Test Bank For Medical-Surgical Nursing: Assessment And Management Of Clinical Problems, 8th Edition

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Lewis: Medical-Surgical Nursing, 8th EditionChapter 1: Contemporary Nursing PracticeTest BankMULTIPLE CHOICE1.The nurse has admitted a patient with a new diagnosis of pneumonia and explainedto the patient that together they will plan thepatient’scare and set goals for discharge.The patient says,“Howis that different from what the doctordoes?”Which responseby the nurse is most appropriate?a.“Theroleofthenurseistoadministermedicationsandothertreatmentsprescribedbyyourb.“Thenurse’sjobistohelpthedoctorbycollectingdataandcommunicatingwhentherearec.“Nursesperformmanyoftheproceduresdonebyphysicians,butnursesarehereinthehostimethandoctors.”d.“Inadditiontocaringforyouwhileyouaresick,thenurseswillassistyoutodevelopanintomaintainyourhealth.”ANS: DThis response is consistent with the American Nurses Association (ANA) definitionof nursing, which describes the role of nurses in promoting health. The otherresponses describe some of the dependent and collaborative functions of the nursingrole but do not accurately describe thenurse’srole in the health care system.DIF: Cognitive Level: Comprehension REF: 3TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment2.When providing patient care using evidence-based practice, the nurse usesa.clinicaljudgmentbasedonexperience.b.evidencefromaclinicalresearchstudy.c.evidence-basedguidelinesinadditiontoclinicalexpertise.d.evaluationofdatashowingthatthepatientoutcomesaremet.ANS: CEvidence-based practice (EBP) is the use of the best research-based evidencecombined with clinician expertise. Clinical judgment based on thenurse’sclinicalexperience is part of EBP, but clinical decision making also should incorporatecurrent research and research-based guidelines. Evidence from one clinical researchstudy does not provide an adequate substantiation for interventions. Evaluation of

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patient outcomes is important, but interventions should be based on research fromrandomized control studies with a large number of subjects.DIF: Cognitive Level: Comprehension REF: 6-8 TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment3.The nurse primarily uses the nursing process in the care of patientsa.toexplainnursinginterventionstootherhealthcareprofessionalsb.asaproblem-solvingtooltoidentifyandtreatpatients’healthcareneedsc.asascientific-basedprocessofdiagnosingthepatient’shealthcareproblemsd.toestablishnursingtheorythatincorporatesthebiopsychosocialnatureofhumansANS: BThe nursing process is a problem-solving approach to the identification and treatmentofpatients’problems. Diagnosis is only one phase of the nursing process. Theprimary use of the nursing process is in patient care, not to establish nursing theory orexplain nursing interventions to other health care professionals.DIF: Cognitive Level: Comprehension REF: 10TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment4.The nurse plans an every 2-hour turning schedule to prevent skin breakdown for acritically ill patient in the intensive care unit. In this case, the nursing action isconsidered to bea.dependent.b.cooperative.c.independent.d.collaborative.ANS: DWhen implementing collaborative nursing actions, the nurse is responsible primarilyfor monitoring for complications of acute illness or providing care to prevent or treatcomplications. Independent nursing actions are focused on health promotion, illnessprevention, and patient advocacy. A dependent action would require a physician orderto implement. Cooperative nursing functions are not described as one of the formalnursing functions.DIF: Cognitive Level: Application REF: 10-11TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

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5.A patient who has been admitted to the hospital for surgery tells the nurse,“Ido notfeel right about leaving my children with myneighbor.”Which action should thenurse take next?a.Reassurethepatientthatthesefeelingsarecommonforparents.b.Havethepatientcallthechildrentoensurethattheyaredoingwell.c.Calltheneighbortodeterminewhetheradequatechildcareisbeingprovided.d.Gathermoredataaboutthepatient’sfeelingsaboutthechildcarearrangements.ANS: DSince a complete assessment is necessary in order to identify a problem and choose anappropriate intervention, thenurse’sfirst action should be to obtain more information.The other actions may be appropriate, but more assessment is needed before the bestintervention can be chosen.DIF: Cognitive Level: Application REF: 11TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity6.A patient with a stroke is paralyzed on the left side of the body and has developed apressure ulcer on the left hip. The best nursing diagnosis for this patient isa.impairedphysicalmobilityrelatedtoleft-sidedparalysis.b.riskforimpairedtissueintegrityrelatedtoleft-sidedweakness.c.impairedskinintegrityrelatedtoalteredcirculationandpressure.d.ineffectivetissueperfusionrelatedtoinabilitytomoveindependently.ANS: CThepatient’smajor problem is the impaired skin integrity as demonstrated by thepresence of a pressure ulcer. The nurse is able to treat the cause of altered circulationand pressure by frequently repositioning the patient. Although left-sided weakness is aproblem for the patient, the nurse cannot treat the weakness. The“riskfor”diagnosisis not appropriate for this patient, who already has impaired tissue integrity. Thepatient does have ineffective tissue perfusion, but the impaired skin integrity diagnosisindicates more clearly what the health problem is.DIF: Cognitive Level: Application REF: 11 TOP: Nursing Process: DiagnosisMSC: NCLEX: Physiological Integrity

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7.A patient with an infection has a nursing diagnosis of deficient fluid volume relatedto excessive diaphoresis. An appropriate patient outcome identified by the nurse isthat thea.patienthasabalancedintakeandoutput.b.patient’sbeddingischangedwhenitbecomesdamp.c.patientunderstandstheneedforincreasedfluidintake.d.patient’sskinremainscoolanddrythroughouthospitalization.ANS: AThis statement gives measurable data showing resolution of the problem of deficientfluid volume that was identified in the nursing diagnosis statement. The otherstatements would not indicate that the problem of deficient fluid volume was resolved.DIF: Cognitive Level: Application REF: 13 TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity8.A nursing activity that is carried out during the evaluation phase of the nursingprocess isa.determiningifinterventionshavebeeneffectiveinmeetingpatientoutcomes.b.documentingthenursingcareplanintheprogressnotesinthemedicalrecord.c.decidingwhetherthepatient’shealthproblemshavebeencompletelyresolved.d.askingthepatienttoevaluatewhetherthenursingcareprovidedwassatisfactory.ANS: AEvaluation consists of determining whether the desired patient outcomes have beenmet and whether the nursing interventions were appropriate. The other responses donot describe the evaluation phase.DIF: Cognitive Level: Comprehension REF: 16 TOP: Nursing Process: EvaluationMSC: NCLEX: Safe and Effective Care Environment9.During the assessment phase of the nursing process, the nursea.obtainsdatawithwhichtodiagnosepatientproblems.b.usespatientdatatodevelopprioritynursingdiagnoses.c.teachesinterventionstorelievepatienthealthproblems.d.helpsthepatientidentifyrealisticoutcomestohealthproblems.ANS: A

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During the assessment phase, the nurse gathers information about the patient. Theother responses are examples of the intervention, diagnosis, and planning phases ofthe nursing process.DIF: Cognitive Level: Knowledge REF: 11TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment10.An example of a correctly written nursing diagnosis statement isa.alteredtissueperfusionrelatedtoheartfailure.b.riskforimpairedtissueintegrityrelatedtosacralredness.c.ineffectivecopingrelatedtoresponsetobiopsytestresults.d.alteredurinaryeliminationrelatedtourinarytractinfection.ANS: CThis diagnosis statement includes a NANDA nursing diagnosis and an etiology thatdescribes apatient’sresponse to a health problem that can be treated by nursing. Theuse of a medical diagnosis (as in the responses beginning“Altered tissueperfusion”and“Alteredurinaryelimination”)is not appropriate. The response beginning“Riskfor impaired tissueintegrity”uses the defining characteristics as the etiology.DIF: Cognitive Level: Comprehension REF: 11-13 TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment11.The nurse writes a complete nursing diagnosis statement by includinga.aproblemandthesuggestedpatientgoalsoroutcomes.b.aproblem,itscause,andobjectivedatathatsupporttheproblem.c.aproblemwithallitspossiblecausesandtheplannedinterventions.d.aproblemwithitsetiologyandthesignsandsymptomsoftheproblem.ANS: DThe PES format is used when writing nursing diagnoses. The subjective, as well asobjective, data should be included in the defining characteristics. Interventions andoutcomes are not included in the nursing diagnosis statement.DIF: Cognitive Level: Knowledge REF: 11-13 TOP: Nursing Process: DiagnosisMSC: NCLEX: Safe and Effective Care Environment12.Using the Situation-Background-Assessment-Recommendation (SBAR) format, inwhich order should the nurse make these statements to communicate a change inpatient status to a health care provider?

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a.Mr.Awasadmitted2daysagowithheartfailureandhasbeenreceivingfurosemide(Lasixbuthisurineoutputhasbeenlow.b.Ithinkthatheneedstobeevaluatedimmediatelyandmayneedintubationandmechanicalc.Thisisthenurseonthesurgicalunit.IamcallingaboutMr.Ainroom3.Afterassessinghconcernedabouthisshortnessofbreath.d.Today,hehascracklesaudiblethroughouttheposteriorchestandhisO2saturationis89%veryunstable.ANS: CA, D, BThe order of thenurse’sstatements follows the SBAR format.DIF: Cognitive Level: Application REF: 5-6TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment13.Which of these nursing actions for the patient with heart failure is appropriate forthe nurse to delegate to experienced nursing assistive personnel (NAP)?a.Assessforshortnessofbreathorfatigueafterambulation.b.Instructthepatientabouttheneedtoalternateactivityandrest.c.Obtainthepatient’sbloodpressureandpulserateafterambulation.d.Determinewhetherthepatientisreadytoincreasetheactivitylevel.ANS: CNAP education includes accurate vital sign measurement. Assessment and patientteaching require RN education and scope of practice and cannot be delegated.DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment14.Which action by a newly graduated RN working on the postsurgical unit indicatesthat more education about delegation and assignment is needed?a.ThenursedelegatesmeasurementofpatientoralintakeandurineoutputtoNAP.b.Thenursedelegatesassessmentofapatient’sbowelsoundstoexperiencedNAP.c.ThenurseassignsanLPN/LVNtoadministeroralmedicationstoseveralpatients.d.Thenurseassignsa“float”RNfrompediatricstocareforapatientwithdiabetes.ANS: BAssessment requires RN education and scope of practice and cannot be delegated toNAP. The other actions by the new RN are appropriate.

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DIF: Cognitive Level: Application REF: 15-16 | eFig. 1-1OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment15.Which of these tasks is appropriate for the registered nurse to delegate to alicensed practical/vocational nurse?a.Performasteriledressingchangeforaninfectedwound.b.Completetheinitialadmissionassessmentandplanofcare.c.Teachapatientabouttheeffectsofprescribedmedications.d.Documentpatientteachingaboutaroutinesurgicalprocedure.ANS: AThe education and scope of practice of the LPN/LVN include activities such as steriledressing changes. Patient teaching and the initial assessment and development of theplan of care are nursing actions that require RN-level education and scope of practice.DIF: Cognitive Level: Comprehension REF: 15OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care EnvironmentChapter 2: Health Disparities andCulturally Competent CareLewis: Medical-Surgical Nursing, 8th EditionChapter 2: Health Disparities and Culturally Competent CareTest BankMULTIPLE CHOICE1.The nurse obtains information about all these areas during the health interview for anew patient. Which area will be the focus of patient teaching?a.Ageandgenderb.Hispanic/Latinoethnicityc.Familyhistoryofdiabetesd.RefinedcarbohydrateintakeANS: DBehaviors are strongly linked to many health care problems. Thepatient’scarbohydrate intake is a behavior that the patient can change. The other information

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will be useful as the nurse develops an individualized plan for improving thepatient’shealth, but will not be the focus of patient education.DIF: Cognitive Level: Application REF: 20-21 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance2.When developing strategies to decrease health care disparities, the nurse working ina clinic located in a neighborhood with many Vietnamese individuals will includea.improvingpublictransportation.b.obtaininglow-costmedications.c.updatingequipmentandsuppliesfortheclinic.d.educatingstaffaboutVietnamesehealthbeliefs.ANS: DHealth care disparities are due to stereotyping, biases, and prejudice of health careproviders; the nurse can decrease these through staff education. The other strategiesalso may be addressed by the nurse but will not impact health disparities.DIF: Cognitive Level: Application REF: 21-23 | 32 TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance3.Which information will the nurse need to collect when assessing the health status ofa community?a.Averageincomeofcommunitymembersb.Morningtrafficpatternsinthecommunityc.Medianlifeexpectancyforthecommunityd.OccupationsofindividualsinthecommunityANS: CHealth status is the aggregate of all health measures for individuals in a communityand includes data such as life expectancy, birth and death rates, and mortality fromvarious diseases. Although income, traffic patterns, and occupations are factors thatimpact acommunity’shealth status, they are not health measures.DIF: Cognitive Level: Comprehension REF: 20-21TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance4.A family member of an elderly Hispanic patient admitted to the hospital tells thenurse that the patient has traditional beliefs about health and illness. The best actionby the nurse is to

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a.avoidaskinganyquestionsunlessthepatientinitiatesconversation.b.askthepatientwhetheritisimportantthatculturalhealersarecontacted.c.explaintheusualhospitalroutinesformealtimes,care,andfamilyvisits.d.obtainfurtherinformationaboutthepatient’sculturalbeliefsfromthedaughter.ANS: BBecause the patient has traditional health care beliefs, it is appropriate for the nurse toask whether the patient would like a visit by acurandero(a)or other cultural healers.There is no cultural reason for the nurse to avoid asking the patient questions, andquestions may be necessary to obtain necessary health information. The patient (ratherthan the daughter) should be consulted about personal cultural beliefs. The hospitalroutines for meals, care, and visits should be adapted to thepatient’spreferencesrather than expecting the patient to adapt to the hospital schedule.DIF: Cognitive Level: Application REF: 26TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity5.When caring for a patient who is Native American, the best initial action by thenurse is toa.avoidalleyecontactwiththepatient.b.observethepatient’suseofeyecontact.c.lookdirectlyatthepatientwheninteracting.d.askthefamilyaboutthepatient’sculturalbeliefs.ANS: BObservation of thepatient’suse of eye contact will be most useful in determining thebest way to communicate effectively with the patient. Looking directly at the patientor avoiding eye contact may be appropriate, depending on thepatient’sindividualcultural beliefs. The nurse should assess the patient, rather than asking familymembers about thepatient’sbeliefs.DIF: Cognitive Level: Application REF: 24 | 27-28TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity6.A new RN graduate is assessing a newly admitted non–English-speaking Chinesepatient who complains of severe headaches. The charge nurse should intervene if thenewRN’sfirst action is toa.sitdownatthebedside.

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b.palpatethepatient’sscalp.c.callforamedicalinterpreter.d.avoideyecontactwiththepatient.ANS: BMany people of Asian ethnicity believe that touching aperson’shead is disrespectful;the RN should ask permission before touching thepatient’shead. The other actionsare appropriate.DIF: Cognitive Level: Application REF: 29TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity7.If an interpreter is not available when a patient speaks a language different from thenurse’slanguage, it is appropriate for the nurse toa.usespecificmedicaltermsintheLatinform.b.talkslowlysothateachwordisclearlyheard.c.repeatimportantwordssothatthepatientrecognizestheirimportance.d.usesimplegesturestodemonstratemeaningwhiletalkingtothepatient.ANS: DThe use of gestures will enable some information to be communicated to the patient.The other actions will not improve communication with the patient.DIF: Cognitive Level: Comprehension REF: 34TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity8.When planning care for a hospitalized patient who uses culturally based treatments,the most appropriate action by the nurse is toa.coordinatetheuseoffolktreatmentswithorderedmedicaltherapies.b.discouragetheuseofculturallybasedtreatmentsforWesterndiseases.c.teachthepatientthatfolkremedieswillinterferewithWesterntreatments.d.askthepatienttodiscontinuetheculturaltreatmentsduringhospitalization.ANS: AMany culturally based therapies can be accommodated along with the use of Westerntreatments and medications. The nurse should attempt to use both traditional folktreatments and the ordered Western therapies as much as possible. Some culturallybased treatments can be effective in treating“Western”diseases. Not all folk remedies

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interfere with Western therapies. It may be appropriate for the patient to continuesome culturally based treatments while he or she is hospitalized.DIF: Cognitive Level: Comprehension REF: 30-31 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity9.The best example of culturally appropriate nursing care when caring for a newlyadmitted patient isa.havingfamilymembersprovidemostofthepatient’spersonalcare.b.maintainingapersonalspaceofatleast2feetwhenassessingthepatient.c.askingpermissionbeforetouchingapatientduringthephysicalassessment.d.consideringthepatient’sethnicityasthemostimportantfactorinplanningcare.ANS: CMany cultures consider it disrespectful to touch a patient without asking permission,so asking a patient for permission is always culturally appropriate. The other actionsmay be appropriate for some patients but are not appropriate across all cultural groupsor for all individual patients.DIF: Cognitive Level: Comprehension REF: 29TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity10.While talking with the nursing supervisor, a staff nurse expresses frustration that aNative American patient always has several family members at the bedside. The mostappropriate action by the nursing supervisor is toa.remindthenursethatfamilysupportisimportanttothisfamilyandpatient.b.havethenurseexplaintothefamilythattoomanyvisitorswilltirethepatient.c.suggestthatthenurseaskfamilymemberstoleavetheroomduringpatientcare.d.askaboutthenurse’spersonalbeliefsaboutfamilysupportduringhospitalization.ANS: DThe first step in providing culturally competent care is to understandone’sownbeliefs and values related to health and health care. Asking the nurse about personalbeliefs will help to achieve this step. Reminding the nurse that this cultural practice isimportant to the family and patient will not decrease thenurse’sfrustration. Theremaining responses (suggest that the nurse ask family members to leave the room,and have the nurse explain to family that too many visitors will tire the patient) are notculturally appropriate for this patient.

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DIF: Cognitive Level: Application REF: 31TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity11.An 82-year-old Asian American patient tells the nurse that she has lived in theUnited States for 50 years. The patient speaks English but lives in a predominantlyAsian neighborhood. The nurse will need toa.includeafolkhealerwhenplanningthepatient’scare.b.askthepatientaboutanyspecialculturalbeliefsorpractices.c.avoidmakingdirecteyecontactwiththepatientduringcare.d.involvethepatient’soldestsoninmakinghealthcaredecisions.ANS: BFurther assessment of thepatient’shealth care preferences is needed before makingfurther plans for culturally appropriate care. The other responses indicate stereotypingof the patient, based on ethnicity, and would not be appropriate initial actions.DIF: Cognitive Level: Application REF: 25 | 32 TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity12.When planning health care for a community with a large number of recentimmigrants from China, the most important intervention for the nurse to include isa.pregnancytesting.b.tuberculosisscreening.c.contraceptiveteaching.d.colonoscopyinformation.ANS: BTuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is muchhigher in immigrants from China than in the general U.S. population. Teaching aboutcontraceptive use, colonoscopy, and testing for pregnancy also may be appropriate forsome patients but is not generally indicated for all members of this community.DIF: Cognitive Level: Application REF: 29-30 TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity13.When doing an admission assessment for a patient, the nurse notices that thepatient pauses before answering questions about the health history. The mostappropriate action by the nurse is toa.stopdoingtheassessmentandreturnlater.

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b.waitforthepatienttoanswerthequestions.c.askthepatientwhythequestionsrequiresomuchtimetoanswer.d.givethepatientanassessmentformlistingthequestionsandapen.ANS: BPatients from some cultures take time to consider a question carefully beforeanswering. The nurse will show respect for the patient and help develop a trustingrelationship by allowing the patient time to give a thoughtful answer. Asking thepatient why the answers are taking so much time, stopping the assessment, andhanding the patient a form indicate that the nurse does not have time for the patient.DIF: Cognitive Level: Application REF: 28TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity14.Which of these strategies should be a priority when the nurse is planning care for ahypertensive patient who is uninsured?a.Followevidence-basednationalguidelines.b.Assistwithdietarychangesasthefirstaction.c.Teachabouttheimpactofexerciseonhypertension.d.Obtainlessexpensiveantihypertensivemedications.ANS: AThe use of standardized evidence-based guidelines will reduce the incidence of healthcare disparities among various socioeconomic groups. The other strategies also maybe appropriate, but the priority concern should be that the patient receives care thatmeets the accepted standard.DIF: Cognitive Level: Application REF: 32OBJ: Special Questions: Prioritization TOP: Nursing Process: PlanningMSC: NCLEX: Health Promotion and Maintenance15.A Hispanic patient complains of abdominal cramping caused byempacho.Thenurse’sfirst action should be toa.askthepatientwhattreatmentsarelikelytohelp.b.givethepatientmedicationtodecreasethecramping.c.massagethepatient’sabdomenuntilthepainisgone.d.offertocontactacurandero(a)tomakeavisittothepatient.ANS: A

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Further assessment of thepatient’scultural beliefs is appropriate before implementingany interventions for a culture-bound syndrome such asempacho.Althoughmedication, a visit by acurandero(a),or massage may be helpful, more informationabout thepatient’sbeliefs is needed to determine which intervention(s) will be mosthelpful.DIF: Cognitive Level: Application REF: 25 | 31-32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity16.When performing a cultural assessment with a patient of a different culture, thenurse’sfirst action should be toa.waituntilaculturalhealerisavailabletohelpwiththeassessment.b.obtainalistofanyculturalremediesthatthepatientcurrentlyuses.c.askthepatientaboutanyaffiliationwithaparticularculturalgroup.d.tellthepatientwhatthenursealreadyknowsaboutthepatient’sculture.ANS: CAn early step in performing a cultural assessment is to determine whether the patientfeels an affiliation with any cultural group. The other actions may be appropriate if thepatient does identify with a particular culture.DIF: Cognitive Level: Application REF: 32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity17.The nurse working in a clinic in a primarily African American community notes ahigher incidence of uncontrolled hypertension in clinic patients than the nationalaverage. To correct this health disparity, which action should the nurse take first?a.Initiatearegularhome-visitprogrambynursesworkingattheclinic.b.Scheduleteachingsessionsabouthypertensionatcommunityevents.c.Assesstheperceptionsofcommunitymembersaboutthecareattheclinic.d.Obtainlow-costantihypertensivedrugsusingfundingfromgovernmentgrants.ANS: CBefore other actions are taken, additional assessment data are needed to determine thereason for the disparity. The other actions also may be appropriate, but additionalassessment is needed before the next action is selected.

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DIF: Cognitive Level: Application REF: 31-32OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Health Promotion and MaintenanceChapter 3: Health HistoryandPhysical ExaminationLewis: Medical-Surgical Nursing, 8th EditionChapter 3: Health History and Physical ExaminationTest BankMULTIPLE CHOICE1.A patient who is having difficulty breathing is admitted to the hospital. The bestapproach for the nurse to use to obtain a complete health history is toa.obtainsubjectivedataaboutthepatientfromfamilymembers.b.omitsubjectivedatacollectionandobtainthephysicalexamination.c.usethehealthcareprovider’smedicalhistorytoobtainsubjectivedata.d.scheduleseveralshortsessionswiththepatienttogathersubjectivedata.ANS: DIn an emergency situation, the nurse may need to ask only the most pertinentquestions for a specific problem and obtain more information later. A complete healthhistory will include subjective information that is not available in the health careprovider’smedical history. Family members may be able to provide some subjectivedata, but only the patient will be able to give subjective information about theshortness of breath. Since the subjective data about thepatient’srespiratory status willbe essential, obtaining the physical examination alone will not provide sufficientinformation.DIF: Cognitive Level: Application REF: 38TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance2.Immediate surgery is planned for a patient with acute abdominal pain. The questionused by the nurse that will elicit the most complete information about thepatient’scoping-stress tolerance pattern isa.“Canyoutellmehowintenseyourpainisnow?”b.“Whatdoyouthinkcausedthisabdominalpain?”

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