Ch 1 physical assessment

After completing an intial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 bpm. 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:

Subjective

The patients record laboratory studies, objective data and subjective data combine to form the:

Data base

When listening to a patients breath sounds the nurse is unsure of a sound that is heard. The nurses next action should be to:

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:

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:

Intuition

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

EBP emphasizes the use of best evidence with the clinicians experience

The nurse is conduction a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

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?

Abnormal laboratory values

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

Clustering related cues

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the ____ diagnosis.

Nursing

The nursing process is a sequential method of problem solving that nurses use and includes which steps?

Assessment, diagnosis, outcome identification, planning, implementation, evaluation

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficult breathing. How should the nurse prioritized these problems?

Breathing pain and sleep

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

Diagnostic hypothesis

Barriers to incorporating EBP include:

Nurses lack of research skills in evaluating the quality of research studies

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

Assessment

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?

Teach the nurses how to conduct electronic searches for research studies.

When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?

Holistic health view the mind, body and spirit as interdependent

The nurse recognizes that the concept of prevention in describing health is essential because:

Prevention places the emphasis on the link between health and personal behavior.

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

2\.5 cm scar on right lower forearm

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 complete health data base because of the nurses primary responsibility for monitoring the patients health

Which situation is most appropriate during which the nurse performs a focused or problem-centered history?

Patient in an outpatient clinic has cold and influenza-like symptoms

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:

Collect a follow up data base and then check her blood pressure

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?

Simultaneously ask history questions while performing the examinations and initiating life-saving measures

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:

Provide culturally sensitive and appropriate care

In the health promotion model, the focus of the health professional includes:

Helping the consumer choose a healthier lifestyle

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

Evaluate the individuals condition, and compare actual outcomes with expected outcomes

Which statement best describes a proficient nurse? A proficient nurse is one who:

Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient

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

Inspiratory wheezes noted in left lower lobes

Nonproductive cough

Patient reports dyspnea upon exertion

Rate of respirations 16 bpm

1. First level priority problem?
2. Second-level priority problem?
3. Third-level priority problem?

1. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer
2. A teenager who was stung by a bee during a soccer match is having trouble breathing
3. An older adult with a urinary tract infection is also showing signs of confusion and agitation problem