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Chapter 01: Evidence-Based Assessment and more Exercises Nursing in PDF only on Docsity!
HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK
Chapter 01: Evidence-Based Assessment
- 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: a. Objective. .
- A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be C. Subjective. .
- The patient's record, laboratory studies, objective data, and subjective data combine to form the: a. Data base.
- When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: C. Validate the data by asking a coworker to listen to the breath sounds.
- 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: b. A set of rules.
- 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.
- The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? C. EBP emphasizes the use of best evidence with the clinician's experience.
- 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? D. Individual with shortness of breath and respiratory distress
- When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
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. #
- b = First-level priority problem
- c= Second-level priority problem
- a= Third-level priority problem Chapter 02: Cultural Assessment
- The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: B. Learned through language acquisition and socialization.
- During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? d. Culture adapts to specific environmental factors and available natural resources.
- During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? C. Norms
- When discussing the use of the term subculture, the nurse recognizes that it is best described as: D. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
- When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic.
- During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance.
- The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: . D. Understands and attends to the total context of the patients situation.
- The nurse recognizes that an example of a person who is heritage consistent would be a: b. Woman who follows the traditions that her mother followed regarding meals.
- After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. 10.The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? C. Personal effort made to find purpose and meaning in life 11.A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept a. Assimilation
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
- The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply. ❖ B. Select questions that are not complex. ❖ D. Touch patients within the cultural boundaries of their heritage. ❖ E. Pace questions throughout the physical examination.
- The nurse is asking questions about a patient's health beliefs. Which questions are appropriate? Select all that apply. ❖ A. What is your definition of health? ❖ C. How do you describe illness? ❖ D. What did your mother do to keep you from getting sick? ❖ F. How do you keep yourself healthy?
- A patient has finished giving the nurse information about the reason he is seeking care. When
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?
- In using verbal responses to assist the patients narrative, some responses focus on the patient's frame of reference and some focus on the health care provider's perspective. An example of a verbal response that focuses on the health care providers perspective would be: D. Confrontation. 10.When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior? a. Be silent, and allow him to continue when he is ready. 11.A woman is discussing the problems she is having with her 2-year-old son. She says, He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: b. Fits? Tell me what you mean by this. 12.A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I can't believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? c. It must be so hard to face this all alone. 13.A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: d. Mr. K., you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket. 14.The nurse has used interpretation regarding a patient's statement or actions. After using this technique, it would be best for the nurse to: B. Allow time for the patient to confirm or correct the inference. 15.During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just can't seem to leave him. Using interpretation, the nurse's best response would be: C. It sounds as if you might be afraid of how your husband will respond.
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?
a. Allow the child to touch the blood pressure cuff first and then tell them that by using the
blood pressure cuff, we can see how strong her muscles are.
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
- The nurse is conducting an interview. Which of these statements is true regarding open- ended questions? Select all that apply. ❖ B. They allow for self-expression.
❖ C. Open-ended questions build and enhance rapport. ❖ F. They are used when narrative information is needed.
- The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply. ❖ A. Collect the patients data in a direct, face-to-face manner. ❖ D. Type the data into the computer after the narrative is fully explored. ❖ E. Allow the patient to see the monitor during typing. Chapter 4: The Complete Health History
- The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? D. To provide a database of subjective information about the patients past and current health
- When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: B. Provided consistent information and therefore is reliable.
- A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having black stools for the last 24 hours. How would the nurse best document his reason for seeking care? D. J.M. is a 59-year-old man who states that he has been having black stools for the past 24 hours.
- A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? A. Can you point to where it hurts?
- A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which would be the nurses appropriate response to the woman's statement? D. How would you say the pain affects your ability to do your daily activities?
- In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
- A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? B. Grav 6, Term 4, (S)Ab-2, Living 4
- A patient tells the nurse that he is allergic to penicillin. What would be the nurses best
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
- The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? d. Current health promotion activities
- The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation?. C. Questions that are reflective of the normal effects of aging are added. 24.A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or NURSINGTB.COM for what reason he is taking them. An appropriate response from the nurse would be: D. Would you have a family member bring in your medications? 25.The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? B. Are you able to dress yourself?
- The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? D. It helps determine how a person is managing day-to-day activities.
- The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a. Chest pain
- A patient is describing his symptoms to the nurse. Which of these statements reflects a
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.
- The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the community portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? b. Are you a part of any religious or spiritual congregation? 31.The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? D. While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?
- The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? B. When did you come to the United States and from what country? MULTIPLE RESPONSE
- The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. ❖ A. Where is the headache pain? ❖ C. On a scale of 1 to 10, how bad is the pain? ❖ D. How often do the headaches occur? ❖ E. What makes the headaches feel better?
- The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. ❖ B. How many teeth has he lost, and when did he lose them? ❖ C. Is he able to tie his shoelaces? ❖ E. Can he tell time? Chapter 5: Mental Status Assessment
- During an examination. The nurse can assess mental status by which activity?
