9781305971493 test bank

9781305971493 test bankMULTIPLE CHOICE 1. Which foundational behavior is necessary for effective critical thinking? a. Unshakable beliefs and values b. An open-minded attitude c. An ability to disregard evidence inconsistent with set goals d. An ability to recognize the perfect solution ANS: B An open-minded attitude, not clouded by unshakable beliefs and values or preset goals, allows the application of critical thinking. Acceptance that there may not be a perfect solution leaves the field open to new ideas. DIF: Cognitive Level: Comprehension REF: p. 16, Box 2-1 OBJ: 2 (theory) TOP: Factors Influencing Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100°F and an oxygen saturation of 89%, and expectorates frothy mucus. Which finding is an example of subjective data? a. Temperature b. Oxygen saturation c. Frothy mucus d. Chest tightness ANS: D Subjective data is information given by the patient that cannot be measured otherwise. The other data are considered objective data. Objective data are pieces of information that can be measured by the examiner. The nurse should avoid making judgments or conclusions when obtaining data. DIF: Cognitive Level: Application REF: p. 18 OBJ: 8 (clinical) TOP: Assessment Data KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 3. The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source? a. Primary b. Objective c. Secondary d. Complete ANS: A The patient is the primary source of information. Objective refers to a type of data obtained by the nurse that is measured or can be verified through assessment techniques, secondary information is obtained from relatives or significant others, and information is not necessarily complete when the patient is the source. DOWNLOAD THE Test Bank for Medical Surgical Nursing 5th Edition Stromberg harryson DIF: Cognitive Level: Application REF: p. 19 OBJ: 8 (clinical) TOP: Sources of Information KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient’s breath. Which term accurately describes this assessment? a. Inspection b. Observation c. Auscultation d. Olfaction ANS: D Olfaction is an assessment method of smells. Inspection and observation use the sense of vision. Auscultation refers to use of the sense of hearing. DIF: Cognitive Level: Comprehension REF: p. 20 OBJ: 9 (clinical) TOP: Olfaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings? a. Pitting edema present in both feet and ankles b. Edema in both feet and ankles approximately 4 mm deep c. 4 mm pitting edema quickly resolving d. Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds ANS: D Edema should be recorded as to location, depth of pitting, and time for resolution. DIF: Cognitive Level: Application REF: p. 21 OBJ: 9 (theory) TOP: Palpation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. Which technique should the nurse employ to best assess skin turgor? a. Examine mucous membranes of the mouth. b. Compare limbs for similar color. c. Pinch a skinfold on chest to assess for tenting. d. Palpate the ankles for evidence of pitting edema. ANS: C Skin turgor can be assessed by tenting the skin on the chest and recording the speed at which the “tent” subsides. DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: 9 (clinical) TOP: Practical Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? a. The student uses the patient’s full name only on clinical assignments submitted to the instructor.