Comprehension) REF

MSC: Cheat Needs Safe and Effective Care Event Management of Care

10. Which critical thinking skill helps the nurse see relationships among the dats?

Validation

Clusterinat related cues