Fundamentals Nursing Test Banks - Potter 9th Edition Questions and Correct Answers

Fundamentals Nursing Test Banks - Potter 9th Edition Questions and Correct Answers 1.nursing test banks During data collection the nurse may validate data by which method? (Select all that apply) A) Comparing cues to normal function B) Referring to textbooks, journals, and research reports C) Checking consistency of cu es D) Clarifying the patient's statements E) Seeking consensus with colleagues about inferences Ans: A, B, C, D, E Feedback: These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursin g diagnoses. 2. When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? A) Validate inferences with the patient B) Do not share inferences with the patient C) Document all inferences D) Avoi d making any inferences Ans: A Feedback: The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and patient plans of care. 3. While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history? A) Prepa ratory B) Introductory C) Maintenance D) Concluding Ans: C Feedback: Watching the patient to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview. 4. The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate? A) "When I perform the nursing history I will need to ask your family to leave the room." B) "I would lik e to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes ." C) "I will perform a physical assessment while I am obtaining the nursing history." D) "I will leave a form with you to complete the nursing history informatio n I need." Ans: B Feedback: Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. T he physical is performed separately. Family members can offer valuable information as long as the patient gives permission for them to remain present during the history taking. 5. The RN is admitting a patient to a medical unit. The nurse delegates the mea surement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process, the patient complains of a severe headache so the nurse reassesses the vital signs to find the patient's blood pressure ext remely elevated. Whose responsibility is the accuracy of the blood pressure measurement? A) The company that made the blood pressure equipment B) The nurse C) The UAP D) The charge nurse Ans: B Feedback: While the nurse may delegate duties to UAP, the pr ofessional RN is ultimately responsible for the completeness and accuracy of the information. Since this was part of the admission assessment it would be advisable for the nurse to have measured the vital signs herself. 6. A novice nurse is using the asses sment technique of auscultation. What assessment finding can the nurse obtain with this method? A) Size of the liver B) Presence of peristalsis C) Pupil reaction D) Skin temperature Ans: B Feedback: Peristalsis (bowel sounds) are assessed by auscultation with a stethoscope. The size of the liver is determined with percussion, inspection yields pupil size, and skin temperature is assessed through palpation. 7. Which of the following are examples of obj ective data? A) Patient describing his pain B) Laboratory results C) Breath sounds D) Mother describing her child's asthma attack E) a patient's temperature Ans: B, C, E Feedback: Objective data from observation (e.g., posture, skin color, behavior), hea lth records (e.g., laboratory results, reports from other healthcare team members), physical assessment (e.g., breath sounds, strength of extremities), and measurement devices (e.g., blood pressure, temperature) are collected to judge the patient's behavio ral responses to nursing interventions.