Deck 1: Evidence-Based Assessment

Question 1

A visiting nurse is making an initial home visit for a patient who has many chronic medical problems.Which type of database is most appropriate to collect in this setting?

A)A follow-up database to evaluate changes at appropriate intervals
B)An episodic database because of the continuing, complex medical problems of this patient
C)A complete health database because of the nurse's primary responsibility for monitoring the patient's health
D)An emergency database because of the need to collect information and make accurate diagnoses rapidly

Answer 1

A complete health database because of the nurse's primary responsibility for monitoring the patient's health

Question 2

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)Patient newly diagnosed with diabetes needing diabetic teaching
C)Individual with a small laceration on the sole of the foot
D)Individual with shortness of breath and respiratory distress

Answer 2

Individual with shortness of breath and respiratory distress

Question 3

What step of the nursing process includes data collection through health history, physical examination, and interview?

A)Planning
B)Diagnosis
C)Evaluation
D)Assessment

Answer 3

Assessment

Question 4

The patient's record, laboratory studies, objective data, and subjective data combine to form the:

A)Database
B)Admitting data
C)Financial statement
D)Discharge summary

Question 5

Which situation is most appropriate during which the nurse collects episodic or problem-centred data?

A)Patient is admitted to a long-term care facility.
B)Patient has a sudden and severe shortness of breath.
C)Patient is admitted to the hospital for surgery the next day.
D)Patient in an outpatient clinic has cold and influenza-like symptoms.

Question 6

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

Question 7

A patient is at the clinic to have her blood pressure checked.She has been coming to the clinic weekly since she changed medications 2 months ago.The nurse should:

A)Collect a follow-up database and then check her blood pressure.
B)Ask her to read her health record and indicate any changes since her last visit.
C)Check only her blood pressure because her complete health history was documented 2 months ago.
D)Obtain a complete health history before checking her blood pressure because much of her history information may have changed.

Question 8

Expert nurses assess and make decisions through the use of:

A)Critical thinking
B)The nursing process
C)Clinical knowledge
D)Diagnostic reasoning

Question 9

What is an important concept when undertaking a life-cycle approach to health assessment?

A)Consideration of the patient's cultural view of health
B)Being responsive to the patient's gestures to build a relationship
C)Acknowledgement of the effect of poverty on health
D)Awareness of age-specific developmental factors

Question 10

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

Question 11

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard.The nurse's next action should be to:

A)Immediately notify the patient's 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.

Question 12

After completing an initial assessment of a patient, the nurse has charted that his respirations are 18 breaths per minute and his pulse is 58 beats per minute.These types of data would be:

A)Objective
B)Reflective
C)Subjective
D)Introspective

Question 13

The nurse is performing a physical assessment on a newly admitted patient.An example of objective information obtained during the physical assessment includes the:

A)Patient's history of allergies.
B)Patient's use of medications at home.
C)Last menstrual period 1 month ago.
D)2 ´ 5 cm scar on the right lower forearm.

Question 14

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

Question 15

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

A)Validation
B)Clustering related cues
C)Identifying gaps in data
D)Distinguishing relevant data from irrelevant data

Question 16

A patient is brought by ambulance to the emergency department with multiple injuries received in an automobile accident.The patient is alert and cooperative, but his injuries are quite severe.How would the nurse proceed with data collection?

A)Collect history information first and then perform the physical examination and institute life-saving measures.
B)Simultaneously ask history questions while performing the examination and initiating life-saving measures.
C)Collect all information on the history form, including social support patterns, strengths, and coping patterns.
D)Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.

Question 17

The nurse identifies priorities and assesses risk factors with a generally healthy individual to:

A)Identify patterns to discover missing information.
B)Determine areas for health promotion and disease prevention.
C)Distinguish normal from abnormal findings.
D)Determine treatment for a medical diagnosis.

Question 18

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

Question 19

The nurse is conducting a class for new graduate nurses.During the teaching session, the nurse should keep in mind that novice nurses, with less experience, are more likely to base their decisions on:

A)Intuition
B)Clear-cut rules
C)Articles in journals
D)Advice from supervisors

Question 20

The nurse is reviewing information about evidence-informed practice (EIP).Which statement best reflects EIP?

A)EIP relies on tradition for support of best practices.
B)EIP is simply the use of best practice techniques for the treatment of patients.
C)EIP emphasizes the use of best and most appropriate evidence with clinician expertise and patient preference.
D)The patient's own preferences are not important in EIP.

Question 21

What is the purpose of a nursing diagnosis? (Select all that apply.)

A)To evaluate the cause of disease
B)To evaluate a patient's response to treatment
C)To determine the need to initiate supportive measures
D)To order specific diagnostic tests
E)To determine the need for health education

Question 22

Which statement best describes an experienced nurse? An experienced nurse is one who:

A)Has little experience with a specified population and uses rules to guide performance.
B)Takes a linear approach to the nursing process.
C)Is focused only on a patient's disease.
D)Understands a patient's situation as a whole, rather than a list of tasks, and recognizes the long-term goals for the patient.

Question 23

During a clinical examination of a 68-year-old patient, the nurse will:

A)Remind the patient use medication wisely.
B)Perform a tuberculin skin test.
C)Discuss body image and dieting.
D)Helping the consumer choose a healthier lifestyle.

Question 24

The nurse is reviewing data collected after an assessment.Of the data listed below, which would be considered related cues that would be clustered together during data analysis? (Select all that apply.)

A)Inspiratory wheezes noted in left lower lobes
B)Hypoactive bowel sounds
C)Nonproductive cough
D)Edema, +2, noted on left hand
E)Patient reports dyspnea upon exertion
F)Rate of respirations 16 breaths per minute

Question 25

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain.Which would be the next appropriate action?

A)Establish priorities.
B)Identify expected outcomes.
C)Evaluate the individual's condition, and compare actual outcomes with expected outcomes.
D)Interpret data, and then identify clusters of cues and make inferences.

Question 26

A 38-year-old patient who is a recent refugee from Syria is attending the clinic for an initial examination.A potential intervention the nurse will implement is:

A)Cognitive assessment.
B)Fall risk screening.
C)Fasting glucose test.
D)Tuberculin skin test.

Question 27

Which of the following are social determinants of health with potential to influence a patient's health? (Select all that apply.)

A)Poverty
B)Poor research studies
C)Unaffordable housing
D)Lack of education
E)Poor nursing skills

Question 28

The nurse wants to take a relational approach in her nursing practice.The nurse needs to: (Select all that apply.)

A)Identify unit policies and procedures.
B)Identify and manage personal assumptions.
C)Promote the use of best practice guidelines.
D)Determine what is important to patients in the context of their situations.
E)Form decisions based on prevalent stereotyping.

Question 29

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? (Select all that apply.)

A)Low self-esteem
B)Lack of knowledge
C)Abnormal laboratory values
D)Severely abnormal vital signs
E)New confusion and forgetfulness