Rasmussen Health Assessment Exam 1

Rasmussen Health Assessment Exam 1 After completing an initial assessment of a patient, the nurse has charted that his respiration's are eupneic and his pulse is 58 beats per minute. These types of data would be - Objective A patient tells the nurse that he is very nervous, is nauseated, and "feels hot" These types of data would be - Subjective The patients record, laboratory studies, objective data, and subjective data combine to form the - Database When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to - Validate the data by asking a coworker to listen to the breath sounds. The nurse is reviewing information about EBP. Which statement best reflects EBP? - EBP emphasizes the use of best evidence with the clinician's experience. 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? - Individual with shortness of breath and respiratory distress When considering priority setting of problems, the nurse keeps in mind that second level priority include which of these aspect? - Abnormal lab values The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the _______________ diagnosis. - Nursing The nursing process is a sequential method of problem solving the nurses use and includes which steps? - Assessment, diagnosis, outcome identification, planning, implementation, 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. - Breathing, pain, sleep. What step of the nursing process includes data collection by health history, physical exam, and interview - Assessment When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these - Holistic health views the mind, body, and spirit as interdependent The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes - 2-5 cm scar on the right lower forearm 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 complete health data base because of the nurses primary responsibility for monitoring the patients health Which situation is most appropriate during which the nurse performs a focused of problem- centered history - Patient in an outpatient clinic has cold and flu symptoms A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medication 2 months ago. The nurse should - Collect a follow up data vase and the check her blood pressure 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 - Simultaneously ask history questions while performing exam and initiating life saving measures a 42 year old patient of Asian descent is being seen at the clinic for an initial exam. The nurse knows that including cultural information in his health assessment is important to - Provide culturally sensitive and appropriate care the nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next step - Evaluate the individuals condition, and compare actual outcomes with expected outcomes