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After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic (normal) and his pulse is 58 beats per minute. These types of data would be: Objective. . A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be C. Subjective.
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Chapter 01: Evidence-Based Assessment
C. Abnormal laboratory values 10.Which critical thinking skill helps the nurse see relationships among the data? b. Clustering related cues 11.The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a. Nursing 12.The nursing process is a sequential method of problem solving that nurses use and includes which steps? D. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation 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 14.Which of these would be formulated by a nurse using diagnostic reasoning? C. Diagnostic hypothesis 15.Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. 16.What step of the nursing process includes data collection by health history, physical examination, and interview? D. Assessment 17.During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? D. Teach the nurses how to conduct electronic searches for research studies. 18.When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? D. Holistic health views the mind, body, and spirit as interdependent. 19.The nurse recognizes that the concept of prevention in describing health is essential because: C. Prevention places the emphasis on the link between health and personal behavior.
❖ Inspiratory wheezes noted in left lower lobes ❖ Nonproductive cough ❖ Patient reports dyspnea upon exertion ❖ Rate of respirations 16 breaths per minute ANS: A, C, E, F 30.Put the following patient situations in order according to the level of priority. a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. # b. A teenager who was stung by a bee during a soccer match is having trouble breathing. # c. An older adult with a urinary tract infection is also showing signs of confusion and agitation. #
21.A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms. 22.Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? B. Nurses need to recognize that many cultures practice silent suffering as a response to pain. 23.The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? B. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. 24.During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: D. Arises out of each persons unique life experience and his or her personal effort to find purpose in life. 25.The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. 26.A 30-year-old woman has recently moved to the United States with her husband. They are living with the woman's sister until they can get a home of their own. When the company arrives to visit with the woman's sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she doesn't know how to speak perfect English. This woman could be experiencing: a. Culture shock. 27.After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: D. Influenced by the accessibility of over-the-counter medicines. 28.The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? D. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
29.In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? D. Older man with gastrointestinal discomfort 30.When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American- Indian patient? D. What cultural or spiritual beliefs are important to you? 31.During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? C. Refusing to accept blood products as part of treatment 32.The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: D. Subcultures. 33.The nurse is reviewing concepts related to one's heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: b. Religion. 34.When planning a cultural assessment, the nurse should include which component? D. Health-related beliefs 35.Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: D. Being in harmony with nature. MULTIPLE RESPONSE
reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? D. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
toddler if which is done next?
b. Stoop down to her level, and ask her about the toy she is holding. 23.During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child's full cooperation?
24.A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? b. Be totally honest with him, even if the information is unpleasant. 25.A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. 26.The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. 27.During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurse's best response to her crying would be: b. I can see that you are sad remembering this. It is all right to cry. 28.A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. 29.A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? D. She is showing that she is carefully listening to what the nurse is saying.
ask in this situation? a. Do you take medicine? 31.A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? D. How has your health been since your last visit? 32.The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? C. This comment is appropriate because members of the health care team are experts in their area of patient care. 33.A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter 34.During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why haven't you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. 35.The nurse is nearing the end of an interview. Which statement is appropriate at this time? b. Is there anything else you would like to mention? 36.During the interview portion of data collection, the nurse collects data D. Subjective 37.During an interview, the nurse would expect that most of the interview will take place at what distance? c. Social distance 38.A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: d. It makes me uncomfortable when you talk that way. Please stop. MULTIPLE RESPONSE
❖ C. Open-ended questions build and enhance rapport. ❖ F. They are used when narrative information is needed.
D. Child's reactions to previous hospitalizations 19.As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? B. MMR vaccination needs to be repeated at 4 to 6 years of age. 20.In obtaining a review of systems on a healthy 7-year-old girl, the health care provider knows that it would be important to include the: D. Limitations related to her involvement in sports activities. 21.When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? c. Functional assessment
description of the setting of his symptoms? D. This pain happens every time I sit down to use the computer. 29.During an assessment, the nurse uses the CAGE test. The patient answers yes to two of the questions. What could this be indicating? D. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.