Health Assessment Final Test Bank Questions

Health Assessment Final Test Bank Questions 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 - a. Objective Rationale: 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 - c. Subjective Rationale: 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. 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 - c. Validate the data by asking a coworker to listen to the breath sounds Rationale: 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 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 - a. Data base Rationale: 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. 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 - d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation Rationale: The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. 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 - a. Nurses lack of research skills in evaluating the quality of research studies Rationale: As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. 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 - a. Inspiratory wheezes noted in left lower lobes c. Nonproductive cough e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute Rationale: Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to the respiratory cues. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. a. Open-ended questions elicit cold facts b. They allow for self-expression c. Open-ended questions build and enhance rapport d. They leave interactions neutral e. Open-ended questions call for short one- to two-word answers f. They are used when narrative information is needed - b. They allow for self-expression c. Open-ended questions build and enhance rapport f. They are used when narrative information is needed Rationale: Open-ended questions allow for self-expression, build and enhance rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this situation? Select all that apply. a. Collect the patients data in a direct, face-to-face manner. b. Enter all the data as the patient states them. c. Ask the patient to wait as the nurse enters the data. d. Type the data into the computer after the narrative is fully explored. e. Allow the patient to see the monitor during typing. - a. Collect the patients data in a direct, face-to-face manner. d. Type the data into the computer after the narrative is fully explored. e. Allow the patient to see the monitor during typing. Rationale: The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patients narrative story in a direct, face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.