Jarvis Chapter 1 (Evidence Based Assessment)

What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures?

a. complete

b. focused

c. follow up

d. emergency

d

A nurse precepting a student nurse asks, "What's the most important step in the critical-thinking process?"

a. clustering subjective and objective data

b. analyzing health data

c. using evidence based assessment techniques

d. prioritizing health concerns

c

An example of subjective data is

a. decreased range of motion

b. crepitation in left knee joint

c. arthritis

d. left knee has been swollen and hot for past 3 days

d

What type of database is most appropriate for an individual who is admitted to a long-term care facility?

a. focused

b. complete

c. emergency

d. follow up

b

Which of the following is an example of objective data?

a. a sore throat

b. an earache

c. alert and oriented

d. dizziness

c

An example of objective data is

a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.

b. a complaint of left knee pain.

c. crepitation in the left knee joint.

d. left knee has been swollen and hot for the past 3 days.

c

Which of the following is an example of subjective data?

a. Blood glucose 126 md/dL

b. Pain rated at 7 out of 10

c. Heart rate of 76 bpm

d. Bruising on lower leg

b

A complete database is

a. used to collect data rapidly and is often compiled concurrently with lifesaving measures.

b. used to evaluate the cause or etiology of disease.

c. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system.

d. used to perform a thorough or comprehensive health history and physical examination.

d

A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?

a. Ineffective self-health management

b. Impaired gas exchange

c. Readiness for enhanced spiritual well-being

d. Risk for infection

b

Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.)

a. disregard initial cues

b. Approach assessment with a nonjudgmental attitude

c. Cluster associated assessment data

d. Perform assessment in whatever manner works for you.

e. Avoid making assumptions

b, c, e

The concept of health and healing has evolved in recent years. Which is the best description of health?

a. Health is the absence of disease.

b. Health is a dynamic process toward optimal functioning

c. Health depends on an interaction of mind, body, and spirit within the environment.

d. Health is the prevention of disease.

c

Which would be included in the database for a new patient admission to a surgical unit?

a. all subjective and objective data gathered by a health practitioner from a patient

b. all objective data obtained from a patient through inspection, percussion, palpation, and auscultation.

c. A summary of a patient's record, including laboratory studies.

d. All subjective and objective data, data gathered from a patient, and the results of any laboratory or diagnostic studies completed.

d

You are reviewing assessment data of a 45- year - old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of

a. hypothetical reasoning

b. diagnostic reasoning

c. data cluster

d. signs and symptoms

c

A patient in the emergency department with nausea and vomiting. Which would you include in the database?

a. a complete health history and full physical examination

b. a diet and GI history

c. previously identified problems

d. start collection of data in conjunction with livesaving measures.

b

A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond?

a. "It would be most efficient if you visit on an annual basis"

b. "There is no recommendation for the frequency of health care visits."

c. "Your visits may vary, depending on your level of wellness"

d. "Your visits will be based on your preference"

c

You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed?

a. planning

b. assessment

c. implementation

d. diagnosis

a

Which best describes evidence based nursing practice?

a. combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances.

b. appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient

c. completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices.

d. finding value based resources to justify nursing actions when working with patients of diverse cultural backgrounds.

a

What can be determined when the nurse clusters data as part of the critical thinking process?

a. this step identifies problems that may be urgent and require immediate action.

b. this step involves making assumptions in the data.

c. the nurse recognizes relevant information among the data.

d. risk factors can be determined so the nurse knows how to offer health teaching.

c

A patient says she is very nervous and nauseated, and she feels as if she will vomit. This data would be what type of data?

a. objective

b. reflective

c. subjective

d. introspective

c

The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as

a. deductive reasoning

b. intuition

c. the nursing process

d. focused assessment

b

Which would be considered a risk diagnosis?

a. identifying existing levels of wellness

b. evaluating previous problems and goals

c. Identifying potential problems the individual may develop

d. focusing on strengths and reflecting an individual's transition to higher levels of wellness

c

Which would be included in a holistic model of assessment?

a. nursing goals for the patient

b. anticipated growth and development patterns

c. a patient's perception of his or her health status

d. the nurse's perception of disease related to the patient

c

The nurse uses health promotion activities with a new patient. What would this focus include?

a. the nurse would try to change the patient's perception of disease.

b. the nurse would search for identification of biomedical model interventions

c. the nurse would help to identify negative health acts of the patient

d. the nurse would empower the patient to choose a healthier lifestyle.

d

Which is an example of objective data?

a. patient's history of allergies

b. patient's use of medications at home

c. last menstrual period one month ago

d. 2- x 5 cm scar present on the right forearm.

d

During the evaluation phase of the nursing process, which action would be included?

a. validating the nursing diagnosis

b. establishing priorities related to patient care

c. including the patient and family members

d. establishing a timeline for planned outcomes

c

___________________ is the collection of subjective and objective data about a patient's health.

assessment

_________________ data consists of info provided by the affected individual.

subjective

_______________ data includes information obtained by the health care provider through observation and inspecting, percussing, palpating, and auscultating during the physical examination.

objective

the ____________ is the totality of information available about the patient, including subjective data, objective data, and the patient's medical record and laboratory studies.

database

the purpose of assessment is to make a judgement or _________________.

diagnosis

__________________ __________________ is the process of analyzing health data and drawing conclusions to identify diagnoses. (consists of attending to cues, formulating hypothesis, gathering data, and diagnosis)

diagnostic reasoning

the nursing process includes six phases which can be remembered using the acronym "____________________"

ADOPIE

"ADOPIE" stands for:

assessment, diagnosis, outcome identification, planning, implementation, evaluation

_____________ ______________ is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment.

critical thinking

____________-level priority problems are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.

first

___________-level priority problems require prompt intervention to prevent further deterioration and may include mental status change, acute pain, or abnormal laboratory values.

second

_____________-level priority problems are important to the patients health but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.

third

_____________________ problems are certain physiologic conditions in which the approach to treatment involves multiple disciplines.

collaborative

the ______________ health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment.

holistic

a ______________ database includes a complete health history and full physical examination, yielding the first diagnosis.

complete

a _______________ database is used for a limited or short term problem. It is smaller in scope and more targeted than the complete database.

focused

a _______________ database evaluates the status of any identified problem at regular intervals (short term and chronic)

follow up

_____________ ______________ _________________ is a systematic approach to practice that uses research evidence, clinical expertise, clinician knowledge, and the patient's preferences and values to make decisions about care and treatment.

evidence based practice