Test Bank for Health Assessment in Nursing, 7th North American Edition (Chapters 1-34)

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TEST BANK FOR HEALTH ASSESSMENT INNURSING KELLY TESTBANK-LATESTVERSION||RATED A++||COMPLETE STUDYGUIDE.A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy(gallbladderremoval).Whatistheoverallpurposeofassessmentfor this patient?•Collecting accuratedata•Assisting the primary careprovider•Validatingpreviousdata•Making clinicaljudgments•Apatienthaspresentedtotheemergencydepartment(ED)withcomplaintsofabdominal pain. Which member of the care team would most likely be responsible forcollecting the subjective data on the patient during the initial comprehensiveassessment?•Gastroenterologist•EDnurse•Admissionsclerk•Diagnostictechnician•Thenursehascompletedaninitialassessmentofanewlyadmittedpatientandisapplying the nursing processto plan the patient'scare. What principle should the nurseapply when using the nursing process?•Eachstep isindependent of theothers.•Itisongoing andcontinuous.•Itisused primarily in acute caresettings.•Itinvolvesindependentnursingactions.•The nurse who provides care at an ambulatory clinic is preparing to meet a patientand performacomprehensivehealthassessment.Whichofthefollowingactionsshouldthe nurse perform first?•Reviewthepatient'smedicalrecord.•Obtain basic biographicdata.

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•Consultclinicalresourcesexplainingthepatient'sdiagnosis.•Validate information with thepatient.•Whichofthefollowingpatientsituationswouldthenurseinterpretasrequiringan emergency assessment?•Apediatric patient with severesunburn•Apatient needing an employmentphysical•Apatient who overdosed onacetaminophen•Adistraughtpatient whowantsapregnancytest•In response to a patient's query, the nurse is explaining the differences between thephysician's medical exam and the comprehensive health assessment performed bythe nurse.Thenurseshoulddescribethefactthatthenursingassessmentfocusesonwhich aspect of the patient's situation?•Current physiologicstatus•Effect of health on functionalstatus•Past medicalhistory•Motivation for adherence totreatment•Afterteachingagroupofstudentsaboutthephasesofthenursingprocess,theinstructor determines that the teaching was successful when the students identifywhich phase as being foundational to all other phases?•Assessment•Planning•Implementation•Evaluation•Thenursehascompletedthecomprehensivehealthassessmentofapatientwhohasbeen admitted for the treatment of community-acquired pneumonia. Following thecompletion of this assessment, the nurse periodically performs a partial assessmentprimarily for which reason?•Reassesspreviouslydetectedproblems•Provideinformationforthepatient'srecord•Addressareaspreviouslyomitted•Determinetheneedforcrisisintervention•Thenurseisworkinginanambulatorycareclinicthatislocatedinabusy,inner-city neighborhood. Which patient would the nurse determine to be in most need ofan emergency assessment?•A14-year-oldgirl whoiscrying becauseshethinkssheispregnant

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•A45-year-oldmanwithchestpainanddiaphoresisfor1hour•A3-year-old child with fever, rash, and sorethroat•A20-year-oldmanwitha3-inchshallowlacerationonhisleg•Anurse hascompleted gathering some basic data about a patient who hasmultiplehealth problemsthatstemfromheavyalcoholuse.Thenursehasthenreflectedonherpersonal feelings about the patient and his circumstances. The nurse does thisprimarily to accomplish which of the following?•Determineif pertinent datahasbeenomitted•Identify the need forreferral•Avoidbiasesandjudgments•Construct a plan ofcare•The nurse is collecting data from a patient who has recently been diagnosed with type1 diabetes and who will begin an educational program. The nurse is collectingsubjective andobjectivedata.Whichofthefollowingwouldthenursecategorizeasobjectivedata?•Familyhistory•Occupation•Appearance•History of present healthconcern•An older adult patient has been admitted to the hospital with failure to thriveresulting fromcomplicationsofdiabetes.Whichofthefollowingwouldthenurseimplementin response to a collaborative problem?•Encouragethe patient to increase oral fluidintake.•Provide the patient with a bedtime proteinsnack.•Assist the patient with personalhygiene.•Measurethepatient'sbloodglucosefourtimesdaily.•The nurse at a busy primary care clinic is analyzing the data obtained from thefollowingpatients.Forwhichpatientswouldthenursemostlikelyexpecttofacilitateareferral?•An80-year-oldpatient wholiveswithherdaughter•A50-year-old patient newly diagnosed withdiabetes•An adult presenting for an influenzavaccination•Ateenager seeking information aboutcontraception

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•An instructor is reviewing the evolution of the nurse's role in health assessment. Theinstructordeterminesthattheteachingwassuccessfulwhenthestudentsidentifywhich of the following as the major method used by nurses early in the history of theprofession?•Naturalsenses•Biomedicalknowledge•Simpletechnology•Criticalpathways•Whendescribingtheexpansionofthedepthandscopeofnursingassessmentoverthe past several decades, which of the following would the nurse identify as beingthe primary force?•Documentation•Informatics•Diversification•Technology•Agroupofnursesarereviewinginformationaboutthepotentialopportunitiesfornurses who have advanced assessment skills. When discussing phenomena that havecontributed to these increased opportunities, what should the nurses identify?•Expansion of health carenetworks•Decreasein patient participation incare•The shrinking cost of medicalcare•Public mistrust ofphysicians•Anurse hasdocumented the findingsof a comprehensive assessment of a newpatient. Whatistheprimaryrationalethatthenurseshouldidentifyforaccurateandthoroughdocumentation?•Guaranteeing a continual assessmentprocess•Identifyingabnormaldata•Assuringvalidconclusionsfromanalyzeddata•Allowingfordrawinginferencesandidentifyingproblems•Anursehasreceivedareportonapatientwhowillsoonbeadmittedtothemedicalunit from the emergency department. When preparing for the assessment phase ofthe nursing process, which of the following should the nurse do first?•Collect objectivedata.•Validate importantdata.•Collect subjectivedata.•Document thedata.

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•A community health nurse is assessing an older adult patient in the patient's home.When thenurseisgatheringsubjectivedata,whichofthefollowingwouldthenurseidentify?•Thepatient'sfeelingsofhappiness•Thepatient'sposture•Thepatient'saffect•Thepatient'sbehavior•Anurseonthehospital'ssubacutemedicalunitisplanningtoperformapatient'sfocused assessment. Which of the following statements should inform the nurse'spractice?•The focused assessment should be done before the physicalexam.•Thefocusedassessmentreplacesthecomprehensivedatabase.•Thefocusedassessmentaddressesaparticularpatientproblem.•Thefocused assessment isdone after gathering subjectivedata.•The nurse is reviewing a patient's health history and the results of the most recentphysicalexamination.Whichofthefollowingdatawouldthenurseidentifyasbeing subjective? Select all that apply.•ìI feel so tiredsometimes.î•Weight: 145lbs•Lungscleartoauscultation•patientcomplainsofaheadache•ìMy father died of a heartattack.î•Pupilsequal,round,andreactivetolight•The nurse hasbeen applying the nursing processin the care of an adult patientwho is beingtreatedforacutepancreatitis.Placethenurse'sactionsintheirpropersequence from first to last.•Identifyingoutcomes•Determiningpatient'snursingproblem•Collecting information about thepatient•Determining outcomeachievement•Carrying outinterventionsC,B,A,E,D

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•Anurseiscompletinganassessmentthatwillinvolvegatheringsubjectiveandobjective data. Which of the following assessment techniques will best allow the nurseto collect objective data?•Inspection•Therapeuticcommunication•Interviewing•Activelistening•Thenurseisperformingahealthassessmentonacommunity-dwellingpatientwhois recoveringfromhipreplacementsurgery.Whichofthefollowingactionsshouldthe nurse prioritize during assessment?•Focusthe assessmenton thepatient asamember ofher agegroup.•Interpret the information aboutthe patient incontext.•Corroboratethepatient'sstatementswithtrustedsources.•Gather information from a variety ofsources.•Apatientcomestothehealthcareprovider'sofficeforavisit.Thepatienthasbeenseenin this office on occasion for the past 5 years and arrives today complaining of afever and sore throat. Which type of assessment would the nurse most likely perform?•Comprehensiveassessment•Ongoingassessment•Focusedassessment•Emergencyassessment•A nurse has assessed a patient who was admitted to the medical unit to treat acutecomplicationsof type 1 diabetes. During the assessment, the patient admitted thathis bloodsugarmonitoringwhenheisathomeisìabitsporadic.îHowshouldthenurse best respond to this assessment finding?•IdentifyanursingdiagnosisofIneffectiveHealthMaintenance.•Identify a collaborative problem that should involve the occupationaltherapist.•Makea referralto theunit'ssocialworkdepartment.•Reassessthepatient'sbloodglucoselevel.•The nurse is utilizing the Health Belief Model in the care of a patient whose type 1diabetesisinadequatelycontrolled.Whenimplementingthismodel,thenurseshould begin by assessing which of the following?•Thepatient'smotivationforchange•Thepatient'smedicalcomorbidities•Thepatient'slearningstyle•Thepatient'sprognosisforrecovery

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•Anursewillcompleteaninitialcomprehensiveassessmentofa60-year-oldpatientwho is new to the clinic. What goal should the nurse identify for this type ofassessment?•Identifythe mostappropriate formsofmedical interventionfor thepatient.•Determinethemostlikelyprognosisforthepatient'shealthproblem.•Identifythestatusofthepatient'sairway,breathing,andcirculation.•Establish a baseline for the comparison of future healthchanges.•A nurse who provides care in a hospital setting is creating a plan of nursing care fora patient who hasa diagnosisof chronic renal failure. The nurse'splan specifiesfrequent ongoingassessments.Thefrequencyofthesenursingassessmentsshouldbeprimarily determined by what variable?•Thepatient'sage•Theunit'sprotocols•Thepatient'sacuity•Thenurse'spotentialforliability•A patient who is new to the facility has a recent history of chronic pain that isattributed to fibromyalgia. The nurse has reviewed the available health records andsuspects that painmanagementwillbeamajorfocusofnursingcare.Howcanthenursebestvalidate this assumption?•Reviewthepatient'smedicationadministrationrecordforanalgesicuse.•Askthepatientaboutthemostrecentexperiencesofpain.•Meetwiththepatient'sspouseanddaughtertodiscussthepatient'spain.•Collaboratewith the physician who istreating thepatient.AnswerKey•D•B•B•A•C•B•A•A•B•C•C•D•B

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•A•D•A•C•C•A•C•A, D,E•C, B, A, E,D•A•B•C•A•A•D•C•B•Anurseispreparingtoassessapatientwhoisnewtotheclinic.Whenbeginningthe collection of the patient database, which of the following actions should thenurseprioritize?•Establishing a trustingrelationship•Determiningthepatient'sstrengths•Identifying potential healthproblems•Making clinicalinferences•A nurse is interpreting and validating information from an older adult patient whohas beenexperiencingafunctionaldecline.Thenurseisinwhichphaseoftheinterview?•Introductory•Working•Summary•Closing•A71-year-oldwomanhasbeenadmittedtothehospitalforavaginalhysterectomy,and the nurse is collecting subjective data prior to surgery. Which statement by thenurse could be construed as judgmental?•“Howoften doyour adultchildren typicallyvisityou?”•“Yourhusband'sdeathmusthave beenverydifficultforyou.”•“Youmustquit smokingbecause itaffectsothers, notonlyyou.”

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•“Howwouldyoudescribeyourfeelingsaboutgettingolder?”•A nurse is interviewing a 22-year-old patient of the campus medical clinic. Whichnonverbalbehaviorshouldthenurseadopttobestfacilitatecommunicationduringthis phase of assessment?•Standingwhile the patient isseated•Using a moderate amountof eyecontact•Sittingacrosstheroomfromthepatient•Minimizing facialexpressions•Anurseisprovidingfeedbacktoacolleagueafterobservingthecolleague'sinterviewof a newly admitted patient. Which of the following would the nurse identify as anexample of a closed-ended question or statement?•“Tell me about your relationship with yourchildren?”•“Tellme what you eat in a normalday?”•“Are you allergic to anymedications?”•“Whatisyour typical daylike?”•Apatienthaspresentedtotheemergencydepartmentandishavingdifficultydescribing her vague sensation of physical discomfort and unease. How can thenurse best elicit meaningful assessment data about the nature of the patient'scomplaint?•Ignorethe complaint for nowand returnto it later in theassessment.•Provide a laundry list of descriptivewords.•Restate the question using simplerterms.•Wait in silence until the patient can determine the correctwords.•A nurse is eliciting a patient's health history and the patient asks, “Can I take theherb ginkgobilobawithmyothermedications?”Whatactionwouldbebestifthenurseis unsure of the answer?•Promise to find out the information for thepatient.•Changethe subjectand return tothistopiclater.•Teach the patient to only take prescribedmedications.•Encourage the patient to ask the pharmacist or primary careprovider.•Thenurseispreparingtoassessthementalstatusofa90-year-oldpatientwhoisbeing admittedtothehospitalfromalong-termcarefacility.Whichofthefollowingshould the nurse assess first?•Thepatient'ssensoryabilities•Thepatient'sgeneralintelligence

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•The presence of anyphobias•Thepatient'sjudgmentandinsight•A nurse provides care in a rural hospital that serves a community that has fewminority residents.Wheninterviewingapatientfromaminorityculture,thenursehasenlistedthe assistanceofa“culturebroker.”Howcanthisindividualbestfacilitatethepatient'scare?•Byinterpretingthepatient'slanguageandculture•Byevaluatingthepatient'sculturallybasedhealthpractices•By teaching the patient about healthcare•By making the patient feel comfortable andsafe•Uponenteringanexamroom,thepatientstates,“Well!Iwasgettingreadytoleave.My schedule is very busy and I don't have time to waste waiting until you have thetime to see me!” Which response by the nurse would be most appropriate?•“Ourschedule isvery busyalso. We got to youassoon aswecould.”•“Noone isforcing you to be here, and you are free to leave at anytime.”•“Wouldyouliketoreportyourcomplaintstosomeonewithpower?”•“You'recertainly justifiedin being upset,but I amready to beginyour examnow.”•A nurse has admitted a patient to the medical unit and is describing the purpose forobtainingacomprehensivehealthhistory.Whichofthefollowingpurposesshouldthe nurse describe?•“Thishelpsustocompleteyourhealthrecordaccurately.”•“Thishelpsustoestablishatrustinginterpersonalrelationship.”•“Thishelpsustoevaluatetheseriousnessofyourriskfactorsfordisease.”•“Thishelpsushaveanappropriatefocusforthephysicalexamination.”•A clinic nurse has reviewed a new patient's available health record and will nowbegin takingthepatient'shealthhistory.Whichofthefollowingquestionsshouldthenurseask first when obtaining the health history?•“Do you have adequate health insurancecoverage?”•“Are you generally fairlyhealthy?”•“Whatisyourmajor healthconcern atthistime?”•“Didyoubringallyourmedicationswithyou?”•A patient has presented for care with complaints of persistent lower back pain.When usingthemnemonicCOLDSPA,whichquestionshouldthenurseusetoevaluatethe“P”?•“Whatmakesitworse?”

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•“When did itstart?”•“Howdoesitfeel?”•“Howwouldyou rateyourpain?”•Amedicalnursehascompletedthereviewofsystemscomponentofthepatient'shealth history. Which assessment finding should the nurse document under thereview ofsystems?•“Highschooldiplomaplus2yearsofcollege”•“Caregiver reliable source ofinformation”•“Menarche at age13”•“Lungscleartoauscultationbilaterally”•A patient has been admitted following an unexplained weight loss of 15 pounds overthe past3months.Howshouldthenursebestassessthesubjectivecomponentofthepatient's nutritional status?•Ask the patient to explainMyPlate.•Obtaina 24-hour dietrecall.•Askaboutthecontentsofonetypicalmeal.•Elicitthepatient'sfavoritefoods.•A patient's elevated body mass index (BMI) has prompted the nurse to assess thepatient's activityandexerciselevel.Whichstatementwouldindicatetothenursethatthepatientis getting the recommended amount of exercise?•“I walk briskly on the treadmill once or twice aweek.”•“I play basketball with a team every Friday night withoutfail.”•“Igoto astepclassforanhour threetimesaweek.”•“I swim for at least half an hour each Saturdaymorning.”•During an assessment, the nurse determines that a patient sees more than oneprimary careproviderandhasobtainedprescriptionsfromeachprovider.Whichmethodwould be most appropriate to determine a patient's current medicationregimen?•Askthepatienttoidentifywhichmedicationstakeneveryday.•Askthepatienttobringallthemedicationsandsupplementstoaninterview.•Askthe caregiver whether the patient istaking prescribedmedications.•Askthe patient about the use of any over-the-countermedications.•Thenurseispreparingtoassessanadultwoman'sactivitiesrelatedtohealthpromotion andmaintenance.Whichquestionshouldthenurseasktoobtainthemostobjectiveand thorough assessment data?

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•“Doyoualwayswear yourseatbeltwhendriving?”•“Howmuch beer,wine, or alcoholdo youdrink?”•“Doyouusecondomswitheachsexualencounter?”•“Couldyou describe howyou perform self-breastexams?”•Anurseiscreatingagenogramofapatient'sfamilyhealthhistory.Thenurseshoulduse which of the following symbols to denote the patient's female relatives?•Circle•Square•Triangle•Rectangle•A patient has just been admitted to the postsurgical unit from postanesthetic recovery,andthenurseisintheintroductoryphaseofthepatientinterview.Whichofthefollowing activities should the nurse perform first?•Collaborate with the patient to identifyproblems.•Explainthe purpose of theinterview.•Determinethepatient'svitalsigns.•Obtain family health historydata.•Duringtheinterview,thepatientstates,“Istodaythe12th?Mywifedied2monthsago today.” Which of the following responses would be most appropriate?•“Whatwasthecauseofyourwife'sdeath?”•“Howdoesthatmakeyoufeelrightnow?”•“You probably must besad.”•“Are you feeling sad, depressed, angry, orupset?”•Thenurseisusingthemnemonic“COLDSPA”toassessapatient'scomplaintoflower abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to10. The nurse is assessing which aspect of the complaint?•Character•Onset•Severity•Pattern•Thenurseisobtaininginformationaboutapatient'spasthealthhistory.Whichpatient statement would best reflect this component of assessment?•“Mymom'sstill alive,but mydad died10 yearsago ofheartfailure.”•“I have a brother with leukemia and a sister withhypertension.”

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•“Ihad surgery5 yearsagoto repairan inguinalhernia.”•“I have been having some pain when I urinate for the last severaldays.”•A nurse is teaching a recent nursing graduate about the significance of verbal andnonverbal communication during patient care. The new graduate demonstrates anunderstandingofthesetechniquesbycitingwhatexampleofverbalcommunication?•Maintainingan openattitude•Using silenceappropriately•Providingalaundrylistofdescriptorswhenneeded•Maintaining an open and encouraging facialexpression•Theadmissionofanewresidenttoalong-termcarefacilityhasnecessitatedathorough health history. Place the following focuses in the correct sequence in whichthe nurse should perform them, beginning with the section obtained first.•Familyhealthhistory•Reason for seekingcare•Biographicdata•Reviewofbodysystems•History of presentconcern•Past healthhistoryC,B,E,F,A,D•The nurse is completing a review of systems for a patient. Which of the followinginformationwouldthenursedocumentrelatedtothepatient'smusculoskeletalsystem? Select all that apply.•Jointstiffness•Rhinorrhea•Shortnessofbreath•Chestpain•Musclestrength•Kneeswelling•The nurse is completing an assessment of a 50-year-old female patient who hassought careforrecurrentmigrainesthathavenotrespondedtotreatment.Followingthereview of systems, how should the nurse best document unremarkable results ofthe subjective portion of the gastrointestinal assessment?•“patient'sgastrointestinalhealthiswithinreferencerangesforage.”

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•“patientdeniesGIsignsandsymptoms.”•“Gastrointestinalproblemsareabsent.”•“patientdeniesrecent constipation,diarrhea,bowel incontinence,orabdominalpain.”•A 60-year-old woman with a bunion will undergo surgery later today. The patienttells thenurseinthesurgicaldaycareadmittingdepartment,“I'msureI'vebeenaskedthese questions before. Can't we just focus on my foot and not all these othertopics?” How should the nurse best explain the rationale for obtaining a healthhistory?•“Ingeneral,it'snecessaryforustogatherasmuchinformationabouteachpatientaspossible.”•“Wewanttomakesureyournursing carematchesyourneedsascloselyaspossible.”•“Thecareteamneedstocross-referenceyourdiagnostictestingwiththe information that I'm asking you about.”•“Wedon'twanttomakethemistakeoffocusingsolelyonthemedicalproblemthat brought you here.”•During the nurse's assessment of the patient's exercise and activity habits, the patientlaughsandthenstates,“Unlessyou'reincludingchannelsurfing,Idon'treallydomuch of anything.” How should the nurse best follow up this patient's statement?•Brieflydescribesomeofthe potentialbenefitsofregularexercise.•Askthepatientifheunderstandstheriskfactorsforheartdiseaseanddiabetes.•Explaintothepatientthatheshouldbeperformingaerobicexercisefor20to30 minutes at least three times a week.•DocumentthenursingdiagnosisofRiskforActivityIntolerancerelatedto sedentary lifestyle.•Anurseisobtainingsubjectivedatafromanadultpatientwhoisnewtotheclinic.The nurse has asked the patient, “Where do you usually turn for help in a time ofcrisis?” What domain is this nurse assessing?•Thepatient'sfamilyrelationships•Thepatient'scurrentlevel ofsocialandrelationalstability•Thepatient'scriticalthinkingandproblem-solvingabilities•Thepatient'sstressmanagementandcopingstrategiesAnswerKey•A•B

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•C•B•C•B•A•A•A•D•D•C•A•C•B•C•B•D•A•B•B•C•C•C•C, B, E, F, A,D•A, E,F•D•B•A•D•A patient has presented to the clinic for the treatment of an ovarian cyst. Which ofthe followingwouldbemostimportantforthenursetodoimmediatelybeforeperforming this woman's physical exam?•Explainthepurposeoftheinterviewtothepatient.•Constructthepatient'sfamilygenogram.•Establishthepatient'sreliabilityashistorian.•Collect necessary equipment essential to theexam.•A young adult patient has come to the clinic for her scheduled Pap (Papanicolaou)test and pelvic examination. The nurse is implementing actions to help reduce apatient's anxietyduringthephysicalexam.Whichofthefollowingwouldbemostappropriate?

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•Ensuringpatient'sprivacybyprovidinganexaminationgown•Providing a comfortable, warm roomtemperature•Arranging exam equipment on a bedside traytable•Explainingwhystandardprecautionsarebeingused•A nurse is admitting a new patient to the subacute medical unit and is completing acomprehensiveassessment.Thenurseisappropriatelyapplyingstandardprecautionsby performing which of the following actions?•Performinghand hygienebetween examinationsof eachbodypart•Discardingin thetrash canthe safetypin thatwasusedto assesssensoryperception•Wearingglovesto palpatethetongue andbuccalmembranes•Wearing a gown, gloves, and mask during the physicalexam•The nurse is using a Wood's light for a patient who has complaints of itching,burning, andpeelingoftheskinbetweenhistoes.Thenurseisassessingforwhatetiologyofthe patient's symptoms?•Parasiticinfection•Fungalinfection•Bacterialinfection•Allergicreaction•A nurse has gathered the necessary equipment for the physical assessment of anadult patient.Forwhichofthefollowingassessmentswoulditbemostappropriateforanurse to use a centimeter-scale ruler for measurement?•Mid-armcircumference•patient'sheight•Skin lesionsize•Pupillarysize•Thenurseispreparingtoassessanolderadultpatient'snearvision.Whichofthe following pieces of equipment would be most appropriate for the nurse touse?•Newspaper•Snellenchart•Ophthalmoscope•Penlight

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•Anursepractitionerisperformingacomprehensivephysicalexaminationofa51-year-old man. After performing a digital-rectal exam for prostate enlargement andtenderness, the nurse checks the fecal material on the gloved finger for the presenceof which of the following?•Parasites•Blood•Bacteria•Fungus•Thenurseisexamininganolderadultpatientandusingagoniometer.Whichofthe following would the nurse be assessing?•Extremityedema•Jointflexion/extension•Two-pointdiscrimination•Vibratorysensation•AfemalepatientistoldthatsheneedsapelvicexamandPapanicolaou(Pap)smear.She says ìAbsolutely not! There's no way I'll let you do that to me!î Which responseby the nurse would be most appropriate?•Explainthe importance of the pelvic exam and Pap smear, but respect thepatient'swishesandomittheexam.•Tellthe patient thatthisisthe onlyway she canbe checked forcancer.•Ask the patient if she would prefer another practitioner to perform theexam.•Proceedwiththepelvicexamanddocumentthepatient'sprotestsinthehealthrecord.•The nurse is preparing to perform a physical examination on a female patient whohas beentransferredtothemedicalunitfromtheemergencydepartment.Thenurseshould begin the collection of objective data with which of the followingexaminations?•Head and neckexamination•Palpation of lymphnodes•Breastexamination•Vitalsigns•The nurse is to collect a throat culture from a patient who has signs and symptoms ofa respiratoryinfection,includingfrequent,productivecoughing.Thenursedemonstrates the best adherence to standard precautions by using which of thefollowing pieces ofequipment?•Eyegoggles

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•Facemask•Covergown•Faceshield•The nurse ispreparing to perform the physical examination of an older adult patientwho willbeginrehabilitationfromanischemicstroke.Whichofthefollowingactionswould be most appropriate?•Omitintrusivepartsoftheexam.•Try to minimize positionchanges.•Allowpatienttoremaindressed.•Dim the room light to ensureprivacy.•Thenurseispreparingtoassesstheperipheralpulsesofapatient.Thenurseshouldplace the patient in which position?•Sittingupright•Supine•Simsposition•Prone•Whenassessingthetemperatureofthefeetofanolderpatientwithdiabetes,thenurse would use which part of the hand to obtain the most accurate assessmentdata?•Finger padsurface•Palmar handsurface•Dorsal handsurface•Ulnar handsurface•Apatienthasadocumentedhistoryofhepatomegaly(liverenlargement),andthenurse recognizes the need to perform deep palpation during the physicalassessment. The nurse should perform which of the following actions?•Useonehandand depresstheskin1centimeter.•Usethedominanthandtodepresstheskinone-halftothree-quartersofaninch.•Usebothhandstodepresstheskinone-halfofaninch.•Usebothhandstodepresstheskin1to2inches.•Theemergencydepartment(ED)nurseisassessingforkidneytendernessinapatient who has presented with complaints of dysuria and back pain. Whatassessment technique should the nurse utilize?•Deeppalpation

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•Indirectpercussion•Moderatepalpation•Bluntpercussion•Inthecourseofperformingapatient'sphysicalassessment,thenursehaschangedfrom using the diaphragm of the stethoscope to using the bell. The nurse is mostlikely assessing which of the following?•Heartsounds•Bowelsounds•Breathsounds•Femoralpulses•Aninstructoristeachingastudentabouttheproperuseofastethoscope.Theinstructor determines the need for additional teaching when the student states whichof thefollowing?•ìPlastic tubing should be longer than 3feet.î•ìThebell isused after using thediaphragm.î•ìWhen using the bell, push on itlightly.î•ìAdiaphragmpicksuplow-pitchedsounds.î•A nurse is preparing to perform the physical examination of an adult patient who haspresentedtotheclinicforthefirsttime.Whichofthefollowingstatementsshouldguide the nurse's use of a stethoscope during this phase of assessment?•Auscultation can be performed throughclothing.•The diaphragm should be held firmly against the bodypart.•The bell of the stethoscope can best detect bowelsounds.•Useof the bell isreserved for advanced practicenurses.•A nurse is appraising a colleague's assessment technique as part of a continuingeducationinitiative.Thenursedemonstratesthepropertechniqueforlightpalpationby performing which of the following actions?•Depressingtheskin1to2centimeterswiththedominanthand•Feelingthesurfacestructuresusingacircularmotion•Placing the nondominant hand on top of the dominanthand•Usingone hand to apply pressure and the other hand to feel thestructure•Thenurseispreparingtoexamineanolderadultpatient.Whichofthefollowingwould be most appropriate for the nurse to do during the examination?•Completethe examination asquicklyaspossible.•Speak clearly and slowly when explaining aprocedure.

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•Begin the examination with auscultation instead ofinspection.•Maintain the supine position for each part of theexamination.•Thenurseassistsapatientintothedorsalrecumbentposition.Assessmentofwhicharea is contraindicated when the patient is in this position?•Chest•Head•Peripheralpulses•Abdomen•Thenurseisgatheringthenecessaryequipmentpreparatorytoexaminingapatient'sears. The nurse will be checking bone and air conduction of sound. Which of thefollowing should the nurse obtain?•Penlight•Tonguedepressor•Tuningfork•Otoscope•The nurse is evaluating the setting prior to beginning a patient's physicalexamination. Thenurseshouldconfirmthepresenceofwhichofthefollowing?Selectallthatapply.•Adequatelighting•Cool roomtemperature•Quietsurroundings•Soft chair ortable•Table forequipment•Door orcurtain•Thenurseisusingherfingerpadstopalpateapatient'sbodypartduringthephysical examination. Which of the following would the nurse best be able todetect?•Temperature•Vibrations•Pulses•Fremitus•Anurseisreviewingthefourbasicphysicalexaminationtechniquesandtheirsequence prior to receiving a new patient from postanesthetic recovery. The nurseshould plan to perform which technique first?•Inspection

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•Palpation•Percussion•Auscultation•Thenurseispercussingtheareaoverthepatient'slungsandhearsaloud,low-pitched, hollow sound. The nurse documents this finding as which of thefollowing?•Flatness•Resonance•Tympany•Dullness•A 20-year-old female patient has presented to the clinic, and the nurse is preparing toperformacomprehensiveassessment.Thepatientstates,ìI'dreallyliketohavemymom in the room. That's okay, isn't it?î How should the nurse best respond to thepatient'srequest?•ìOfcourse. There'sa chairin theexam roomwhere shecansit.î•ìThat'sno problem.I'll justhave to getyou tosign aprivacy waiverfirst.î•ìThat'sfine,butbeawarethatsomeoftheexaminationsmightbeembarrassingfor you or her.î•ìIt'sbesttoundergotheexaminationaloneinordertomakesureIgetaccurate data, but if you really want her present, we can do that.î•The nurse is inspecting the dominant hand of an older adult patient and notes thepresenceofirregularlyshapedbrownlesionsonthedorsalsurfaceofthepatient'shand. What action should the nurse perform next?•Obtain a tissue sample forpathology•Comparetheappearanceofthepatient'sotherhand•Palpatethelesionsfortendernessandwarmth•Perform health promotion teaching about sunprotection•A young man has presented to the clinic with a 2-week history of headcongestion, fever,andmalaise.Whatassessmenttechniqueshouldthenurseutilizetoassessfor sinus tenderness?•Lightpalpation•Deeppalpation•Directpercussion•Bluntpercussion

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AnswerKey•D•A•C•B•C•A•B•B•A•D•D•B•B•C•D•D•A•C•B•B•B•D•C•A, C, E,F•C•A•B•A•B•C•Anurseiscompletingtheintakeassessmentofanolderadultwhohasjustrelocatedtoa long-termcarefacility.Whichofthefollowingnursingactionswouldbemostimportant to ensure accurate data when gathering the resident's information?•Documenting thedata•Validating thedata•Identifying patient supportsystems•Determining patientneeds

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•Anurseisassessingafemalepatientwhoseworseningsciaticahaspromptedhertoseek care. Which of the patient's following statements would the nurse most likelyneed tovalidate?•ìIdon'tgenerallyhaveproblemswithpain.î•ìI feel very weak and tired rightnow.î•ìI'vehad twocesareandeliveries.î•ìMy mother died of breast cancer in hersixties.î•A patient who had a mastectomy is being discharged home on postoperative day 1.Knowingthatthepatientlivesalone,whichdatawouldbemostimportantforthenurseto validate for this patient?•Ifthepatienthastransportationforfollow-upappointments•Ifthepatientusuallyfunctionsindependently•Whatsupportsystemsareinplace toassistthepatient•Ifthepatienthasareligiousbeliefregardingillness•When describing the importance of documenting initial assessment data to a groupof newnurses,whichofthefollowingwouldthenurseemphasizeastheprimaryreason?•Healthcareinstitutionshaveestablishedpoliciesregardingdocumentation.•Incorrectconclusionsmaybemadewithoutdocumentationofthenurse'sopinions.•Itsatisfieslegalstandardsestablishedbyhealthcareorganizationsandinstitutions.•Itbecomesthefoundation fortheentirenursingprocess.•Anursehasdocumentedthenursinghistoryandphysicalexaminationofapatient.This health information is best described as which of the following?•Subjective data and objectivedata•Interpretation andinference•Observation andinspection•Data andresults•The nurse is caring for a patient with influenza symptoms and is documenting theinitial andongoingassessmentdatabase.Whichofthefollowingwouldthenurseemphasizeas the major rationale for this action?•Reducingthe fragmentation ofcare•Maximizingthe efficiency ofcare•Promoting communication betweendisciplines•Facilitating achievement of professionalstandards

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•Anursehascompletedapatient'sinitialassessmentandisnowinterpretingandmaking inferencesfromthedata.Thenurseisinvolvedinwhichphaseofthenursingprocess?•Analysis•Planning•Implementation•Evaluation•A54-year-oldpatientisreceivingafollow-upassessmentinaclinic,followingabnormal findings on her recent mammogram. Which of the following statementsbest reflects appropriate documentation by the nurse?•ìpatient depressed because of fear of breastbiopsyî•ìpatient with lower backpainî•ìpatienthasunkemptappearanceandavoidseyecontactî•ìpatienthasgoodlungsoundsinrightandleftlungsî•Anurseisworkinginahealthcarefacilitythatuseschartingbyexception.Whichofthe following would the nurse expect to document?•Liver palpationnormal•Notendernessonpalpation•Bowelsoundsnormoactive•Decreased range of motion in rightshoulder•A task force has been established at a hospital with the aim of overhauling theassessmentformsthatareusedthroughoutthefacility.Whichofthefollowingoptionsis most likely to help standardize the process of data collection?•Open-endedform•Integrated cued checklistform•Cued or checklistform•Nursing minimum dataset•Anurseisprovidingin-service trainingto agroup ofnursesina facilitythat hasjust beguntouseanintegratedcuedchecklistfordocumentation.Whichofthefollowingwouldthenurseidentifyasamajoradvantageofthistypeofdocumentation?•Ithelpsnursestoclusterassessmentdata.•Itprovideslinesforthenurses'comments.•Itincludesspecializeddataparticulartoeachpatient.•Itstandardizesdatacollection.

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•A group of nursing students is reviewing the purposes of assessment documentationin preparation for a class discussion. The students demonstrate understanding of theinformationwhentheyidentifywhichofthefollowingasoneoftheprimarypurposes?•Itprovidesachronologicsourceofpatientassessmentdata.•Itcreatesa databaseforcare thatwasnot renderedtothepatient.•Itreplacesthepatientacuityclassificationsystem.•Itdirectlyformulatesthenursingdiagnoses.•A nurse is comparing the subjective data and objective data obtained from anassessmentofapatientwhoisthoughttohavehepatitisA.Thisnurse'scomparisonwill achieve what benefit to this patient's care?•Formulation of nursingdiagnoses•Identification of missingdata•Determination of documentation form touse•Validation ofdata•A nurse is preparing an in-service education program for a group of staff nursesabout documentation, including documentation of assessment data. The nursedemonstrates understandingofthesignificanceofdocumentationbyincludingadiscussionofwhich of the following as playing a role in this area? Select all thatapply.•JointCommission•State nurse practiceact•Medicare•Local or citygovernment•Institutionalagency•Anursehascompletedanassessmentofapatientwithcholecystitisandisaboutto document the findings. Which statement best reflects accuratedocumentation?•patientappearsupsetaboutupcomingsurgery.•patientwasinterviewedaboutprevioushistoryofhypertension.•Skin pale, warm, and dry without evidence oflesions.•patient'soralintakeissatisfactory.•Anurseisusinganursingminimumdatasettodocumentfindingsfollowingthe assessmentofapatient.Thisnurseismostlikelyprovidingcareinwhichsetting?•Acute carefacility•Long-term carefacility

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•Urgent carecenter•Healthclinic•Whileperformingtheinitialassessmentofapatient,thepatienttellsthenursethatthisis his first hospitalization and that he has no previous surgeries. The nurseshould document which of the following?•patientdeniespriorhospitalizationsandsurgeries•patienthasnotbeen hospitalized beforenor hashehad anysurgery•patientanswerednotoprevioushospitalizationsorsurgery•Negative for pasthospitalizations•An instructor is describing various ways that a nurse can validate data to a group ofnursingstudents.Theinstructordeterminesthatadditionalteachingisnecessarywhen the students identify which of the following as a reliable method?•Repeating theassessment•Asking additionalquestions•Havingthe patient repeatwhat wassaid•Checkingfindingswithanotherhealthcareprofessional•Anurseisworkingonanacuteneurologicalunit.Whichassessmentformwouldthe nurse most likely use to document assessment data?•Open-endedform•Focused assessmentform•Frequent assessmentform•Ongoing assessmentform•A group of students is reviewing information from class about the purposes ofassessmentdocumentation.Thestudentsdemonstrateunderstandingofthematerial when they state which of the following?•ìDocumentationhelpssupportreimbursementbutgiveslittleepidemiologicdata.î•ìDocumentationprovidesa permanentlegalrecord ofcaregiven andnotgiven.î•ìDocumentationisa viablemeansof communicationbutisrepetitious.î•ìDocumentationhelpsdeterminepatienteducationneedsbutnotstaffmix.î•Anurseisprovidingaverbalupdatetoapatient'sprimarycareproviderbecauseofthe patient'sworseningnausea.WhenusinganSBARformattoprovideareport,thenurse should complete the report with which of the following statements?•ìWhatwouldyouliketodotoaddressthispatient'snausea?î•ìIthink thispatient would benefitfrom anantiemetic.î

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•ìThispatienthasnorecent historyofany nauseaorvomiting.î•ìThispatientrateshisnauseaassevenoutoften.î•Asurgicalpatient'spainhasbecomeincreasinglysevereovernight,andshehasreceived her maximum current doses of analgesics. The nurse has consequentlyphoned the surgeon to obtain a new order for analgesia. After the surgeon tells thenurse the new order, how should the nurse best validate this information?•Read the order back to the surgeon forconfirmation.•Compare the order with the standard timing and dosage of theanalgesic.•Comparetheorder tothe patient'sexistingmedication administrationrecord(MAR).•Haveanother nurse read the orderthat the nurse hastranscribed.•An audit of a hospital unit's incident reports reveals that several errors have resultedfromincompleteorinaccurateinformationduringchange-of-shifthandoff.Inorderto prevent such errors, what practice should be encouraged on the unit?•Delegatehandoffreportstounlicensedcareproviderswhohavefewerdemandson their time.•Useanintermediarytoreceivereportfromthefirstnurseandthenprovidethe handoff report to the second nurse.•Involveasfewpeople aspossible inthe verbalreport.•Encouragenursestoperformhandoffasquicklyaspossible.•Apatienthasilluminatedhiscalllightandtellsthenursethatheishavingìtenoutoftenî pain.Thenurse'sinitialinspectionrevealsthatthepatientiswatchingvideosonhistablet computer and appears to be at ease physically and emotionally. How shouldthe nurse validate the patient's subjective complaint of pain?•Askthe patientto repeathisratingof hispain.•Observethepatientforseveralsecondstoseeifhisdemeanororhisbehaviorchanges.•Consultthepatient'smedicationadministrationrecord(MAR)tocheckforrecent analgesic use.•Performfurtherassessmentsaddressingvariousaspectsofthepatient'spain.•Ahospitalnurseisadmittingapatientwithadocumentedhistoryofacutepancreatitis, livercirrhosis,malnutrition,andfrequenttraumaticinjuries.Whatassessmentfinding would most clearly warrant validation?•Thepatient'sbloodpressureis148/88mmHg.•Thepatient isoriented to person and place but not totime.•Thepatientstatesthatsheonlydrinksalcoholonasocialbasis.•Thepatientstates,ìMyskin'skind ofyellowbecauseofmyliver.î

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•A small, rural hospital is revising the policies and procedures surroundingdocumentationinanefforttoalignpracticeswiththeHealthInformationTechnology for Economic and Clinical Health (HITECH) Act. How can therequirements of this legislation best be met?•Expand the use of the Nursing Minimum DataSet.•Eliminatetheuseofverbalhandoffsbetweennurses.•Increase interdisciplinary collaboration in thehospital.•Increasetheuse ofelectronic healthrecords(EHRs) inthehospital.•Thenurseisreviewingandanalyzingdatafromtheinitialassessmentofanewly admitted patient who is a 79-year-old man. What assessment findingmost clearly indicates a need for further data?•Theman hasmale patternbaldness.•Theman hasa diffuserash onhistorso.•Theman'sheartrateis63beatsperminute.•The man had an inguinal hernia repair in2008.•Therehasbeensomeresistancetotheplannedtransitiontoelectronichealthrecords (EHRs)inahospitalsystem,withmanycaregiversquestioningtherationaleforthis change in practice. What potential advantage of EHRs shouldadministrators cite?•Increased influence for the nursingprofession•Elimination ofdocumentation•Improved continuity ofcare•Reduced nursingworkload•While assisting an older adult with morning hygiene, the nurse notes a lesion on thepatient'scoccyxregion.Howshouldthenursebestdocumentthisobjectiveassessmentfinding?•ìPossiblepressureulcerobserved overpatient'scoccyxregion.î•ìReddenedareanoted onskinsurface superficialtopatient'scoccyx.î•ìAreaof nonblanchingerythema notedover patient'scoccyx, 2cm◊2cm.î•ìImpaired Skin Integrity related to decreasedmobility.î•A nurse is conscientious in adhering to the requirements of the Health InsurancePortabilityandAccountabilityAct(HIPAA)whenprovidingcareforpatients.What action best meets these legal requirements for care?•Havingacolleague auditthe nurse'sdocumentation toensureobjectivity•Maintainingtheprivacyandconfidentialityofpatients'medicalrecords•Usingelectronicrecordswheneverpossible,ratherthanpaper-basedrecords

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•Collaboratingwith thepatient and hisor her family prior todocumentingAnswerKey•B•A•C•D•A•C•A•C•D•C•A•A•D•A, B, C,E•C•B•A•C•B•B•B•A•C•D•C•D•B•C•C•B•A nurse has completed a comprehensive assessment of a patient and has begun theprocessofdataanalysis.Dataanalysisshouldallowthenursetoproducewhichofthe following direct results?•Outcomesevaluation•Nursingdiagnoses•Holisticinterventions

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•An interdisciplinary plan ofcare•A new nursing graduate recently made an oversight during the analysis of apatient's assessmentdatathatresultedinapostoperativecomplication.Whatcharacteristicof data analysis makes it a challenging aspect of nursing practice?•Abnormal data must beidentified.•Itrequirestheprioridentificationofnursingdiagnoses.•Itrequiressophisticateddiagnosticreasoningskills.•Conclusionsmustbeclearlyandaccuratelydocumented.•Ahospitalnursehasidentifiedaneedtoimprovehercriticalthinkingskillsinaneffort toimprovepatientcare.Thenurseshouldidentifywhichofthefollowingcharacteristics of critical thinking?•Itisaninnateskillthatsomeindividualspossessandwhichothersdonot.•Itdoesnot includepastexperiences.•Itisbased primarily on getting correct and timelyinformation.•Itinvolvesreflectionsonthoughtsbeforereachingconclusions.•Theemergencydepartmenthascollectedextensivedatafromapatientwhohaspresented with a new onset of severe abdominal pain. What nursing action should thenurse perform before proceeding with data analysis?•Validate the collecteddata.•Formulate a nursingdiagnosis.•Makeinferencesaboutthedata.•Identifythepatient'sstrengths.•Anursehascompletedapatient'sinitialassessmentandispreparingtoidentifyabnormal data and the patient's strengths. Successful completion of this phase of thenursing process most requires which of the following?•Knowledge of anatomy andphysiology•Awarenessofthepatient'smedicalprognosis•Inferencesaboutthepatient•Knowledge about the referralprocess•A nurse is planning a patient's care following the completion of an initialassessment. Whenformulatingarisknursingdiagnosis,whichpieceofdatawouldbemostuseful?•Thepatient hasan elevatedwhite blood cellcount.•Thepatientis66yearsofage.•Thepatient haspain in herjoints, especially in themorning.

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