Chapter 01: Critical Thinking in Health Assessment MULTIPLE CHOICE 1.

After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be: 1. objective. 2. reflective. 3. subjective. 4. introspective. ANS: 1 Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical exam. DIF: Comprehension REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he ³feels hot.´ This type of data would be: 1. objective. 2. reflective. 3. subjective. 4. introspective. ANS: 3 Subjective data are what the person says about himself or herself during history taking. DIF: Comprehension REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care

are more likely to make their decisions using: 1. The patient¶s record. validate the data by asking a coworker to listen to the breath sounds. ANS: 3 Validate any data that you need to make sure are accurate. 2. the nurse is unsure about a sound that is heard. admitting data. ask an expert to listen. ANS: 1 Together with the patient¶s record and laboratory studies. DIF: Knowledge REF: Page: 2 MSC: NCLEX: General 4. database. document the sound exactly as it was heard. If you have less experience in an area.3. discharge summary. intuition. 3. 4. The nurse should: 1. without a background of skills and experience to draw from. notify the patient¶s physician immediately. DIF: Analysis REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 5. and subjective data combine to form the: 1. 3. ANS: 2 Novice nurses operate from a set of rules (such as the nursing process). Novice nurses. DIF: Comprehension General REF: Pages: 2-3 MSC: NCLEX: . the objective and subjective data form the database. 3. 4. advice from supervisors. financial statement. When listening to a patient¶s breath sounds. objective data. articles in journals. laboratory studies. assess again in 20 minutes to note whether the sound is still present. 2. 4. a set of rules. 2.

A patient with postoperative pain 2.. establishing an airway.6. 4. apply theory in real situations. work with physicians to provide patient care.g. DIF: Comprehension General REF: Page: 3 MSC: NCLEX: 7. supporting breathing. follow physician orders in providing patient care. life-threatening. This is referred to as: 1. clinical knowledge. DIF: Comprehension General REF: Pages: 3-4 MSC: NCLEX: 8. 2. Critical thinking in the expert nurse is greatly enhanced by opportunities to: 1. ANS: 1 The depth and breadth of expert knowledge. intuition. diagnostic reasoning. 3. Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. and monitoring abnormal vital signs). An individual with shortness of breath and respiratory distress ANS: 4 First-level priority problems are those that are emergent. 4. greatly enhances a nurse¶s critical thinking ability. maintaining circulation. the nursing process. and immediate (e. An individual with a small laceration on the sole of the foot 4. ANS: 1 Intuition is characterized by pattern recognition²expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. develop nursing diagnoses for commonly occurring illnesses. 2. A newly diagnosed diabetic who needs diabetic teaching 3. largely gained from opportunities to apply theory in real situations. 3. DIF: Comprehension REF: Page: 5 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . Which of the following is an example of a first-level priority problem? 1.

Clustering related cues 3. Identifying gaps in data 4. admission diagnosis. DIF: Comprehension REF: Page: 5 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 10. collaborative diagnosis. Distinguishing relevant from irrelevant ANS: 2 Clustering related cues helps the nurse to see relationships among the data. acute pain. DIF: Comprehension General REF: Page: 5 MSC: NCLEX: 11. DIF: Comprehension REF: Page: 6 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . Abnormal laboratory values 4.. mental status change. 2. Low self-esteem 2. 3. Lack of knowledge 3. Which critical thinking skill helps the nurse to see relationships among the data? 1. or risks to safety or security). ANS: 1 An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the: 1. abnormal laboratory values. medical diagnosis. Second-level priority problems include which of the following? 1. Validation 2.g.9. nursing diagnosis. Severely abnormal vital signs ANS: 3 Second-level priority problems are those that require prompt intervention to forestall further deterioration (e. 4.

breathing ANS: 1 First-level priority problems are immediate priorities (remember the ABCs). implementation. and evaluation. A newly admitted patient is in acute pain. Medical diagnosis 3. evaluation. DIF: Comprehension REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 13. implementation. discharge. followed by second-level problems and then third-level problems. and is having difficulty breathing. evaluation. follow-up 2. How should the nurse prioritize these problems? 1. planning. The nursing process is a sequential method of problem solving that includes which five steps? 1. Sleep. discharge planning 4. treatment. the nursing process calls for a nursing diagnosis. has not been sleeping well lately. sleep. diagnosis.12. Breathing. Nursing diagnosis 2. Diagnostic assessment ANS: 3 Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis. diagnosis. pain. treatment. Breathing. Sleep. Assessment. sleep 2. diagnosis. discharge planning 3. diagnosis. pain 3. pain. Diagnostic hypothesis 4. planning. treatment. evaluation ANS: 4 The nursing process is a method of problem solving that includes assessment. assessment. Admission. Admission. DIF: Comprehension General REF: Page: 2 MSC: NCLEX: . Which of the following would be formulated by a nurse using diagnostic reasoning? 1. DIF: Analysis REF: Page: 6 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 14. breathing. Assessment. pain 4.

and interview? 1. would include underdiagnoses. physical examination. Evaluation 4. 3. ANS: 1 The biomedical model of Western tradition views health as the absence of disease. and interview.15. including performing the health history. What is the step of the nursing process that includes data collection by health history. 4. and identification of strengths. Diagnosis 3. Health and disease are considered a cyclical process. Health is viewed as the absence of disease. DIF: Knowledge REF: Page: 2 MSC: NCLEX: General 17. 2. 4. A nursing diagnosis made by a critical thinker using a dynamic nursing process would diagnose the actual problem and would also: 1. is the assessment step of the nursing process. Optimal health is viewed as high-level wellness. Assessment ANS: 4 Data collection. check the appropriateness of goals. 2. prediction of potential problems. as used by a critical thinker. DIF: Knowledge REF: Page: 7 MSC: NCLEX: General . Planning 2. diagnoses of actual problems. predict potential problems. continue to reassess. modify the diagnosis if necessary. The treatment of disease is nursing¶s primary focus. ANS: 2 A dynamic nursing process. 3. Which statement illustrates the biomedical model of Western traditional views? 1. DIF: Comprehension General REF: Page: 6 MSC: NCLEX: 16. physical examination.

Why is the concept of prevention essential in describing health? 1. Which of the following statements most accurately describes this change? 1. evaluate the response of the whole person to actual or potential health problems. but the public¶s concept of health has expanded since the 1950s. DIF: Knowledge REF: Page: 6 MSC: NCLEX: General . ANS: 1 The accurate diagnosis and treatment of illness are important parts of health care. exercise and nutrition. and nutrition are essential to health. exercise. Accurate diagnosis and treatment by a physician are essential for all health care. Assessment of health is critical to identifying disease-causing pathogens. ANS: 3 A natural progression to prevention now rounds out our concept of health. 4. evaluate the etiology of disease. and the social and natural environment. 2. 4. Disease can be prevented by treating the external environment. Lifestyle. personal habits. 3. The means to prevention is through treatment provided by primary health care practitioners. Which statement about nursing diagnoses is true? They: 1. ANS: 3 Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems. Guidelines to prevention place emphasis on the link between health and personal behavior.18. 2. focus on the function and malfunction of a specific organ system in response to disease. 4. are a process based on the medical diagnosis. DIF: Comprehension General REF: Page: 7 MSC: NCLEX: 19. Prevention places emphasis on the link between health and personal behavior. 3. We have an increasing interest in lifestyle. personal habits. An individual is considered healthy when signs and symptoms of disease have been eliminated. DIF: Comprehension General REF: Page: 7 MSC: NCLEX: 20. 3. The majority of deaths among Americans under age 65 years are not preventable. The public¶s concept of health has changed since the 1950s. 2.

21. percussing. college health service. In these settings the nurse is the first health professional to see the patient and has primary responsibility for monitoring the person¶s health care. 2. women¶s health care agency. A complete health database because of the nurse¶s primary responsibility for monitoring the patient¶s health 4. An episodic database because of the continuing. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. 4. 2 v 5 cm scar present on the right lower forearm. patient¶s history of allergies. patient¶s use of medications at home. An emergency database because of the need to rapidly collect information and make accurate diagnoses ANS: 3 The complete database is collected in a primary care setting. ANS: 4 Objective data are the patient¶s record. visiting nurse agency. and auscultating during the physical examination. and information that the health professional observes by inspecting. 3. laboratory studies. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . last menstrual period 1 month ago. palpating. complex medical problems of this patient 3. DIF: Application REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 22. Which type of database is most appropriate to collect in this setting? 1. or community health agency. A follow-up database to evaluate changes at appropriate intervals 2. An example of objective information obtained during the physical assessment includes the: 1. such as a pediatric or family practice clinic. independent or group private practice.

23. Simultaneously ask history questions while performing the examination and initiating life-saving measures. 2. The nurse should: 1. check only her blood pressure because her complete health history was documented 2 months ago. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. including social support patterns. the nurse collects a ³mini´ database. 3. 3. ask her to read her health record and indicate any changes since her last visit. ANS: 2 The emergency database calls for a rapid collection of the database. It concerns mainly one problem. A patient is at the clinic to have her blood pressure checked. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 25. Collect history information first. A patient¶s admission to the hospital for surgery the following day 4. 2. 4. severe shortness of breath 3. She has been coming to the clinic weekly since she changed medications 2 months ago. collect a follow-up database and then check her blood pressure. A patient¶s admission to a long-term care facility 2. one cue complex. Collect all information on the history form. ANS: 1 A follow-up database is used in all settings to follow up short-term or chronic health problems. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 24. then perform the physical examination and institute life-saving measures. A patient has sudden. How would the nurse proceed with the data collection? 1. Which situation is most appropriate for an episodic history? 1. or one body system. A patient in an outpatient clinic has cold and flu-like symptoms ANS: 4 In an episodic or problem-centered database. He is alert and cooperative. and coping patterns. obtain a complete health history before checking her blood pressure because much of her history information may have changed. strengths. 4. smaller in scope than the completed database. but his injuries are quite severe. DIF: Analysis REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . often compiled concurrently with life-saving measures. Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit.

DIF: Knowledge REF: Page: 7 MSC: NCLEX: Health Promotion and Maintenance . the focus of the health professional includes: 1. ANS: 4 The age-specific charts for the periodic health examination define a lifetime schedule of health care. changing the patient¶s perceptions of disease. In the health promotion model. make accurate disease diagnoses. 4. ANS: 4 The inclusion of cultural considerations in health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care. A 42-year-old Asian patient is being seen at the clinic for an initial examination. 2. 3. 4. provide cultural health rights for the individual. helping the consumer choose a healthier lifestyle. They are used to help identify the diagnosis of an illness.26. 4. 3. 3. They recommend that every individual receive an annual physical exam. 2. provide culturally sensitive and appropriate care. organized into packages for eight specific age groups. 2. DIF: Comprehension MSC: NCLEX: Psychosocial Integrity REF: Page: 10 28. The nurse knows that it is important to include cultural information in his health assessment to: 1. They list a frequency schedule for periodic health visits for a specific age group. DIF: Knowledge REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 27. Which statement correctly describes the age-specific charts for the periodic health examination? 1. identify the cause of his illness. identification of biomedical model interventions. They are helpful in identifying developmental delays in children. ANS: 4 In the health promotion model. identifying negative health acts of the consumer. the focus of the health professional is on helping the consumer choose a healthier lifestyle.

Evaluating previous problems and goals 3. not the nurse¶s perception or goals. Identifying potential problems the individual may develop 4. Anticipated growth and development patterns 3. During this step. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. 2. Evaluate the individual¶s condition and compare actual outcomes with expected outcomes. Identifying existing levels of wellness 2. A holistic model includes the patient¶s perception of his or her health status. Establish priorities. which of the following would be considered a risk diagnosis? 1. Nursing goals for the patient 2. Which of the following would be included in a holistic model of assessment? 1.29. A patient¶s perception of his or her health status 4. and spirit as functioning as a whole within the environment. Interpret data and then identify clusters of cues and make inferences. Which would be the next appropriate action? 1. When nursing diagnoses are being classified. ANS: 3 Evaluation is the next step after the implementation phase of the nursing process. body. DIF: Application REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . DIF: Comprehension REF: Page: 7 MSC: NCLEX: Health Promotion and Maintenance 30. 4. The nurse¶s perception of disease related to the patient ANS: 3 Holistic health views the mind. the nurse should evaluate the individual¶s condition and compare actual outcomes with expected outcomes. Focusing on strengths and reflecting an individual¶s transition to higher levels of wellness ANS: 3 Risk diagnoses are potential problems that an individual does not currently have but is particularly vulnerable to develop. Identify expected outcomes. DIF: Application REF: Page: 5 MSC: NCLEX: General 31. 3.

A nurse who understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient ANS: 4 The proficient nurse. A = first-level priority problem 2. A teenager who was stung by a bee during a soccer match is having trouble breathing. 2. Which term best describes a proficient nurse? 1. 1. is able to understand a patient situation as a whole rather than a list of tasks and is able to see how today¶s nursing actions apply to the point the nurse wants the patient to reach at a future time. with more time and experience than the novice nurse. A nurse who sees actions in the context of daily plans for patients 4.32. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution 3. 3. C = third-level priority problem 1. B = second-level priority problem 3. ANS: MSC: 3. A nurse who has little experience with a specified population and uses rules to guide performance 2. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. An older adult with a urinary tract infection is also showing signs of confusion and agitation. DIF: Application REF: Page: 3 MSC: NCLEX: General MATCHING Put the following patient situations in order according to level of priority: 1. ANS: MSC: 2 DIF: Analysis REF: Page: 5 NCLEX: Safe and Effective Care Environment: Management of Care 3 DIF: Analysis REF: Page: 5 NCLEX: Safe and Effective Care Environment: Management of Care 1 DIF: Analysis REF: Page: 5 NCLEX: Safe and Effective Care Environment: Management of Care . ANS: MSC: 2.

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