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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 his respirations

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: A

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

him or herself during history taking. The terms reflective and introspective are not used to

describe data.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2

MSC: Client Needs: Safe and Effective Care Environment: 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:

a. Objective.

b. Reflective.

c. Subjective.

d. Introspective.

ANS: C

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.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2

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

3. 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: A

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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.

DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 2

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

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

ANS: C

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.

DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 2

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

5. 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.

b. A set of rules.

c. Articles in journals.

d. Advice from supervisors.

ANS: B

Novice nurses operate from a set of defined, structured rules. The expert practitioner uses

intuitive links.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 3

MSC: Client Needs: General

6. 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: A

Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of

assessment data and act without consciously labeling it. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4

MSC: Client Needs: General

7. The nurse is reviewing information about evidence-based practice (EBP). Which statement

best reflects EBP?

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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 preferences are not important with EBP.

ANS: C

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.

DIF: Cognitive Level: Applying (Application) REF: dm. 5

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

8. 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

ANS: D

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) (see Table 1-1).

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4

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

9. 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: C

Second-level priority problems are those that require prompt intervention to forestall further

deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety

or security) (see Table 1-1).

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4

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

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

a. Validation

b. Clustering related cues

c. Identifying gaps in data

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d. Distinguishing relevant from irrelevant

ANS: B

Clustering related cues helps the nurse see relationships among the data.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2

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

11. 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: A

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.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 6

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

12. 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

b. Admission, assessment, diagnosis, treatment, and discharge planning

c. Admission, diagnosis, treatment, evaluation, and discharge planning

d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

ANS: D

The nursing process is a method of problem solving that includes assessment, diagnosis,

outcome identification, planning, implementation, and evaluation.

DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 3

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

13. 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?

a. Breathing, pain, and sleep

b. Breathing, sleep, and pain

c. Sleep, breathing, and pain

d. Sleep, pain, and breathing

ANS: A

First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing,

and circulation), followed by second-level problems, and then third-level problems.

DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 4

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

14. Which of these would be formulated by a nurse using diagnostic reasoning?

a. Nursing diagnosis

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