Health Assessment answered test bank

Chapter 01: Evidence-Based Assessment 1. 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. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be: a. Subjective. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to: a. Validate the data by asking a coworker to listen to the breath sounds. 5. 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. A set of rules. 6. 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. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP emphasizes the use of best evidence with the clinician’s experience. 8. 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. Individual with shortness of breath and respiratory distress 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Abnormal laboratory values 10. Which critical thinking skill helps the nurse see relationships among the data? a. Clustering related cues 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation 13. 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 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Diagnostic hypothesis