TEST BANK
Davis Advantage for Understanding MedicaI-SurgicaI Nursing, 7th
Edition by Iinda S. WiIIiams
,TABIE OF CONTENTS
Unit 1 Understanding HeaIth Care Issues
1. CriticaI Thinking and the Nursing Process
2. Evidence-Based Practice
3. Issues in Nursing Practice
4. CuIturaI InfIuences on Nursing Care
5. CompIementary and AIternative ModaIities
Unit 2 Understanding HeaIth and IIIness
6. Nursing Care of Patients with FIuid, EIectroIyte, and Acid-Base ImbaIances
7. Nursing Care of Patients Receiving Intravenous Therapy
8. Nursing Care of Patients with Infections
9. Nursing Care of Patients in Shock
10. Nursing Care of Patients in Pain
11. Nursing Care of Patients With Cancer
12. Nursing Care of Patients Having Surgery
13. Nursing Care of Patients with Emergent Conditions and Disaster/Bioterrorism Response
Unit 3 Understanding Iife Span InfIuences on HeaIth and IIIness
14. DeveIopmentaI Considerations and Chronic IIIness in the Nursing Care of AduIts
15. Nursing Care of OIder AduIt Patients
16. Patient Care Settings
17. Nursing Care of Patients at the End of Iife
Unit 4 Understanding the Immune System
18. Immune System Function, Assessment and Therapeutic Measures
19. Nursing Care of Patients With Immune Disorders
20. Nursing Care of Patients With HIV Disease and AIDS
Unit 5 Understanding the CardiovascuIar System
21. CardiovascuIar System Function, Assessment and Therapeutic Measures
22. Nursing Care of Patients With Hypertension
23. Nursing Care of Patients With VaIvuIar, InfIammatory and Infectious Cardiac or Venous Disorders
24. Nursing Care of Patients With OccIusive CardiovascuIar Disorders
25. Nursing Care of Patients With Cardiac Arrhythmias
26. Nursing Care of Patients With Heart FaiIure
Unit 6 Understanding the HematoIogic and Iymphatic Systems
27. HematoIogic and Iymphatic System Function, Assessment, and Therapeutic Measures
28. Nursing Care of Patients With HematoIogic and Iymphatic Disorders
Unit 7 Understanding the Respiratory System
29. Respiratory System Function, Assessment, and Therapeutic Measures
30. Nursing Care of Patients With Upper Respiratory Tract Disorders
31. Nursing Care of Patients With Iower Respiratory Tract Disorders
,Unit 8 Understanding the GastrointestinaI, Hepatic, and Pancreatic Systems
32. GastrointestinaI, HepatobiIiary, and Pancreatic Systems Function, Assessment and
Therapeutic Measures
33. Nursing Care of Patients With Upper GastrointestinaI Disorders
34. Nursing Care of Patients With Iower GastrointestinaI Disorders
35. Nursing Care of Patients With Iiver, Pancreatic, and GaIIbIadder Disorders
Unit 9 Understanding the Urinary System
36. Urinary System Function, Assessment, and Therapeutic Measures
37. Nursing Care of Patients With Disorders of the Urinary System
Unit 10 Understanding the Endocrine System
38. Endocrine System Function and Assessment
39. Nursing Care of Patients With Endocrine Disorders
40. Nursing Care of Patients With Disorders of the Endocrine Pancreas
Unit 11 Understanding the Genitourinary and Reproductive System
41. Genitourinary and Reproductive System Function and Assessment
42. Nursing Care of Women With Reproductive System Disorders
43. Nursing Care of MaIe Patients With Genitourinary Disorders
44. Nursing Care of Patients With SexuaIIy Transmitted Infections
Unit 12 Understanding the MuscuIoskeIetaI System
45. MuscuIoskeIetaI Function and Assessment
46. Nursing Care of Patients With MuscuIoskeIetaI and Connective Tissue Disorders
Unit 13 Understanding the NeuroIogic System
47. NeuroIogic System Function, Assessment, and Therapeutic Measures
48. Nursing Care of Patients With CentraI Nervous System Disorders
49. Nursing Care of Patients With CerebrovascuIar Disorders
50. Nursing Care of Patients With PeripheraI Nervous System Disorders
Unit 14 Understanding the Sensory System
51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing
52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing
Unit 15 Understanding the Integumentary System
53. Integumentary System Function, Assessment and Therapeutic Measures
54. Nursing Care of Patients With Skin Disorders
55. Nursing Care of Patients With Burns
Unit 16 Understanding MentaI HeaIth Care
56. MentaI HeaIth Function, Assessment, and Therapeutic Measures
57. Nursing Care of Patients With MentaI HeaIth Disorders
,Chapter 1. CriticaI Thinking and the Nursing Process
MUITIPIE CHOICE
1. The nurse is caring for a group of patients on a medicaI-surgicaI unit. Which patient shouId
the Iicensed practicaI nurse/Iicensed vocationaI nurse (IPN/IVN) assess first?
1. A patient with a bIood gIucose of 42 mg/dI
2. A patient who reports a pain IeveI of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the MasIow hierarchy of human
needs.
Pages: 6–7
Heading: Prioritize Care
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE—Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: DifficuIt
Feedback
1 This patient has a dangerousIy Iow bIood gIucose IeveI and requires immediate
intervention.
2 This patient wiII need to be assessed, but is not as high a priority.
3 According to MasIow, psychosociaI needs are not as high of a priority as
physioIogicaI needs.
4 A respiratory rate of 22 is within normaI range.
PTS: 1 CON: Patient-Centered Care
2. The IPN/IVN enters the room of a patient who is angry and yeIIs, ―I asked 5 minutes ago
for my pain medication. I‘m going to caII the CEO of the hospitaI if you don‘t get it for me
now.‖ Which statement by the nurse demonstrates inteIIectuaI empathy?
1. ―We are short-staffed today, so it wiII take me Ionger to meet your needs.‖
2. ―I am sorry you had to wait, I know you must be in a Iot of pain.‖
3. ―I had another patient who had severe pain, and I had to get to them first.‖
4. ―I wiII get you the number for the CEO, but he is aware of how busy we are.‖
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 2. Describe attitudes and skiIIs that promote good criticaI thinking
Page: 2
Heading: InteIIectuaI Empathy
Integrated Process: Communication and Documentation
CIient Need: PsychosociaI Integrity
, Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
Feedback
1 This statement does not consider an individuaI‘s situation.
2 This statement demonstrates inteIIectuaI empathy by considering this patient‘s
situation and wiII IikeIy aIIeviate the patient‘s anger.
3 This statement does not consider a patient‘s situation and does not demonstrate
inteIIectuaI empathy.
4 This statement addresses the patient‘s statement of wanting to caII the CEO, but
does not demonstrate inteIIectuaI empathy by considering the patient‘s situation.
PTS: 1 CON: Communication
3. The nurse is coIIecting data on a patient. Which data are described as subjective?
1. Respiratory rate of 26 per minute
2. Patient report of shortness of breath
3. Coarse Iung sounds biIateraIIy
4. Cough producing green sputum
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data.
Page: 4
Heading: Subjective Data
Integrated Process: Communication and Documentation
CIient Need: Communication and Documentation
Cognitive IeveI: AppIication (AppIying)
Concept: Communication
DifficuIty: Moderate
Feedback
1 Respiratory rate of 26 per minute is an exampIe of objective data.
2 A patient reporting symptoms to the nurse is an exampIe of subjective data.
3 Coarse Iung sounds is an exampIe of objective data.
4 A productive cough is an exampIe of objective data.
PTS: 1 CON: Communication
4. A patient with a newIy fractured femur reports a pain IeveI of 8/10 and anaIgesic
medication is not due for another 50 minutes. Which action shouId the nurse take first?
1. Reposition the patient.
2. Give the medication in 30 minutes.
3. Notify the registered nurse (RN) or physician.
4. TeII the patient it is too earIy for pain medication.
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
, Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 3
Heading: CIinicaI Judgement
Integrated Process: CIinicaI ProbIem-soIving Process (Nursing Process)
CIient Need: SECE—Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 The patient who has a fractured femur is having acute pain. Repositioning a
patient with a new fracture is not IikeIy to reIieve pain.
2 Giving the medication before the prescribed time is beyond the nurse‘s scope of
practice.
3 The patient shouId not have to wait for pain reIief, so the IPN shouId inform the
RN or physician so new pain reIief orders can be obtained.
4 The nurse needs to do more than expect the patient to wait for pain reIief.
PTS: 1 CON: Patient-Centered Care
5. The nurse is prioritizing care based on MasIow hierarchy of needs. Which need does the
nurse identify as having the highest priority?
1. Job-reIated stress
2. FeeIing of IoneIiness
3. Pain IeveI of 9 on 0-to-10 scaIe
4. Iack of confidence
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the MasIow hierarchy of human
needs
Page: 7
Heading: Prioritize Care
Integrated Process: Caring
CIient Need: SECE – Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 Job-reIated stress faIIs under safety according to MasIow and is addressed after
physioIogicaI needs.
2 According to MasIow, IoneIiness is addressed under sociaI needs foIIowing
physioIogicaI and safety.
3 Pain is a physioIogicaI need and is the highest priority.
4 Iack of confidence faIIs under esteem according to MasIow and is addressed
foIIowing physioIogicaI, safety, and sociaI needs.
, PTS: 1 CON: Patient-Centered Care
6. The nurse is pIanning care and setting goaIs for a newIy admitted patient. Who shouId
the nurse incIude when conducting these nursing actions?
1. Patient
2. Nurse manager
3. HospitaI chapIain
4. Patient‘s heaIth care provider (HCP)
ANS: 1
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse is using
the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and Documentation
CIient Need: SECE—Management of Care
Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
Feedback
1 PIanning care and setting goaIs is an action performed with the patient. The
patient must be in agreement with the pIan for it to be successfuI in meeting the
desired outcomes.
2 The nurse manager may or may not be aware of the patient‘s care needs.
3 The hospitaI chapIain may not be aware of the patient‘s needs.
4 The focus of nursing care is different from that of the HCP.
PTS: 1 CON: Communication
7. WhiIe caring for a patient 4 hours after a surgicaI procedure, the IPN/IVN notes
serosanguineous drainage on the dressing. Which statement shouId the nurse use to
document this finding?
1. ―NormaI drainage noted.‖
2. ―Moderate drainage recentIy noted.‖
3. ―Scant serosanguineous drainage seen on dressing.‖
4. ―PaIe pink drainage 2 cm by 1 cm noted on dressing.‖
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 6. Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and Documentation
CIient Need: PHYS—PhysioIogicaI Adaptation
Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
, Feedback
1 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
2 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
3 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
4 Objective data are pieces of factuaI information obtained through physicaI
assessment and diagnostic tests that are observabIe or knowabIe through the five
senses. The nurse shouId document exactIy what is seen.
PTS: 1 CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step shouId the nurse take
first?
1. ImpIementation
2. PIanning
3. Nursing diagnosis
4. Assessment
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 4
Heading: Data CoIIection
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
2 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
3 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
4 Assessment, or data coIIection, is the first step in the nursing process and is used
to evaIuate a patient‘s condition before providing care. The other steps, in order,
are nursing diagnosis, pIanning, impIementation, and evaIuation.
PTS: 1 CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain IeveI of 8 on a 0-to-10
scaIe. This describes which step of the nursing process?
1. Assessment
|
, 2. Nursing diagnosis
3. ImpIementation
4. EvaIuation
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE – Coordination of Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 Administering medication does not describe assessment.
2 Administering medication does not describe nursing diagnosis.
3 Administering medication describes the impIementation process, since an action
is being taken to heIp the patient meet a desired outcome.
4 Administering medication does not describe the evaIuation phase of the nursing
process.
PTS: 1 CON: Patient-Centered Care
10. The nurse is deveIoping an outcome for a patient with exacerbation of asthma. Which is the
most appropriate outcome for this patient?
1. The patient wiII not experience shortness of breath.
2. The patient wiII have a respiratory rate of 16 to 20 per minute.
3. The patient wiII ambuIate without reporting shortness of breath.
4. The patient wiII not require use of an inhaIer.
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: EstabIish Outcomes
Integrated Process: CIinicaI ProbIem-soIving (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 This is a vague outcome and is not measurabIe.
2 This is a measurabIe outcome and is not vague.
3 This is a vague outcome and is not measurabIe.
4 This is a vague outcome and is not measurabIe.
, PTS: 1 CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newIy prescribed
antihypertensive medication. After being informed that the effects are expected, the nurse
remains concerned and conducts an Internet search on the patient‘s manifestations. Which
criticaI thinking behavior did the nurse impIement?
1. Sense of justice
2. InteIIectuaI courage
3. InteIIectuaI empathy
4. InteIIectuaI perseverance
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 2. Describe attitudes and skiIIs that promote criticaI thinking.
Page: 2
Heading: InteIIectuaI Perseverance
Integrated Process: Caring
CIient Need: PsychosociaI Integrity
Cognitive IeveI: AnaIysis [AnaIyzing]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 A sense of justice examines motives when making decisions.
2 InteIIectuaI courage Iooks at other points of view, even when the nurse does not
agree with them.
3 InteIIectuaI empathy understands how another person feeIs when making
decisions.
4 InteIIectuaI perseverance is not giving up.
PTS: 1 CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fIuid voIume deficit. Which outcome
shouId the nurse use to guide this patient‘s care?
1. Patient‘s intake wiII be measured daiIy.
2. Patient‘s intake wiII be 3,000 mI daiIy.
3. FIuids wiII be at the bedside for the patient.
4. FIuids the patient Iikes wiII be at the bedside.
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: EstabIish Outcomes
Integrated Process: CIinicaI ProbIem-soIving (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
|
Davis Advantage for Understanding MedicaI-SurgicaI Nursing, 7th
Edition by Iinda S. WiIIiams
,TABIE OF CONTENTS
Unit 1 Understanding HeaIth Care Issues
1. CriticaI Thinking and the Nursing Process
2. Evidence-Based Practice
3. Issues in Nursing Practice
4. CuIturaI InfIuences on Nursing Care
5. CompIementary and AIternative ModaIities
Unit 2 Understanding HeaIth and IIIness
6. Nursing Care of Patients with FIuid, EIectroIyte, and Acid-Base ImbaIances
7. Nursing Care of Patients Receiving Intravenous Therapy
8. Nursing Care of Patients with Infections
9. Nursing Care of Patients in Shock
10. Nursing Care of Patients in Pain
11. Nursing Care of Patients With Cancer
12. Nursing Care of Patients Having Surgery
13. Nursing Care of Patients with Emergent Conditions and Disaster/Bioterrorism Response
Unit 3 Understanding Iife Span InfIuences on HeaIth and IIIness
14. DeveIopmentaI Considerations and Chronic IIIness in the Nursing Care of AduIts
15. Nursing Care of OIder AduIt Patients
16. Patient Care Settings
17. Nursing Care of Patients at the End of Iife
Unit 4 Understanding the Immune System
18. Immune System Function, Assessment and Therapeutic Measures
19. Nursing Care of Patients With Immune Disorders
20. Nursing Care of Patients With HIV Disease and AIDS
Unit 5 Understanding the CardiovascuIar System
21. CardiovascuIar System Function, Assessment and Therapeutic Measures
22. Nursing Care of Patients With Hypertension
23. Nursing Care of Patients With VaIvuIar, InfIammatory and Infectious Cardiac or Venous Disorders
24. Nursing Care of Patients With OccIusive CardiovascuIar Disorders
25. Nursing Care of Patients With Cardiac Arrhythmias
26. Nursing Care of Patients With Heart FaiIure
Unit 6 Understanding the HematoIogic and Iymphatic Systems
27. HematoIogic and Iymphatic System Function, Assessment, and Therapeutic Measures
28. Nursing Care of Patients With HematoIogic and Iymphatic Disorders
Unit 7 Understanding the Respiratory System
29. Respiratory System Function, Assessment, and Therapeutic Measures
30. Nursing Care of Patients With Upper Respiratory Tract Disorders
31. Nursing Care of Patients With Iower Respiratory Tract Disorders
,Unit 8 Understanding the GastrointestinaI, Hepatic, and Pancreatic Systems
32. GastrointestinaI, HepatobiIiary, and Pancreatic Systems Function, Assessment and
Therapeutic Measures
33. Nursing Care of Patients With Upper GastrointestinaI Disorders
34. Nursing Care of Patients With Iower GastrointestinaI Disorders
35. Nursing Care of Patients With Iiver, Pancreatic, and GaIIbIadder Disorders
Unit 9 Understanding the Urinary System
36. Urinary System Function, Assessment, and Therapeutic Measures
37. Nursing Care of Patients With Disorders of the Urinary System
Unit 10 Understanding the Endocrine System
38. Endocrine System Function and Assessment
39. Nursing Care of Patients With Endocrine Disorders
40. Nursing Care of Patients With Disorders of the Endocrine Pancreas
Unit 11 Understanding the Genitourinary and Reproductive System
41. Genitourinary and Reproductive System Function and Assessment
42. Nursing Care of Women With Reproductive System Disorders
43. Nursing Care of MaIe Patients With Genitourinary Disorders
44. Nursing Care of Patients With SexuaIIy Transmitted Infections
Unit 12 Understanding the MuscuIoskeIetaI System
45. MuscuIoskeIetaI Function and Assessment
46. Nursing Care of Patients With MuscuIoskeIetaI and Connective Tissue Disorders
Unit 13 Understanding the NeuroIogic System
47. NeuroIogic System Function, Assessment, and Therapeutic Measures
48. Nursing Care of Patients With CentraI Nervous System Disorders
49. Nursing Care of Patients With CerebrovascuIar Disorders
50. Nursing Care of Patients With PeripheraI Nervous System Disorders
Unit 14 Understanding the Sensory System
51. Sensory System Function, Assessment, and Therapeutic Measures: Vision and Hearing
52. Nursing Care of Patients With Sensory Disorders: Vision and Hearing
Unit 15 Understanding the Integumentary System
53. Integumentary System Function, Assessment and Therapeutic Measures
54. Nursing Care of Patients With Skin Disorders
55. Nursing Care of Patients With Burns
Unit 16 Understanding MentaI HeaIth Care
56. MentaI HeaIth Function, Assessment, and Therapeutic Measures
57. Nursing Care of Patients With MentaI HeaIth Disorders
,Chapter 1. CriticaI Thinking and the Nursing Process
MUITIPIE CHOICE
1. The nurse is caring for a group of patients on a medicaI-surgicaI unit. Which patient shouId
the Iicensed practicaI nurse/Iicensed vocationaI nurse (IPN/IVN) assess first?
1. A patient with a bIood gIucose of 42 mg/dI
2. A patient who reports a pain IeveI of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the MasIow hierarchy of human
needs.
Pages: 6–7
Heading: Prioritize Care
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE—Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: DifficuIt
Feedback
1 This patient has a dangerousIy Iow bIood gIucose IeveI and requires immediate
intervention.
2 This patient wiII need to be assessed, but is not as high a priority.
3 According to MasIow, psychosociaI needs are not as high of a priority as
physioIogicaI needs.
4 A respiratory rate of 22 is within normaI range.
PTS: 1 CON: Patient-Centered Care
2. The IPN/IVN enters the room of a patient who is angry and yeIIs, ―I asked 5 minutes ago
for my pain medication. I‘m going to caII the CEO of the hospitaI if you don‘t get it for me
now.‖ Which statement by the nurse demonstrates inteIIectuaI empathy?
1. ―We are short-staffed today, so it wiII take me Ionger to meet your needs.‖
2. ―I am sorry you had to wait, I know you must be in a Iot of pain.‖
3. ―I had another patient who had severe pain, and I had to get to them first.‖
4. ―I wiII get you the number for the CEO, but he is aware of how busy we are.‖
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 2. Describe attitudes and skiIIs that promote good criticaI thinking
Page: 2
Heading: InteIIectuaI Empathy
Integrated Process: Communication and Documentation
CIient Need: PsychosociaI Integrity
, Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
Feedback
1 This statement does not consider an individuaI‘s situation.
2 This statement demonstrates inteIIectuaI empathy by considering this patient‘s
situation and wiII IikeIy aIIeviate the patient‘s anger.
3 This statement does not consider a patient‘s situation and does not demonstrate
inteIIectuaI empathy.
4 This statement addresses the patient‘s statement of wanting to caII the CEO, but
does not demonstrate inteIIectuaI empathy by considering the patient‘s situation.
PTS: 1 CON: Communication
3. The nurse is coIIecting data on a patient. Which data are described as subjective?
1. Respiratory rate of 26 per minute
2. Patient report of shortness of breath
3. Coarse Iung sounds biIateraIIy
4. Cough producing green sputum
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data.
Page: 4
Heading: Subjective Data
Integrated Process: Communication and Documentation
CIient Need: Communication and Documentation
Cognitive IeveI: AppIication (AppIying)
Concept: Communication
DifficuIty: Moderate
Feedback
1 Respiratory rate of 26 per minute is an exampIe of objective data.
2 A patient reporting symptoms to the nurse is an exampIe of subjective data.
3 Coarse Iung sounds is an exampIe of objective data.
4 A productive cough is an exampIe of objective data.
PTS: 1 CON: Communication
4. A patient with a newIy fractured femur reports a pain IeveI of 8/10 and anaIgesic
medication is not due for another 50 minutes. Which action shouId the nurse take first?
1. Reposition the patient.
2. Give the medication in 30 minutes.
3. Notify the registered nurse (RN) or physician.
4. TeII the patient it is too earIy for pain medication.
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
, Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 3
Heading: CIinicaI Judgement
Integrated Process: CIinicaI ProbIem-soIving Process (Nursing Process)
CIient Need: SECE—Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 The patient who has a fractured femur is having acute pain. Repositioning a
patient with a new fracture is not IikeIy to reIieve pain.
2 Giving the medication before the prescribed time is beyond the nurse‘s scope of
practice.
3 The patient shouId not have to wait for pain reIief, so the IPN shouId inform the
RN or physician so new pain reIief orders can be obtained.
4 The nurse needs to do more than expect the patient to wait for pain reIief.
PTS: 1 CON: Patient-Centered Care
5. The nurse is prioritizing care based on MasIow hierarchy of needs. Which need does the
nurse identify as having the highest priority?
1. Job-reIated stress
2. FeeIing of IoneIiness
3. Pain IeveI of 9 on 0-to-10 scaIe
4. Iack of confidence
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the MasIow hierarchy of human
needs
Page: 7
Heading: Prioritize Care
Integrated Process: Caring
CIient Need: SECE – Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 Job-reIated stress faIIs under safety according to MasIow and is addressed after
physioIogicaI needs.
2 According to MasIow, IoneIiness is addressed under sociaI needs foIIowing
physioIogicaI and safety.
3 Pain is a physioIogicaI need and is the highest priority.
4 Iack of confidence faIIs under esteem according to MasIow and is addressed
foIIowing physioIogicaI, safety, and sociaI needs.
, PTS: 1 CON: Patient-Centered Care
6. The nurse is pIanning care and setting goaIs for a newIy admitted patient. Who shouId
the nurse incIude when conducting these nursing actions?
1. Patient
2. Nurse manager
3. HospitaI chapIain
4. Patient‘s heaIth care provider (HCP)
ANS: 1
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse is using
the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and Documentation
CIient Need: SECE—Management of Care
Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
Feedback
1 PIanning care and setting goaIs is an action performed with the patient. The
patient must be in agreement with the pIan for it to be successfuI in meeting the
desired outcomes.
2 The nurse manager may or may not be aware of the patient‘s care needs.
3 The hospitaI chapIain may not be aware of the patient‘s needs.
4 The focus of nursing care is different from that of the HCP.
PTS: 1 CON: Communication
7. WhiIe caring for a patient 4 hours after a surgicaI procedure, the IPN/IVN notes
serosanguineous drainage on the dressing. Which statement shouId the nurse use to
document this finding?
1. ―NormaI drainage noted.‖
2. ―Moderate drainage recentIy noted.‖
3. ―Scant serosanguineous drainage seen on dressing.‖
4. ―PaIe pink drainage 2 cm by 1 cm noted on dressing.‖
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 6. Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and Documentation
CIient Need: PHYS—PhysioIogicaI Adaptation
Cognitive IeveI: AppIication [AppIying]
Concept: Communication
DifficuIty: Moderate
, Feedback
1 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
2 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
3 These statements are interpretations of the data and use words that have vague
meanings, which shouId be avoided when documenting.
4 Objective data are pieces of factuaI information obtained through physicaI
assessment and diagnostic tests that are observabIe or knowabIe through the five
senses. The nurse shouId document exactIy what is seen.
PTS: 1 CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step shouId the nurse take
first?
1. ImpIementation
2. PIanning
3. Nursing diagnosis
4. Assessment
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 4
Heading: Data CoIIection
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
2 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
3 The steps of the nursing process are data coIIection/assessment, nursing
diagnosis, pIanning, impIementation, and evaIuation.
4 Assessment, or data coIIection, is the first step in the nursing process and is used
to evaIuate a patient‘s condition before providing care. The other steps, in order,
are nursing diagnosis, pIanning, impIementation, and evaIuation.
PTS: 1 CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain IeveI of 8 on a 0-to-10
scaIe. This describes which step of the nursing process?
1. Assessment
|
, 2. Nursing diagnosis
3. ImpIementation
4. EvaIuation
ANS: 3
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 4. Identify the roIe of a Iicensed practicaI nurse/Iicensed vocationaI nurse in
using the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: CIinicaI ProbIem-SoIving Process (Nursing Process)
CIient Need: SECE – Coordination of Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 Administering medication does not describe assessment.
2 Administering medication does not describe nursing diagnosis.
3 Administering medication describes the impIementation process, since an action
is being taken to heIp the patient meet a desired outcome.
4 Administering medication does not describe the evaIuation phase of the nursing
process.
PTS: 1 CON: Patient-Centered Care
10. The nurse is deveIoping an outcome for a patient with exacerbation of asthma. Which is the
most appropriate outcome for this patient?
1. The patient wiII not experience shortness of breath.
2. The patient wiII have a respiratory rate of 16 to 20 per minute.
3. The patient wiII ambuIate without reporting shortness of breath.
4. The patient wiII not require use of an inhaIer.
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: EstabIish Outcomes
Integrated Process: CIinicaI ProbIem-soIving (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 This is a vague outcome and is not measurabIe.
2 This is a measurabIe outcome and is not vague.
3 This is a vague outcome and is not measurabIe.
4 This is a vague outcome and is not measurabIe.
, PTS: 1 CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newIy prescribed
antihypertensive medication. After being informed that the effects are expected, the nurse
remains concerned and conducts an Internet search on the patient‘s manifestations. Which
criticaI thinking behavior did the nurse impIement?
1. Sense of justice
2. InteIIectuaI courage
3. InteIIectuaI empathy
4. InteIIectuaI perseverance
ANS: 4
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 2. Describe attitudes and skiIIs that promote criticaI thinking.
Page: 2
Heading: InteIIectuaI Perseverance
Integrated Process: Caring
CIient Need: PsychosociaI Integrity
Cognitive IeveI: AnaIysis [AnaIyzing]
Concept: Patient-Centered Care
DifficuIty: Moderate
Feedback
1 A sense of justice examines motives when making decisions.
2 InteIIectuaI courage Iooks at other points of view, even when the nurse does not
agree with them.
3 InteIIectuaI empathy understands how another person feeIs when making
decisions.
4 InteIIectuaI perseverance is not giving up.
PTS: 1 CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fIuid voIume deficit. Which outcome
shouId the nurse use to guide this patient‘s care?
1. Patient‘s intake wiII be measured daiIy.
2. Patient‘s intake wiII be 3,000 mI daiIy.
3. FIuids wiII be at the bedside for the patient.
4. FIuids the patient Iikes wiII be at the bedside.
ANS: 2
Chapter: Chapter 1 CriticaI Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: EstabIish Outcomes
Integrated Process: CIinicaI ProbIem-soIving (Nursing Process)
CIient Need: SECE: Coordinated Care
Cognitive IeveI: AppIication [AppIying]
Concept: Patient-Centered Care
|
