NR 509 Week 1 Study Guide

NR 509 Week 1 Study Guide Chapter 01: Evidence-Based Assessment 1. 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. These types of data would be: a. Objective. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be: a. Subjective. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. 4. 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: a. Validate the data by asking a coworker to listen to the breath sounds. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. A set of rules. 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP emphasizes the use of best evidence with the clinician’s experience. 8. 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. Individual with shortness of breath and respiratory distress 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Abnormal laboratory values 10. Which critical thinking skill helps the nurse see relationships among the data? a. Clustering related cues 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a. Nursing 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation 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? a. Breathing, pain, and sleep 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Diagnostic hypothesis 1 15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies. 16. What step of the nursing process includes data collection by health history, physical examination, and interview? a. Assessment 17. 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. Teach the nurses how to conduct electronic searches for research studies. 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Holistic health views the mind, body, and spirit as interdependent. 19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Prevention places the emphasis on the link between health and personal behavior. 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. 2  5 cm scar on the right lower forearm. 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly 22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to the hospital for surgery the following day. b. Patient in an outpatient clinic has cold and influenza-like symptoms. 23. 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: a. Collect a follow-up data base and then check her blood pressure. 24. 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 data collection? a. Simultaneously ask history questions while performing the examination and initiating life-saving measures. 25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: 2 a. Provide culturally sensitive and appropriate care. 26. In the health promotion model, the focus of the health professional includes: a. Helping the consumer choose a healthier lifestyle. 27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Evaluate the individual’s condition, and compare actual outcomes with expected outcomes. 28. Which statement best describes a proficient nurse? A proficient nurse is one who: a. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient. 29. 30. 31. MULTIPLE RESPONSE 32. 1. 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 b. Nonproductive cough c. Patient reports dyspnea upon exertion d. Rate of respirations 16 breaths per minute 2. 3. MATCHING 4. Put the following patient situations in order according to the level of priority. a. .A teenager who was stung by a bee during a soccer match is having trouble breathing. b. An older adult with a urinary tract infection is also showing signs of confusion and agitation. c. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer 5. 6. 7. 8. Chapter 04: The Complete Health History 1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a. To provide a database of subjective information about the patient’s past and current health 2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient: a. Provided consistent information and therefore is reliable. 3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care? 3 a. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours. 4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response? a. “Can you point to where it hurts?” 5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement? a. “How would you say the pain affects your ability to do your daily activities?” 6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. 7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. Grav 6, Term 4, (S)Ab-2, Living 4 8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? a. “Describe what happens to you when you take penicillin.” 9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a. Mental illness. 10. The review of systems provides the nurse with: a. Information regarding health promotion practices. 11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin? a. Patient denies any color change. 12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a. “Do you perform testicular self-examinations?” 13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a. “I’m able to transfer myself from the wheelchair to the bed without help.” 14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a. “What did you do to cope with the loss of both your husband and mother?” 15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? 4 a. Alcohol can interact with all medications and can make some diseases worse. 16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a. “Describe what she is doing to indicate she is having pain.” 17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram? a. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members 18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a. Child’s reactions to previous hospitalizations 19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a. MMR vaccination needs to be repeated at 4 to 6 years of age. 20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider knows that it would be important to include the: a. Limitations related to her involvement in sports activities. 21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a. Functional assessment 22. The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a. Current health promotion activities 23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a. Questions that are reflective of the normal effects of aging are added. 24. A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. “Would you have a family member bring in your medications?” 25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a. “Are you able to dress yourself?” 26. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a. It helps determine how a person is managing day-to-day activities. 27. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? 5 a. Chest pain 28. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a. “This pain happens every time I sit down to use the computer.” 29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating? a. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment. 30. The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. “Are you a part of any religious or spiritual congregation?” 31. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?” 32. The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a. “When did you come to the United States and from what country?” 33. MULTIPLE RESPONSE 1. The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. “Where is the headache pain?” b. “On a scale of 1 to 10, how bad is the pain?” c. “How often do the headaches occur?” d. “What makes the headaches feel better?” 2. The nurse is conducting a developmental history on a 5-year-old child. Which questions a. “How many teeth has he lost, and when did he lose them?” b. “Is he able to tie his shoelaces?” c. “Can he tell time?” 34. 35. 36. Chapter 05: Mental Status Assessment 1. During an examination, the nurse can assess mental status by which activity? a. Observing the patient and inferring health or dysfunction 2. The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. 3. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: