Batesc13thcEdition
REF: p. 741
MSC: Client Needs: Health Promotion and Maintenance
13. A 50-year-old woman calls the clinic because she has noticed some changes in her body and
breasts and wonders if these changes could be attributable to the hormone replacement
therapy (HRT) she started 3 months earlier. The nurse should tell her:
a HRT is at such a low dose that side effects are very unusual.
b HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding.
c Vaginal bleeding - correct answersANS: B
Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other
responses are not correct.
CHAPTER 1 Foundations for Clinical Proficiency
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.
b. Reflective.
c. Subjective.
d. Introspective. - correct answersANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. Subjective data is what the person says about
him or herself during history taking. The terms reflective and introspective are not used to
,describe data.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - correct answersANS: C
Subjective data are what the person says about him or herself during history taking. Objective
data are what the health professional observes by inspecting, percussing, palpating, and
auscultating during the physical examination. The terms reflective and introspective are not
used
to describe data.
3. The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - correct answersANS: A
Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
,c.cValidatecthecdatacbycaskingcaccoworkerctoclistenctocthecbreathcsounds.
d.cAssesscagaincinc20cminutesctocnotecwhethercthecsoundciscstillcpresent.c-
ccorrectcanswersANS:cC
Whencunsurecofcacsoundcheardcwhileclisteningctocacpatientscbreathcsounds,cthecnursecvali
datescthe
datactocensurecaccuracy.cIfcthecnursechasclesscexperiencecincancarea,cthenchecorcshecasksc
ancexpert
toclisten.
5.cThecnurseciscconductingcacclasscforcnewcgraduatecnurses.cDuringcthecteachingcsession,ct
he
nursecshouldckeepcincmindcthatcnovicecnurses,cwithoutcacbackgroundcofcskillscandcexperie
nce
fromcwhichctocdraw,carecmoreclikelyctocmakectheircdecisionscusing:
acIntuition.
bcAcsetcofcrules.
ccArticlescincjournals.
dcAdvicecfromcsupervisors.c-ccorrectcanswersANS:cB
Novicecnursescoperatecfromcacsetcofcdefined,cstructuredcrules.cThecexpertcpractitionercuse
s
intuitiveclinks.
6.cExpertcnursesclearnctocattendctocacpatterncofcassessmentcdatacandcactcwithoutcconscio
uslyclabelingcit.cThesecresponsescarecreferredctocas:
acIntuition.
bcThecnursingcprocess.
ccClinicalcknowledge.
dcDiagnosticcreasoning.c-ccorrectcanswersANS:cA
Intuitioncisccharacterizedcbycpatterncrecognitioncexpertcnursesclearnctocattendctocacpattern
cofcassessmentcdatacandcactcwithoutcconsciouslyclabelingcit.cThecothercoptionscarecnotccor
rect.
, 7.cThecnurseciscreviewingcinformationcaboutcevidence-
basedcpracticec(EBP).cWhichcstatement
bestcreflectscEBP?
acEBPcreliesconctraditioncforcsupportcofcbestcpractices.
bcEBPciscsimplycthecusecofcbestcpracticectechniquescforcthectreatmentcofcpatients.
ccEBPcemphasizescthecusecofcbestcevidencecwithcthecclinicianscexperience.
dcThecpatientscowncpreferencescarecnotcimportantcwithcEBP.c-ccorrectcanswersANS:cC
EBPciscacsystematiccapproachctocpracticecthatcemphasizescthecusecofcbestcevidencecinccom
bination
withcthecclinicianscexperience,cascwellcascpatientcpreferencescandcvalues,cwhencmakingcde
cisions
aboutccarecandctreatment.cEBPciscmorecthancsimplycusingcthecbestcpracticectechniquesctoc
treat
patients,candcquestioningctraditionciscimportantcwhencnoccompellingcandcsupportivecresear
ch
evidencecexists.
8.cThecnurseciscconductingcacclassconcprioritycsettingcforcacgroupcofcnewcgraduatecnurses.
cWhichciscancexamplecofcacfirst-levelcprioritycproblem?
acPatientcwithcpostoperativecpain
bcNewlycdiagnosedcpatientcwithcdiabetescwhocneedscdiabeticcteaching
ccIndividualcwithcacsmallclacerationconcthecsolecofcthecfoot
dcIndividualcwithcshortnesscofcbreathcandcrespiratorycdistressc-ccorrectcanswersANS:cD
First-
levelcprioritycproblemscarecthosecthatcarecemergent,clifecthreatening,candcimmediatec(e.g.,
establishingcancairway,csupportingcbreathing,cmaintainingccirculation,cmonitoringcabnormalc
vital
signs)c(seecTablec1-1).
9.cWhencconsideringcprioritycsettingcofcproblems,cthecnurseckeepscincmindcthatcsecond-
levelcprioritycproblemscincludecwhichcofcthesecaspects?
REF: p. 741
MSC: Client Needs: Health Promotion and Maintenance
13. A 50-year-old woman calls the clinic because she has noticed some changes in her body and
breasts and wonders if these changes could be attributable to the hormone replacement
therapy (HRT) she started 3 months earlier. The nurse should tell her:
a HRT is at such a low dose that side effects are very unusual.
b HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding.
c Vaginal bleeding - correct answersANS: B
Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other
responses are not correct.
CHAPTER 1 Foundations for Clinical Proficiency
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.
b. Reflective.
c. Subjective.
d. Introspective. - correct answersANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. Subjective data is what the person says about
him or herself during history taking. The terms reflective and introspective are not used to
,describe data.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective. - correct answersANS: C
Subjective data are what the person says about him or herself during history taking. Objective
data are what the health professional observes by inspecting, percussing, palpating, and
auscultating during the physical examination. The terms reflective and introspective are not
used
to describe data.
3. The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary. - correct answersANS: A
Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
,c.cValidatecthecdatacbycaskingcaccoworkerctoclistenctocthecbreathcsounds.
d.cAssesscagaincinc20cminutesctocnotecwhethercthecsoundciscstillcpresent.c-
ccorrectcanswersANS:cC
Whencunsurecofcacsoundcheardcwhileclisteningctocacpatientscbreathcsounds,cthecnursecvali
datescthe
datactocensurecaccuracy.cIfcthecnursechasclesscexperiencecincancarea,cthenchecorcshecasksc
ancexpert
toclisten.
5.cThecnurseciscconductingcacclasscforcnewcgraduatecnurses.cDuringcthecteachingcsession,ct
he
nursecshouldckeepcincmindcthatcnovicecnurses,cwithoutcacbackgroundcofcskillscandcexperie
nce
fromcwhichctocdraw,carecmoreclikelyctocmakectheircdecisionscusing:
acIntuition.
bcAcsetcofcrules.
ccArticlescincjournals.
dcAdvicecfromcsupervisors.c-ccorrectcanswersANS:cB
Novicecnursescoperatecfromcacsetcofcdefined,cstructuredcrules.cThecexpertcpractitionercuse
s
intuitiveclinks.
6.cExpertcnursesclearnctocattendctocacpatterncofcassessmentcdatacandcactcwithoutcconscio
uslyclabelingcit.cThesecresponsescarecreferredctocas:
acIntuition.
bcThecnursingcprocess.
ccClinicalcknowledge.
dcDiagnosticcreasoning.c-ccorrectcanswersANS:cA
Intuitioncisccharacterizedcbycpatterncrecognitioncexpertcnursesclearnctocattendctocacpattern
cofcassessmentcdatacandcactcwithoutcconsciouslyclabelingcit.cThecothercoptionscarecnotccor
rect.
, 7.cThecnurseciscreviewingcinformationcaboutcevidence-
basedcpracticec(EBP).cWhichcstatement
bestcreflectscEBP?
acEBPcreliesconctraditioncforcsupportcofcbestcpractices.
bcEBPciscsimplycthecusecofcbestcpracticectechniquescforcthectreatmentcofcpatients.
ccEBPcemphasizescthecusecofcbestcevidencecwithcthecclinicianscexperience.
dcThecpatientscowncpreferencescarecnotcimportantcwithcEBP.c-ccorrectcanswersANS:cC
EBPciscacsystematiccapproachctocpracticecthatcemphasizescthecusecofcbestcevidencecinccom
bination
withcthecclinicianscexperience,cascwellcascpatientcpreferencescandcvalues,cwhencmakingcde
cisions
aboutccarecandctreatment.cEBPciscmorecthancsimplycusingcthecbestcpracticectechniquesctoc
treat
patients,candcquestioningctraditionciscimportantcwhencnoccompellingcandcsupportivecresear
ch
evidencecexists.
8.cThecnurseciscconductingcacclassconcprioritycsettingcforcacgroupcofcnewcgraduatecnurses.
cWhichciscancexamplecofcacfirst-levelcprioritycproblem?
acPatientcwithcpostoperativecpain
bcNewlycdiagnosedcpatientcwithcdiabetescwhocneedscdiabeticcteaching
ccIndividualcwithcacsmallclacerationconcthecsolecofcthecfoot
dcIndividualcwithcshortnesscofcbreathcandcrespiratorycdistressc-ccorrectcanswersANS:cD
First-
levelcprioritycproblemscarecthosecthatcarecemergent,clifecthreatening,candcimmediatec(e.g.,
establishingcancairway,csupportingcbreathing,cmaintainingccirculation,cmonitoringcabnormalc
vital
signs)c(seecTablec1-1).
9.cWhencconsideringcprioritycsettingcofcproblems,cthecnurseckeepscincmindcthatcsecond-
levelcprioritycproblemscincludecwhichcofcthesecaspects?
