Nursing Health Assessment Test Bank Questions - Chapter 1

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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 a. Objective
b. Reflective
c. Subjective
d. Introspective
A patient tells the nurse that he is very nervous, nauseous, and
"feels hot." What type of assessment data is this?
a. Objective
C
b. Reflective
c. Subjective
d. Introspective
What do the patient's record, laboratory studies, objective data,
and subjective data combine to form?
a. Database
A
b. Admitting data
c. Financial statement
d. Discharge summary
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
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.
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
B on?
a. Intuition
b. A set of rules
c. Articles in journals
d. Advice from supervisors
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
C 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 impor-
tant.
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
D
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
When considering priority setting of problems, the nurse keeps in
mind that second-level priority problems include which of these
aspects?
C a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
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Which critical-thinking skill helps the nurse see relationships
among the data?
a. Validation
B
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
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
D planning
c. Admission, diagnosis, treatment, evaluation, and discharge
planning
d. Assessment, diagnosis, outcome identification, planning, im-
plementation, and
evaluation
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 a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
Which is a barrier to incorporating EBP?
a. Nurses' lack of research skills in evaluating the quality of re-
search studies
A
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills
During a staff meeting, nurses discuss the problems with ac-
cessing research studies to incorporate evidence-based clinical
decision
making into their practice. Which suggestion by the nurse manag-
er would best help these problems?
D
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 re-
search studies.
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.
D 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 interdepen-
dent
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
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.
The nurse is performing a physical assessment on a newly admit-
ted patient. Which is an example of objective information obtained

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during the physical assessment?
a. Patient's history of allergies
D 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 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?
C a. A follow-up database
b. A focused database
c. A complete database
d. An emergency database
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.
D 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 symp-
toms.
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.
A 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
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 ex-
amination and
institute lifesaving measures.
b. Simultaneously ask history questions while performing the ex-
B
amination 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
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?
D
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
What is a focus of the health professional in the health promotion
model?
D
a. Changing people's perceptions of disease
b. Identifying biomedical model interventions

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c. Identifying negative health acts of people
d. Teaching and helping people choose a healthier lifestyle
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
D 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.
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.)
a. Inspiratory wheezes noted in left lower lobes
A, C, E, F
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
Which best describes evidence-based nursing?
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
A
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

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