Assesment techniques for adult
patients
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. - ANS>>A
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating
during the physical examination. Subjective data is what the person says about him or
herself during history
taking. The terms reflective and introspective are not used to describe data
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - ANS>>C
Subjective data are what the person says about him or herself during history taking.
Objective data are what the
health professional observes by inspecting, percussing, palpating, and auscultating
during the physical
examination. The terms reflective and introspective are not used to describe data.
The patients record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - ANS>>A
Together with the patients record and laboratory studies, the objective and subjective
data form the data base.
The other items are not part of the patients record, laboratory studies, or data
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. - ANS>>C
When unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure
accuracy. If the nurse has less experience in an area, then he or she asks an expert to
listen.
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. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. - ANS>>B
Novice nurses operate from a set of defined, structured rules. The expert practitioner
uses intuitive links.
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.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning - ANS>>A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
of assessment data and
act without consciously labeling it. The other options are not correct
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 treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with EBP. - ANS>>C
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the
,clinicians experience, as well as patient preferences and values, when making
decisions about care and
treatment. EBP is more than simply using the best practice techniques to treat patients,
and questioning
tradition is important when no compelling and supportive research evidence exists
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
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 - ANS>>D
First-level priority problems are those that are emergent, life threatening, and immediate
(e.g., establishing an
airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs).
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 - ANS>>C
Second-level priority problems are those that require prompt intervention to forestall
further deterioration (e.g.,
mental status change, acute pain, abnormal laboratory values, risks to safety or
security).
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 - ANS>>B
Clustering related cues helps the nurse see relationships among the data.
The nurse knows that developing appropriate nursing interventions for a patient relies
on the
appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative - ANS>>A
, An accurate nursing diagnosis provides the basis for the selection of nursing
interventions to achieve outcomes
for which the nurse is accountable. The other items do not contribute to the
development of appropriate nursing
interventions
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 planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation - ANS>>D
The nursing process is a method of problem solving that includes 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?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing - ANS>>A
First-level priority problems are immediate priorities, remembering the ABCs (airway,
breathing, and
circulation), followed by second-level problems, and then third-level problems.
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment - ANS>>C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the
nursing process calls for a
nursing diagnosis.
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. - ANS>>A
patients
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. - ANS>>A
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating
during the physical examination. Subjective data is what the person says about him or
herself during history
taking. The terms reflective and introspective are not used to describe data
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - ANS>>C
Subjective data are what the person says about him or herself during history taking.
Objective data are what the
health professional observes by inspecting, percussing, palpating, and auscultating
during the physical
examination. The terms reflective and introspective are not used to describe data.
The patients record, laboratory studies, objective data, and subjective data combine to
form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - ANS>>A
Together with the patients record and laboratory studies, the objective and subjective
data form the data base.
The other items are not part of the patients record, laboratory studies, or data
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. - ANS>>C
When unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure
accuracy. If the nurse has less experience in an area, then he or she asks an expert to
listen.
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. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors. - ANS>>B
Novice nurses operate from a set of defined, structured rules. The expert practitioner
uses intuitive links.
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.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning - ANS>>A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
of assessment data and
act without consciously labeling it. The other options are not correct
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 treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with EBP. - ANS>>C
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the
,clinicians experience, as well as patient preferences and values, when making
decisions about care and
treatment. EBP is more than simply using the best practice techniques to treat patients,
and questioning
tradition is important when no compelling and supportive research evidence exists
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
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 - ANS>>D
First-level priority problems are those that are emergent, life threatening, and immediate
(e.g., establishing an
airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs).
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 - ANS>>C
Second-level priority problems are those that require prompt intervention to forestall
further deterioration (e.g.,
mental status change, acute pain, abnormal laboratory values, risks to safety or
security).
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 - ANS>>B
Clustering related cues helps the nurse see relationships among the data.
The nurse knows that developing appropriate nursing interventions for a patient relies
on the
appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative - ANS>>A
, An accurate nursing diagnosis provides the basis for the selection of nursing
interventions to achieve outcomes
for which the nurse is accountable. The other items do not contribute to the
development of appropriate nursing
interventions
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 planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation - ANS>>D
The nursing process is a method of problem solving that includes 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?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing - ANS>>A
First-level priority problems are immediate priorities, remembering the ABCs (airway,
breathing, and
circulation), followed by second-level problems, and then third-level problems.
Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment - ANS>>C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the
nursing process calls for a
nursing diagnosis.
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. - ANS>>A
