Medical Surgical Nursing Preparation for Practice 2nd Ed by Osborn

Osborn, Medical-Surgical Nursing, 2e Question 1 Type: MCSA While conducting a health assessment, the nurse documents a patient’s response under the heading “chief complaint.” Which part of the assessment is the nurse conducting? 1. History of present illness 2. Family history 3. Psychosocial history 4. Past medical history Correct Answer: 1 Rationale 1: The history of the present illness includes information about what brought the patient to the health care provider. The reason is usually written verbatim in the health record and often becomes the chief complaint. Rationale 2: The patient’s chief complaint is not part of the family history. Rationale 3: The patient’s chief complaint is not part of the psychosocial history. Rationale 4: The patient’s chief complaint is not part of the past medical history. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-1 Question 2 Type: MCSA A patient comes to the emergency department and states, “I am having chest pain and I feel short of breath.” How is the data the patient has just given the nurse classified? 1. Nonspecific 2. Objective 3. Factual 4. Subjective Correct Answer: 4 Rationale 1: Nonspecific is not a term used to describe types of assessment data. Rationale 2: Objective data is information collected when the nurse uses the senses: observation, palpation, auscultation, percussion, and smell. Rationale 3: Factual is not a term used to describe types of assessment data. Rationale 4: Subjective data is information the patient provides to the nurse. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-3 Question 3 Type: MCSA The nurse has completed the collection and analysis of data from a patient assessment. What is the nurse’s next action? 1. Evaluate outcomes from care. 2. Plan care. 3. Determine patient care goals. 4. Formulate nursing diagnoses. Correct Answer: 4 Rationale 1: Evaluation occurs after care is implemented. Rationale 2: Planning occurs later in the nursing process. Rationale 3: Determining patient goals is a later step of the nursing process. Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is the next step of the nursing process. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6-2