Exam (elaborations) Nursing Fundamentals

1. Nursing test banks During data collection the nurse may validate data by which method? (Select all that apply) A) Comparing cues to normal function B) Referring to textbooks, journals, and research reports C) Checking consistency of cues D) Clarifying the patient's statements E) Seeking consensus with colleagues about inferences Ans: A, B, C, D, E Feedback: These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses. 2. When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? A) Validate inferences with the patient B) Do not share inferences with the patient C) Document all inferences D) Avoid making any inferences Ans: A Feedback: The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and patient plans of care. 3. While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history? A) Preparatory B) Introductory C) Maintenance D) Concluding Ans: C Feedback: Watching the patient to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview. 4. The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate? A) "When I perform the nursing history I will need to ask your family to leave the room." B) "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."