Deck 1: Evidence-Based Assessment

Question 1

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

Answer 1

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

Question 2

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

Answer 2

Clustering related cues

Question 3

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

A) A follow-up database
B) A focused database
C) A complete database
D) An emergency database

Answer 3

A complete database

Question 4

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) EBP does not consider the patient's own preferences as important.

Question 5

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. What type of assessment data is this?

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

Question 6

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 interdependent.

Question 7

A patient is brought by ambulance to the emergency department with multiple injuries 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 lifesaving measures.
B) Simultaneously ask history questions while performing the examination and initiating lifesaving measures.
C) Collect all information on the history form, including social support patterns, strengths, and coping patterns.
D) Perform lifesaving measures and delay asking any history questions until the patient is transferred to the intensive care unit.

Question 8

A patient tells the nurse that he is very nervous, nauseous, and "feels hot." What type of assessment data is this?

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

Question 9

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 10

The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take?

A) Collect a follow-up database and then check the patient's blood pressure.
B) Ask the patient to read her health record and indicate any changes since her last visit.
C) Check the patient's blood pressure.
D) Obtain a complete health history on the patient before checking her blood pressure.

Question 11

In which situation is it most appropriate for the nurse to perform a focused or problem-centered history?

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 a scheduled surgery.
D) Patient in an outpatient clinic has cold and influenza-like symptoms.

Question 12

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?

A) Low self-esteem
B) Lack of knowledge
C) Abnormal laboratory values
D) Severely abnormal vital signs

Question 13

The nurse recognizes that which concept of prevention is essential in describing health?

A) Disease can be prevented by treating the external environment.
B) The majority of deaths among Americans 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.

Question 14

What do the patient's record, laboratory studies, objective data, and subjective data combine to form?

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

Question 15

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.

Question 16

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. Which action should the nurse take next?

A) Notify the patient's physician.
B) Document the sound exactly as it was heard.
C) Validate the data by asking another nurse to listen to the breath sounds.
D) Assess again in 20 minutes to note whether the sound is still present.

Question 17

The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on?

A) Intuition
B) A set of rules
C) Articles in journals
D) Advice from supervisors

Question 18

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

Question 19

Which is a barrier to incorporating EBP?

A) Nurses' lack of research skills in evaluating the quality of research studies
B) Lack of significant research studies
C) Insufficient clinical skills of nurses
D) Inadequate physical assessment skills

Question 20

The nurse is performing a physical assessment on a newly admitted patient. Which is an example of objective information obtained during the physical assessment?

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

Question 21

What is a focus of the health professional in the health promotion model?

A) Changing people's perceptions of disease
B) Identifying biomedical model interventions
C) Identifying negative health acts of people
D) Teaching and helping people choose a healthier lifestyle

Question 22

Which statement best describes a proficient nurse?

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.

Question 23

Third-level priority problem

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

Question 24

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. Why is it important for the nurse to consider the basics of the patient's culture during the patient's health assessment?

A) Identify the cause of his illness.
B) Make accurate disease diagnoses.
C) The U.S. is becoming increasingly diverse.
D) Provide culturally relevant health care.