Test Bank for Essentials For Nursing Practice 9th Edition Potter | Complete ()

The nurse suspects that a patient is being abused by the spouse based on the presence of many unexplained bruises and the nonverbal behavior of the patient. Which critical thinking technique was used by the nurse? a. Intuition b. Humility c. Curiosity d. Fairness ANS: A The fact that the nurse “senses” something is not right about the situation is intuition. Intuition is the inner sensing or “gut feeling” that something is so. For example, a nurse walks into a patient’s room and, by looking at the patient’s appearance without the benefit of a thorough assessment, senses that he or she has worsened physically. Curiosity is the desire to learn more about something. Fairness is the ability to remain impartial. Humility is the quality of being modest or unassertive. DIF: Cognitive Level: Apply (Application) OBJ: Describe the characteristics of a critical thinker. TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. Which behavior demonstrates basic critical thinking expected of beginning nursing students? a. Creating a personalized bowel elimination program for a patient with constipation due to narcotic pain medications b. Elevating the patient’s leg and applying ice packs when the patient’s postoperative pain is not relieved with prescribed pain medications c. Asking the instructor for assistance when having difficulty inserting the urinary catheter into the male patN ientR ’s bI laddG er B.C M d. Advocating for delay in theUpatSientN’s dTischargOe when the nurse suspects that a serious surgical complication has developed ANS: C The student nurse is at the basic level because he or she asked the instructor what to do. At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. Complex critical thinkers begin to separate themselves from experts. In complex critical thinking you learn to synthesize knowledge. This means that you develop a new thought or idea based on your experience and knowledge over time. The third level of critical thinking is commitment. You anticipate the need to make choices without assistance from others. You accept accountability for whatever decisions you make. DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the components of a critical thinking model for clinical decision making. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 5. The nurse becomes very skilled at feeding patients with dysphagia after working on a rehabilitation unit for many years. Which component of critical thinking allows the nurse to function at this high level of practice? a. Integrity b. Experience c. Risk taking d. Responsibility Essentials for Nursing Practice 9th Edition Potter Test Bank BANK U S N T O ANS: B The nurse has become very skilled at feeding stroke patients due to many years of experience. The nurse is not taking a risk with patients as the nurse is very skilled. The nurse demonstrates integrity and responsibility by carefully maintaining high professional standards of care for patients. DIF: Cognitive Level: Analyze (Analysis) OBJ: Explain how experience and professional standards influence a nurse’s critical thinking. TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 6. The nurse feels strongly that the patient may be suffering from physical abuse. The nurse reports the situation to protective services even though the physician insists that the patient is simply accident-prone. Which component of critical thinking leads the nurse to file the report even though the physician believes it is not needed? a. Fairness b. Creativity c. Discipline d. Confidence ANS: D The nurse’s confidence in the assessment of the patient’s situation leads the nurse to file a report with protective services even though the physician believes it is not needed. Fairness is the ability to listen to both sides of a discussion. Discipline is demonstrated when the nurse takes the time to do the job thoroughly. Creativity is demonstrated when the nurse uses imagination skills to come up with new solutions or ideas. DIF: Cognitive Level: Apply N(ApRplicaItionG) B.C M OBJ: Describe the characteristics of a critical thinker. TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 7. The nurse comes up with creative methods to help soothe agitated patients with dementia when the usual approaches fail. Which term best describes the action of the nurse? a. Concept mapping b. Diagnostic reasoning c. Scientific method d. Effective problem solving ANS: D Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options, which the nurse did in this scenario. In commitment, you anticipate the need to make choices without assistance from others. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. In diagnostic reasoning, the information a nurse collects and analyzes leads to a diagnosis of a patient’s condition. Nurses do not make medical diagnoses; they make nursing diagnoses, which is a part of diagnostic reasoning. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort Essentials for Nursing Practice 9th Edition Potter Test Bank BANK 8. The experienced trauma nurse determines that the patient may have suffered a cervical spinal cord injury as the patient is unable to feel or move the arms or legs. Which term best describes the nurse’s ability to make this conclusion? a. Data collection b. Clinical inference c. Scientific method d. Standardized criteria ANS: B The nurse demonstrated clinical inference by using extensive experience to reach the conclusion that the patient had suffered a spinal cord injury. Clinical inference is the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options. Data collection is a component of assessment in the nursing process. Standardized criteria do not assist the nurse to realize that the patient suffered a spinal cord injury. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Adaptation 9. The nurse implements interventions to address risk for falls after noting that the patient is unsteady when getting out of bed. The nurse is using which skill in this situation? a. Medical diagnosis b. Scientific method c. Diagnostic reasoning d. Data collection ANS: C BANK The nurse used diagnostic reasoning by using data (unsteady patient) to arrive at a patient’s health problem/nursing diagnosis (risk for falls). Diagnostic reasoning is the analytical process for determining a patient’s health problems. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis risk for falls. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the relationship of the nursing process to critical thinking. TOP: Nursing Process: Diagnosis MSC: NCLEX: Safety and Infection Control 10. Which action of the nurse demonstrates clinical decision making? a. The nurse performs a detailed health history and physical assessment when the patient is admitted to the unit. b. The nurse determines that the patient is at risk for constipation due to use of Essentials for Nursing Practice 9th Edition Potter Test Bank BANK U S N T O postoperative narcotic pain medication. c. The nurse applies a hydrocolloid dressing to the patient’s decubitus ulcer as ordered by the physician. d. The nurse assesses the patient’s oral mucus membranes each morning to check for candida infection or ulceration. ANS: B The nurse demonstrates clinical decision making when solving problems and formulating nursing diagnoses for patients. An example of this is the determination that the patient is at risk for constipation due to use of postoperative narcotic pain medication. Application of a hydrocolloid dressing is implementation of the physician’s order. Assessment (health history and mucus membranes) forms the starting point for clinical decision making. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 11. Which patient’s need constitutes the highest priority for the nurse? a. The patient who is waiting for discharge teaching in order to go home b. The constipated patient who has not had a bowel movement in 3 days c. The patient with sudden onset of slurred speech and right-sided weakness d. The patient who requires linen changes after being incontinent of urine and stool ANS: C The patient with sudden onset of slurred speech and right-sided weakness has signs of an acute stroke. This patient must be treated immediately to preserve neurological function and prevent permanent deficits. The discharged patient and the constipated patient will have to wait until the nurse has takenNcarRe ofItheGstroBk.e CpatiMent. The nurse can delegate care for the incontinent patient to the nursing assistant. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 12. Which action by the nurse best demonstrates independent thinking? a. Removing and carefully cleaning the patient’s dentures every night b. Initiating swallow precautions when the patient shows signs of aspiration c. Teaching the diabetic patient how to self-administer insulin injections d. Actively listening to the patient when recording the patient’s health history ANS: B The nurse demonstrates independent thinking by initiating swallow precautions when the patient shows signs of aspiration. The nurse took the initiative to act when signs of aspiration were noted. Independent thinking is not demonstrated by performing routine oral care, teaching the patient how to inject insulin, or using active listening skills. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 13. Which action by the nurse is an example of a workaround? a. In order to save time, the nurse scans medication bar codes after administration to Essentials for Nursing Practice 9th Edition Potter Test Bank ANS: D BANK U S N T O the patient. b. The nurse prioritizes care for patients so that the most urgent patient needs are addressed first. c. The nurse helps the nursing assistant to change the linens after a patient is incontinent of stool and urine. d. The nurse seeks assistance from another nurse when having difficulty advancing the urinary catheter into the bladder. ANS: A A workaround is a shortcut that may endanger patients in an attempt to save time. Medication bar codes should always be scanned before administration to patients to prevent errors. Scanning bar codes after administration in an attempt to save time is a workaround. Prioritization of patient care, assisting other staff members, and seeking assistance are not examples of workarounds. DIF: Cognitive Level: Apply (Application) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 14. The nurse asks another nurse for assistance when trying to determine the best way to manage a postoperative patient’s pain. Which critical thinking attitude is demonstrated by the nurse? a. Humility b. Confidence c. Risk taking d. Fairness ANS: A Critical thinkers who use humNilitRy adImitGwhBCey Mdo not know and try to find the knowledge they need to make a proper decision. Humility is recognizing when one needs more information to make a decision. When a nurse is new to a clinical division and unfamiliar with the patients, he or she should ask for an orientation to the area and ask nurses regularly assigned to the area for assistance. If your knowledge causes you to question a health care provider’s order, do so. This illustrates risk taking. To be confident is to feel certain in your ability to accomplish a task or goal such as performing a nursing procedure or making a diagnostic decision; do not let a patient think that you are unsure of performing care safely. Fairness is listening to both sides in any discussion and dealing with situations justly. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Implementation MSC: NCLEX: Basic Care and Comfort 15. The new nurse keeps a diary to record experiences, patient encounters, and feelings when beginning work in the nursing profession. Which critical thinking action is used by the nurse? a. Professional standards b. Nursing process c. Concept mapping d. Purposeful reflection Essentials for Nursing Practice 9th Edition Potter Test Bank BANK N R I G B.C M Purposeful reflection leads to a deeper understanding of issues and the development of judgment and skill. One activity that will help a nurse develop into a critical thinker is reflective journaling. A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. The nursing process is a systematic process that incorporates diagnostic reasoning and clinical decision making through five steps: assessment, diagnosis, planning, implementation, and evaluation. Professional standards for critical thinking refer to ethical criteria for nursing judgments (e.g., advocacy, patient autonomy, and beneficence), evidence-based criteria used for assessment and evaluation, and criteria for professional responsibility. DIF: Cognitive Level: Apply (Application) OBJ: Describe how reflection improves clinical decision making. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. Which is the best tool that the nurse can use to make sense of the patient’s multiple medical diagnoses, assessment findings, and medications? a. Plan of care b. Concept map c. Reflective journal d. Intellectual standards ANS: B A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. Concept maps are visual road mUapSs thNat hiTghlightOthe meanings of these relationships. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. In the nursing process, a plan of care is written to guide nursing care, but it does not show relationships as well as does a concept map. Paul (1993) identified 14 intellectual standards universal for critical thinking. An intellectual standard is a guideline or principle for rational thought, but it does not show relationships like a concept map does. DIF: Cognitive Level: Apply (Application) OBJ: Discuss the relationship of the nursing process to critical thinking. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17. The nurse inappropriately assumed that the patient did not require pain medication due to a history of substance abuse. Which critical thinking concept did the nurse fail to use? a. Criticism b. Maturity c. Analysis d. Organization ANS: C Essentials for Nursing Practice 9th Edition Potter Test Bank BANK Analysis is demonstrated when the nurse keeps an open mind when forming judgments about patient assessment findings. The nurse failed to carefully analyze assessment findings by mistakenly assuming that the patient did not require pain medication due to a history of substance abuse. Criticism and organization are not critical thinking skills. Maturity is reflecting on your own judgments and realizing multiple solutions are acceptable. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the importance of clinical judgment in a nurse’s ability to make clinical decisions. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18. A nurse uses personal experience as well as knowledge of body mechanics and medical equipment in order to determine the safest way to transfer the paraplegic patient from the bed to the wheelchair. Which critical thinking concept is demonstrated by the nurse? a. Evaluation b. Explanation c. Development d. Self-regulation ANS: B Explanation is demonstrated when the nurse uses personal experience and applicable knowledge bases to determine the best plan of care for the patient. Scientific knowledge and experience to choose strategies you use in the care of patient is explanation; it supports your findings and conclusions. Evaluation is looking at all situations objectively and systematically and using criteria to determine results of nursing actions. Self-regulation is reflecting on your experiences and identifying ways you can improve your own performance. Development is not a critical thinking skill. DIF: Cognitive Level: AnalyzNe U(ARnSalyIsNis)GT B.CO M OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Planning MSC: NCLEX: Safety and Infection Control 19. The nurse readily accepts an opportunity to become certified in wound care and ostomy management. Which critical thinking concept is demonstrated by the nurse? a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness ANS: D Inquisitiveness is being eager to acquire knowledge and learning explanations even when applications of the knowledge are not immediately clear and to value learning for learning’s sake. Analyticity is being alert to potentially problematic situations and using evidence-based knowledge. Maturity is reflecting on your own judgments and realizing multiple solutions are acceptable. Systematicity is being organized, focusing, and working hard in any inquiry. DIF: Cognitive Level: Apply (Application) OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Teaching and Learning MSC: NCLEX: Safety and Infection Control Essentials for Nursing Practice 9th Edition Potter Test Bank BANK 20. In a facility with an outbreak of Clostridium difficile, the nurse manager determines that staff members are continuing to use alcohol-based hand sanitizer when caring for patients with Clostridium difficile infection despite the policy which requires hand hygiene using soap and water. Which step of the scientific method was performed by the nurse manager? a. Identification of the problem b. Formation of the hypothesis c. Investigation of the hypothesis d. Evaluation of the intervention ANS: A The problem is identified when the nurse manager determines that staff members are not following agency policy about hand hygiene. The nurse manager could hypothesize that a reminder program will increase employee compliance with the hand-hygiene policy. The nurse manager could implement a patient/visitor survey to determine if employees are compliant with the hand-hygiene policy. Evaluation is done after the reminder program is implemented to determine the rate of employee compliance. DIF: Cognitive Level: Apply (Application) OBJ: Describe the components of a critical thinking model for clinical decision making. TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 21. Which action by the nurse demonstrates the use of fairness for critical thinking? a. Adherence to the six rights when administering medication to a patient b. Clarification of an unusually high dosage medication with the prescriber c. Effective pain management is provided for all patients regardless of background d. Development of a personalized swallowing precautions protocol for the patient ANS: C BANK Fairness means the nurse deals with situations justly. This means that bias or prejudice does not enter into a decision. All patients are provided with the same pain-management standards regardless of their background, ethnicity, or insurance status. Creativity involves original thinking. This means you find solutions outside of the standard routines of care while still following standards of practice. A critical thinker’s favorite question is, “Why?” and represents curiosity. Clarifying an unusually high dosage of a medication with a prescriber demonstrates risk taking. Following the “six rights” is being responsible and accountable. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 22. Which statement is true about critical thinking? a. It is the same thing as the nursing process. b. It is moving from writing a plan of care to thinking. c. It is a haphazard method of providing nursing care. d. It is a continuous process characterized by open-mindedness. ANS: D Essentials for Nursing Practice 9th Edition Potter Test Bank BANK Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant. It is not the same thing as the nursing process, but the nursing process is a specific critical thinking competency. It is not a haphazard method; it is logical, with attitudes and standards. Although critical thinking helps write a care plan, actually writing a care plan is a step (planning) in the nursing process. DIF: Cognitive Level: Analyze (Analysis) OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 23. The nurse carefully performs a careful physical assessment and health history for the patient, making sure not to miss any body systems. Which attitude for critical thinking is demonstrated by the nurse? a. Integrity b. Planning c. Discipline d. Diagnosis ANS: C The nurse is being thorough, which is using the critical thinking attitude of discipline. A disciplined thinker misses few details and follows an orderly or systematic approach when collecting information, making decisions, or taking action. A person of integrity is honest and willing to admit to any mistakes or inconsistencies in his or her own behavior, ideas, and beliefs. Planning and nursing diagnosis are steps in the nursing process, not attitudes for critical thinking. DIF: Cognitive Level: Apply N(AUpRplSicaItiNonG) T B.CO M OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The nurse noted a rise in skin infections on the nursing unit. After a literature review was completed, a new bathing protocol using disposable wash basins and pH balanced skin cleansers was suggested. Which steps of the scientific process were used by the nurse? (Select all that apply.) a. Identify the problem. b. Collect the data. c. Answer the question. d. Evaluate the results. e. Publish findings. ANS: A, B The nurse identified the problem as a rise in skin infections. Data collection was done with the literature review. The question will be answered after implementation of a new bathing protocol. The results will be evaluated after the bathing protocol is implemented. The findings may be published after the protocol has been shown to be effective for preventing skin infections. DIF: Cognitive Level: Analyze (Analysis) Essentials for Nursing Practice 9th Edition Potter Test Bank BANK OBJ: Describe the components of a critical thinking model for clinical decision making. TOP: Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort BANK Essentials for Nursing Practice 9th Edition Potter Test Bank BANK Chapter 09: Nursing Process Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. The nurse carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR). Which step of the nursing process is being performed by the nurse? a. Assessment b. Implementation c. Evaluation d. Diagnosis ANS: A Assessment is the thorough and systematic collection of data about a patient. The data will reveal a patient’s current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves. DIF: Cognitive Level: Apply (Application) OBJ: Describe each step of the nursing process. TOP: Nursing Process: AssessN menR t I GMSB C:.CNCLM EX: Management of Care U S N T O 2. The nurse is caring for a patient who has just arrived at the hospital with chest pain. Which is the most important question for the nurse to ask the patient? a. “Did your family doctor tell you to come to the hospital?” b. “When did your chest pain begin?” c. “Do you have a family history of heart disease?” d. “Did someone come to the hospital with you?” ANS: B The nurse’s first priority is to assess the patient’s current health status including when the chest pain began. This information will be communicated to the physician to facilitate appropriate care for the patient. Determining a family history of heart disease or if the patient is accompanied by a friend or family member is less important than assessing the patient’s chest pain. It is helpful to know if the primary care physician sent the patient to the emergency department, but it is not the highest priority. DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3. The nurse is caring for a patient who came to the hospital with acute shortness of breath. What is the priority action of the nurse as the assessment process is started? a. Pull the curtain around the bed and ensure patient privacy. b. Listen to the patient’s lung sounds and check the pulse oximetry level. Essentials for Nursing Practice 9th Edition Potter Test Bank BANK U S N T O c. Tell the patient that the physician will be in shortly to start treatment. d. Reassure the patient that the shortness of breath will be relieved shortly. ANS: B The priority action of the nurse caring for the patient who has just presented with shortness of breath is to listen to the patient’s lung sounds and check the pulse oximetry level. This information will be presented to the physician in order to facilitate appropriate treatment. Providing privacy and telling the patient when to expect the physician is not as important as assessing the patient’s respiratory status. The patient’s shortness of breath may not be relieved shortly and the nurse should avoid providing false assurance. DIF: Cognitive Level: Apply (Application) OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4. The nurse is caring for a nonverbal patient who just had surgery. The nurse notes that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. The nurse decides that the patient is in pain and decides to administer an analgesic. What is the correct term for this nursing action? a. Setting priorities b. Recognizing inconsistencies c. Using empathy d. Making inferences ANS: D The nurse made an inference that the patient is experiencing pain. An inference is a nurse’s judgment or interpretation of a cue. The nurse did not have to determine if relieving the patient’s pain was the highesNt priRoritIy inGthisBCuatiMon. Empathy was not an issue as it refers to the nurse’s ability to understand the patient’s perspective. There was no inconsistency in the patient’s assessment data. DIF: Cognitive Level: Apply (Application) OBJ: Explain the type of conclusions that result from data analysis. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 5. A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a. The patient’s catheter drained 400 mL of urine during the last 8 hours. b. The patient’s incision is clean, dry, and intact with staples. c. The patient reports having sharp, burning pain with urination. d. The patient refused breakfast after vomiting 200 mL green emesis. ANS: C Subjective data are patients’ verbal descriptions of their health problems. The description of sharp, burning pain with urination is subjective as it could only be felt and reported by the patient. Only patients provide subjective data. Urinary output, incision appearance, and emesis are all objective data. Objective data are observations or measurements of a patient’s health status. DIF: Cognitive Level: Analyze (Analysis) OBJ: Differentiate between subjective and objective data. Essentials for Nursing Practice 9th Edition Potter Test Bank BANK U S N T O TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 6. The nurse has just completed an assessment for a patient. Which data will the nurse categorize as objective? a. The patient felt less short of breath after receiving a nebulizer treatment. b. The patient’s lung sounds are diminished bilaterally with expiratory wheezes. c. The patient worries that the insurance company will not pay the hospital bill. d. The patient wonders if supplemental oxygen at home would be beneficial. ANS: B Objective data are observations or measurements of a patient’s health status. Diminished lung sounds are objective data. Subjective data are patients’ verbal descriptions of their health problems. Only patients provide subjective data. DIF: Cognitive Level: Analyze (Analysis) OBJ: Differentiate between subjective and objective data. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7. The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident? a. The patient was found on the floor and his urinal was on the floor next to him. b. The patient’s nurse assistant always took her time to answer his call lights. c. The patient probably urinated on the floor and slipped on the wet floor. d. The patient is grouchy and inappropriate, always causing trouble for the nurses. ANS: A When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, preciseN, anRd coInsisGtenBt)..NCursMes do not include personal interpretive statements. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. Grouchy and inappropriate are personal interpretive statements and should be avoided. DIF: Cognitive Level: Analyze (Analysis) OBJ: Describe the types of conclusions resulting from data analysis. TOP: Nursing Process: Communication and Documentation MSC: NCLEX: Safety and Infection Control 8. Every time the nurse asks the patient a question for the admission assessment, the patient’s husband interrupts and answers the question for her. What is the best action of the nurse? a. Enter the husband’s responses into the patient’s chart. b. Request that the husband leave the room. c. Complete the admission assessment after the husband has gone home. d. Allow time for the patient to answer each question. ANS: D Essentials for Nursing Practice 9th Edition Potter Test Bank BANK A patient is usually the best source of information. A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. The nurse should not wait to complete the assessment as that may delay treatment. The patient’s husband should not be asked to leave the room unless he becomes disruptive to the patient’s care.