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Health
Assessment
Exam1: Study
Guide 2023
Chapter 1 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. 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.
- 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. 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.
- The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratory studies, or data.
c. Clinical knowledge. d. Diagnostic reasoning. Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct.
- The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
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 clinician’s experience. d. The^ patient’s^ own preferences are not important with EBP. EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s 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.
- 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
- 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 from irrelevant Clustering related cues helps the nurse see relationships among the data.
- 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 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.
- 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 The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
- 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?
- What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment
Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2).
- 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? a. Form^ a^ committee^ to conduct research studies. b. Post^ published^ research studies on the unit’s bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies. Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research.
- When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease^ originates^ from the external environment. b. The individual human is a closed system. c. Nurses^ are^ responsible^ for a patient’s health state. d. Holistic^ health^ views^ the^ mind, body, and spirit as
under age 65 years are not preventable. c. Prevention^ places^ the^ emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners. A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior.
- 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. Objective data are the patient’s record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data.
- A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data^ base to evaluate changes at appropriate
intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health^ data base because of the nurse’s primary responsibility for monitoring the patient’s health d. An^ emergency^ data^ base because of the need to collect information and make accurate diagnoses rapidly The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency, or community health agency. In these settings,
d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed. A follow-up data base is used in all settings to follow up short- term or chronic health problems. The other responses are not appropriate for the situation.
- A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, 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. The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation.
- A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide^ cultural^ health rights for the individual. d. Provide^ culturally sensitive and appropriate care. The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.
- 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. Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individual’s condition and compares the actual outcomes with expected outcomes (See Figure 1-2).
- Which statement best describes a proficient nurse? A proficient nurse is one who: a. Has^ little^ experience^ with^ a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees^ actions in^ the^ context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long- term goals for the patient. The proficient nurse, with more time and experience than the
novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how today’s nursing actions can apply to the point the nurse wants the patient to reach at a future time. MULTIPLE RESPONSE
- 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
