NUR 245 Exam 1 with Complete
Solutions
The concept of health and healing has evolved in recent years. Which is the best
description of health?
a. health is the absence of disease
b. health is a dynamic process toward optimal functioning
c. health depends on an interaction of mind, body, and spirit within environment
d. health is the prevention of disease - ANS-d. health is the prevention of disease
Which would be included in the database for a new patient admission to a surgical unit?
a. all subjective and objective data gathered by a health practitioner from a patient
b. all objective data obtained from a patient through inspection, percussion, palpation,
and auscultation
c. a summary of a patients record, including laboratory studies
d. all subjective and objective data gathered from a patient, and the results of any
laboratory or diagnostic studies completed - ANS-d. all subjective and objective data
gathered from a patient and the results of any laboratory or diagnostic studies
completed
You are reviewing assessment data of a 45-yr old male patient and note pain of 8 on a
scale of 10, labored breathing, and pale skin color on the electronic health record. This
documentation is an example of:
a. hypothetical reasoning
b. diagnostic reasoning
c. data. cluster
d. signs and symptoms - ANS-c. data cluster
a patient is is the emergency department with nausea and vomiting. which would you
include in the database?
a. a complete health history and full physical exam
b. diet and GI history
c. previously identified problems
d. start collection of data in conjunction with lifesaving measures - ANS-b. diet and GI
history
a patient has recently received health insurance and would like to know how often he
should visit the provider. How do you respond
a. "it would be most efficient if you visit on an annual basis"
b. "there is no recommendation for the frequency of health care visits."
c. "your visits may vary, depending on your level of wellness."
,D. "You visits will be based on your preference." - ANS-c. "you visits may vary
depending on your level of wellness."
You are reviewing concepts related to steps in the nursing process for determining
prioritization and developing patient outcomes. To what are these actions attributed?
a. planning
b. assessment
c. implementation
d. diagnosis - ANS-a. planning
What does the nursing process ADPIE stand for? - ANS-A: assessment
D: diagnosis
P: planning
I: implementation
E: evaluation
nursing process assesement - ANS-collect data:
review clinical record
health history
physical exam
functional assessment
risk assessment
review of the literature
use evidence based techniques
document relative data
nursing process Diagnosis - ANS-compare clinical findings with normal and abnormal
variation and developmental events
interpret data:
-identify clusters of clues
-make hypothesis
-test hypothesis
-derrive diagnosis
validate diagnosis
document diagnosis
nursing process planning - ANS--establish priorities
-develop outcomes
-set timelines for outcomes
- IDENTIFY INTERVENTIONS
-integrate evidence based trends
, -document plan of care
Nursing Process: Implementation - ANS--implement in safe and timely manner
-use evidence-based interventions
-collaborate with colleagues
-use community resources
-provide health teaching and health promotion
-document implementation and any modification
nursing process: evaluation - ANS--progress toward outcomes
-conduct systematic, ongoing criterian based evaluation
-include patient and significant others
-use ongoing assessment to revise diagnosis, outcomes, plan
Which best describes evidence-based nursing practice?
a. combining clinical expertise with the use of nursing research to provide the best care
for patients while considering the patients values and circumstances
b. appraising and looking at the implications of one or two articles as they relate to the
culture and ethnicity of the patient
c. competing a literature search to find relevant articles that use nursing research to
encourage nurses to use good practices
d. finding value-based resources to justify nursing actions when working with patients of
diverse cultural backgrounds - ANS-a. combining clinical expertise with the use of
nursing research to provide the best care for patients values and circumstances
what can be determined when the nurse clusters data as part of the critical thinking
process?
a. this step identifies problems that may be urgent and require immediate action
b. this step involves making assumptions in the data
c. the nurse recognizes relevant information among the data
d. risk factors can be determined so the nurse knows how to offer health teaching -
ANS-c. the nurse recognizes relevant information among the data
a patient says she is very nervous and nauseated and she feels as if she will vomit. this
data would be what type?
a. objective
b. reflective
c. subjective
d. introspective - ANS-c. subjective
the expert nurse differs from the novice nurse by acting without consciously thinking
about the actions. this is referred to as:
a. deductive reasoning
b. intuition
c. the nursing process
d. focused assessment - ANS-b. intuition
Solutions
The concept of health and healing has evolved in recent years. Which is the best
description of health?
a. health is the absence of disease
b. health is a dynamic process toward optimal functioning
c. health depends on an interaction of mind, body, and spirit within environment
d. health is the prevention of disease - ANS-d. health is the prevention of disease
Which would be included in the database for a new patient admission to a surgical unit?
a. all subjective and objective data gathered by a health practitioner from a patient
b. all objective data obtained from a patient through inspection, percussion, palpation,
and auscultation
c. a summary of a patients record, including laboratory studies
d. all subjective and objective data gathered from a patient, and the results of any
laboratory or diagnostic studies completed - ANS-d. all subjective and objective data
gathered from a patient and the results of any laboratory or diagnostic studies
completed
You are reviewing assessment data of a 45-yr old male patient and note pain of 8 on a
scale of 10, labored breathing, and pale skin color on the electronic health record. This
documentation is an example of:
a. hypothetical reasoning
b. diagnostic reasoning
c. data. cluster
d. signs and symptoms - ANS-c. data cluster
a patient is is the emergency department with nausea and vomiting. which would you
include in the database?
a. a complete health history and full physical exam
b. diet and GI history
c. previously identified problems
d. start collection of data in conjunction with lifesaving measures - ANS-b. diet and GI
history
a patient has recently received health insurance and would like to know how often he
should visit the provider. How do you respond
a. "it would be most efficient if you visit on an annual basis"
b. "there is no recommendation for the frequency of health care visits."
c. "your visits may vary, depending on your level of wellness."
,D. "You visits will be based on your preference." - ANS-c. "you visits may vary
depending on your level of wellness."
You are reviewing concepts related to steps in the nursing process for determining
prioritization and developing patient outcomes. To what are these actions attributed?
a. planning
b. assessment
c. implementation
d. diagnosis - ANS-a. planning
What does the nursing process ADPIE stand for? - ANS-A: assessment
D: diagnosis
P: planning
I: implementation
E: evaluation
nursing process assesement - ANS-collect data:
review clinical record
health history
physical exam
functional assessment
risk assessment
review of the literature
use evidence based techniques
document relative data
nursing process Diagnosis - ANS-compare clinical findings with normal and abnormal
variation and developmental events
interpret data:
-identify clusters of clues
-make hypothesis
-test hypothesis
-derrive diagnosis
validate diagnosis
document diagnosis
nursing process planning - ANS--establish priorities
-develop outcomes
-set timelines for outcomes
- IDENTIFY INTERVENTIONS
-integrate evidence based trends
, -document plan of care
Nursing Process: Implementation - ANS--implement in safe and timely manner
-use evidence-based interventions
-collaborate with colleagues
-use community resources
-provide health teaching and health promotion
-document implementation and any modification
nursing process: evaluation - ANS--progress toward outcomes
-conduct systematic, ongoing criterian based evaluation
-include patient and significant others
-use ongoing assessment to revise diagnosis, outcomes, plan
Which best describes evidence-based nursing practice?
a. combining clinical expertise with the use of nursing research to provide the best care
for patients while considering the patients values and circumstances
b. appraising and looking at the implications of one or two articles as they relate to the
culture and ethnicity of the patient
c. competing a literature search to find relevant articles that use nursing research to
encourage nurses to use good practices
d. finding value-based resources to justify nursing actions when working with patients of
diverse cultural backgrounds - ANS-a. combining clinical expertise with the use of
nursing research to provide the best care for patients values and circumstances
what can be determined when the nurse clusters data as part of the critical thinking
process?
a. this step identifies problems that may be urgent and require immediate action
b. this step involves making assumptions in the data
c. the nurse recognizes relevant information among the data
d. risk factors can be determined so the nurse knows how to offer health teaching -
ANS-c. the nurse recognizes relevant information among the data
a patient says she is very nervous and nauseated and she feels as if she will vomit. this
data would be what type?
a. objective
b. reflective
c. subjective
d. introspective - ANS-c. subjective
the expert nurse differs from the novice nurse by acting without consciously thinking
about the actions. this is referred to as:
a. deductive reasoning
b. intuition
c. the nursing process
d. focused assessment - ANS-b. intuition
