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Exam (elaborations)

NUR 305 HEALTH ASSESSMENT LECTURE FINAL

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NUR 305 HEALTH ASSESSMENT LECTURE FINAL

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NUR 305 HEALTH ASSESSMENT LECTURE FINAL

When considering priority setting of problems, the nurse keeps in mind that second-
level priority problems include which of these aspects?


a.
Low self-esteem
b.
Lack of knowledge
c.
Abnormal laboratory values
d.
Severely abnormal vital signs - Answer -C

Which critical thinking skill helps the nurse see relationships among the data?
a.
Validation
b.
Clustering related cues
c.
Identifying gaps in data
d.
Distinguishing relevant from irrelevant - Answer -B

When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
The nurses next action should be to:


a.
Immediately notify the patients physician.
b.
Document the sound exactly as it was heard.
c.
Validate the data by asking a coworker to listen to the breath sounds.
d.
Assess again in 20 minutes to note whether the sound is still present. - Answer -C

-Identify expected outcomes
-Individualize to the person
-Culturally appropriate
-Realistic
-Measurable
-Include a timeline - Answer -OUTCOME

,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.
b.
Reflective.
c.
Subjective.
d.
Introspective. - Answer -A

-Compare clinical findings with normal and abnormal variation
-Interpret Data-look for cluster cues
-Make Hypotheses
-Test Hypotheses
-Dervive Diagnosis
-Document Diagnosis - Answer -DIAGNOSIS

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.
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 - Answer -ACEF

The nurse has implemented several planned interventions to address the nursing
diagnosis of acute pain. Which would be the next appropriate action?
(AD-O-PIE)

a.
Establish priorities.
b.

, Identify expected outcomes.
c.
Evaluate the individuals condition, and compare actual outcomes with expected
outcomes.
d.
Interpret data, and then identify clusters of cues and make inferences. - Answer -C

Barriers to incorporating EBP include:


a.
Nurses lack of research skills in evaluating the quality of research studies.
b.
Lack of significant research studies.
c.
Insufficient clinical skills of nurses.
d.
Inadequate physical assessment skills - Answer -A

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.
Patients history of allergies.
b.
Patients use of medications at home.
c.
Last menstrual period 1 month ago.
d.
2 5 cm scar on the right lower forearm. - Answer -D

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.
Form a committee to conduct research studies.
b.
Post published research studies on the units bulletin boards.
c.
Encourage the nurses to visit the library to review studies.
d.
Teach the nurses how to conduct electronic searches for research studies. - Answer -D

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