Deck 1: Critical Thinking in Health Assessment

Question 1

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?
1)Breathing,pain,sleep
2)Breathing,sleep,pain
3)Sleep,breathing,pain
4)Sleep,pain,breathing

Answer 1

1
First-level priority problems are immediate priorities (remember the ABCs),followed by second-level problems and then third-level problems.

Question 2

Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it.This is referred to as:
1)intuition.
2)the nursing process.
3)clinical knowledge.
4)diagnostic reasoning.

Answer 2

1
Intuition is characterized by pattern recognition-expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it.

Question 3

The nursing process is a sequential method of problem solving that includes which five steps?
1)Assessment,treatment,evaluation,discharge,follow-up
2)Admission,assessment,diagnosis,treatment,discharge planning
3)Admission,diagnosis,treatment,evaluation,discharge planning
4)Assessment,diagnosis,planning,implementation,evaluation

Answer 3

4
The nursing process is a method of problem solving that includes assessment,diagnosis,planning,implementation,and evaluation.

Question 4

Which of the following is an example of a first-level priority problem?
1)A patient with postoperative pain
2)A newly diagnosed diabetic who needs diabetic teaching
3)An individual with a small laceration on the sole of the foot
4)An individual with shortness of breath and respiratory distress

Question 5

Novice nurses,without a background of skills and experience to draw from,are more likely to make their decisions using:
1)intuition.
2)a set of rules.
3)articles in journals.
4)advice from supervisors.

Question 6

Which statement about nursing diagnoses is true? They:
1)evaluate the etiology of disease.
2)are a process based on the medical diagnosis.
3)evaluate the response of the whole person to actual or potential health problems.
4)focus on the function and malfunction of a specific organ system in response to disease.

Question 7

Second-level priority problems include which of the following?
1)Low self-esteem
2)Lack of knowledge
3)Abnormal laboratory values
4)Severely abnormal vital signs

Question 8

Which statement illustrates the biomedical model of Western traditional views?
1)Health is viewed as the absence of disease.
2)Optimal health is viewed as high-level wellness.
3)Health and disease are considered a cyclical process.
4)The treatment of disease is nursing's primary focus.

Question 9

Why is the concept of prevention essential in describing health?
1)Disease can be prevented by treating the external environment.
2)The majority of deaths among Americans under age 65 years are not preventable.
3)Prevention places emphasis on the link between health and personal behavior.
4)The means to prevention is through treatment provided by primary health care practitioners.

Question 10

Which of the following would be formulated by a nurse using diagnostic reasoning?
1)Nursing diagnosis
2)Medical diagnosis
3)Diagnostic hypothesis
4)Diagnostic assessment

Question 11

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 $\times$ 5 cm scar present on the right lower forearm.

Question 12

The patient's record,laboratory studies,objective data,and subjective data combine to form the:
1)database.
2)admitting data.
3)financial statement.
4)discharge summary.

Question 13

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
1)nursing diagnosis.
2)medical diagnosis.
3)admission diagnosis.
4)collaborative diagnosis.

Question 14

The public's concept of health has changed since the 1950s.Which of the following statements most accurately describes this change?
1)Lifestyle,personal habits,exercise,and nutrition are essential to health.
2)Assessment of health is critical to identifying disease-causing pathogens.
3)Accurate diagnosis and treatment by a physician are essential for all health care.
4)An individual is considered healthy when signs and symptoms of disease have been eliminated.

Question 15

A nursing diagnosis made by a critical thinker using a dynamic nursing process would diagnose the actual problem and would also:
1)continue to reassess.
2)predict potential problems.
3)check the appropriateness of goals.
4)modify the diagnosis if necessary.

Question 16

Which critical thinking skill helps the nurse to see relationships among the data?
1)Validation
2)Clustering related cues
3)Identifying gaps in data
4)Distinguishing relevant from irrelevant

Question 17

After completing an initial assessment on a patient,the nurse has charted that his respirations are eupneic and his pulse is 58.This type of data would be:
1)objective.
2)reflective.
3)subjective.
4)introspective.

Question 18

Critical thinking in the expert nurse is greatly enhanced by opportunities to:
1)apply theory in real situations.
2)work with physicians to provide patient care.
3)follow physician orders in providing patient care.
4)develop nursing diagnoses for commonly occurring illnesses.

Question 19

A patient tells the nurse that he is very nervous,that he is nauseated,and that he "feels hot." This type of data would be:
1)objective.
2)reflective.
3)subjective.
4)introspective.

Question 20

What is the step of the nursing process that includes data collection by health history,physical examination,and interview?
1)Planning
2)Diagnosis
3)Evaluation
4)Assessment

Question 21

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 the data collection?
1)Collect history information first,then perform the physical examination and institute life-saving measures.
2)Simultaneously ask history questions while performing the examination and initiating life-saving measures.
3)Collect all information on the history form,including social support patterns,strengths,and coping patterns.
4)Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit.

Question 22

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain.Which would be the next appropriate action?
1)Establish priorities.
2)Identify expected outcomes.
3)Evaluate the individual's condition and compare actual outcomes with expected outcomes.
4)Interpret data and then identify clusters of cues and make inferences.

Question 23

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?
1)A follow-up database to evaluate changes at appropriate intervals
2)An episodic database because of the continuing,complex medical problems of this patient
3)A complete health database because of the nurse's primary responsibility for monitoring the patient's health
4)An emergency database because of the need to rapidly collect information and make accurate diagnoses

Question 24

MATCHING
Put the following patient situations in order according to level of priority:
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.
A = first-level priority problem

Question 25

MATCHING
Put the following patient situations in order according to level of priority:
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.
C = third-level priority problem

Question 26

Which statement correctly describes the age-specific charts for the periodic health examination?
1)They are used to help identify the diagnosis of an illness.
2)They are helpful in identifying developmental delays in children.
3)They recommend that every individual receive an annual physical exam.
4)They list a frequency schedule for periodic health visits for a specific age group.

Question 27

Which of the following would be included in a holistic model of assessment?
1)Nursing goals for the patient
2)Anticipated growth and development patterns
3)A patient's perception of his or her health status
4)The nurse's perception of disease related to the patient

Question 28

In the health promotion model,the focus of the health professional includes:
1)changing the patient's perceptions of disease.
2)identification of biomedical model interventions.
3)identifying negative health acts of the consumer.
4)helping the consumer choose a healthier lifestyle.

Question 29

When nursing diagnoses are being classified,which of the following would be considered a risk diagnosis?
1)Identifying existing levels of wellness
2)Evaluating previous problems and goals
3)Identifying potential problems the individual may develop
4)Focusing on strengths and reflecting an individual's transition to higher levels of wellness

Question 30

A 42-year-old Asian patient is being seen at the clinic for an initial examination.The nurse knows that it is important to include cultural information in his health assessment to:
1)identify the cause of his illness.
2)make accurate disease diagnoses.
3)provide cultural health rights for the individual.
4)provide culturally sensitive and appropriate care.

Question 31

Which situation is most appropriate for an episodic history?
1)A patient's admission to a long-term care facility
2)A patient has sudden,severe shortness of breath
3)A patient's admission to the hospital for surgery the following day
4)A patient in an outpatient clinic has cold and flu-like symptoms

Question 32

Which term best describes a proficient nurse?
1)A nurse who has little experience with a specified population and uses rules to guide performance
2)A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution
3)A nurse who sees actions in the context of daily plans for patients
4)A nurse who understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient

Question 33

A patient is at the clinic to have her blood pressure checke d.She has been coming to the clinic weekly since she changed medications 2 months ago.The nurse should:
1)collect a follow-up database and then check her blood pressure.
2)ask her to read her health record and indicate any changes since her last visit.
3)check only her blood pressure because her complete health history was documented 2 months ago.
4)obtain a complete health history before checking her blood pressure because much of her history information may have changed.

Question 34

MATCHING
Put the following patient situations in order according to level of priority:
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.
B = second-level priority problem