Question 1

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

Accepted Answer

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 
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 D

Question 2

Expert nurses assess and make decisions through the use of:

Accepted Answer

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

Question 3

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

Accepted Answer

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. 
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. D

Question 4

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

Accepted Answer

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

Question 5

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

Accepted Answer

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. 
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 6

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?

Accepted Answer

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 
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

Question 7

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.)

Accepted Answer

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

Question 8

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.)

Accepted Answer

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 
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 9

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

Accepted Answer

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. 
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 10

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:

Accepted Answer

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. 
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 11

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:

Accepted Answer

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

Question 12

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

Accepted Answer

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. 
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 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?

Accepted Answer

A) Breathing, pain, and sleep 
B) Breathing, sleep, and pain 
C) Sleep, breathing, and pain 
D) Sleep, pain, and breathing 
A) Breathing, pain, and sleep 
B) Breathing, sleep, and pain 
C) Sleep, breathing, and pain 
D) Sleep, pain, and breathing

Question 14

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

Accepted Answer

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

Question 15

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

Accepted Answer

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. 
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 16

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

Accepted Answer

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. 
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 17

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:

Accepted Answer

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

Question 18

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

Accepted Answer

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. 
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 19

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

Accepted Answer

A) Nursing 
B) Medical 
C) Admission 
D) Collaborative 
A) Nursing 
B) Medical 
C) Admission 
D) Collaborative

Question 20

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:

Accepted Answer

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. 
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.

Exam 1: Evidence-Based Assessment

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

Expert nurses assess and make decisions through the use of:

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

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

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

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?

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.)

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.)

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

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:

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:

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

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?

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

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

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

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:

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

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

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:

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Health Assessment

Substance Use and Health Assessment

Interpersonal Violence Assessments

Assessment Techniques and the Clinical Setting

General Survey, Measurement, Vital Signs

Pain Assessment

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Eyes

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus, Rectum, and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Adult, Infant, Child, and Adolescent

Bedside Assessment of the Hospitalized Patient

The Pregnant Woman

Functional Assessment of the Older Adult

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