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Chapter 01: Critical Thinking in Health Assessment Text Bank 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 “feels 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
and subjective data combine to form the: 1. assess again in 20 minutes to note whether the sound is still present. laboratory studies.3. Novice nurses. database. the objective and subjective data form the database. are more likely to make their decisions using: 1. discharge summary. a set of rules. admitting data. DIF: Analysis REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 5. ANS: 2 Novice nurses operate from a set of rules (such as the nursing process). 2. document the sound exactly as it was heard. The patient’s record. the nurse is unsure about a sound that is heard. DIF: Knowledge REF: Page: 2 MSC: NCLEX: General 4. 4. financial statement. 2. 4. without a background of skills and experience to draw from. 2. When listening to a patient’s breath sounds. ANS: 3 Validate any data that you need to make sure are accurate. advice from supervisors. objective data. 4. If you have less experience in an area. ANS: 1 Together with the patient’s record and laboratory studies. 3. The nurse should: 1. 3. 3. DIF: Comprehension REF: Pages: 2-3 MSC: NCLEX: General . validate the data by asking a coworker to listen to the breath sounds. notify the patient’s physician immediately. articles in journals. intuition. ask an expert to listen.
3. diagnostic reasoning. 2. the nursing process. Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. Critical thinking in the expert nurse is greatly enhanced by opportunities to: 1. and monitoring abnormal vital signs). largely gained from opportunities to apply theory in real situations. 4.13 6. life-threatening. greatly enhances a nurse’s critical thinking ability. intuition. An individual with a small laceration on the sole of the foot 4. maintaining circulation. supporting breathing. follow physician orders in providing patient care. A patient with postoperative pain 2. An individual with shortness of breath and respiratory distress ANS: 4 First-level priority problems are those that are emergent. work with physicians to provide patient care. apply theory in real situations. and immediate (e.g. 4. Which of the following is an example of a first-level priority problem? 1. clinical knowledge. DIF: Comprehension REF: Page: 5 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . ANS: 1 Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it.. DIF: Comprehension REF: Pages: 3-4 MSC: NCLEX: General 8. 3. This is referred to as: 1. ANS: 1 The depth and breadth of expert knowledge. establishing an airway. 2. DIF: Comprehension REF: Page: 3 MSC: NCLEX: General 7. develop nursing diagnoses for commonly occurring illnesses. A newly diagnosed diabetic who needs diabetic teaching 3.
or risks to safety or security). 4. collaborative diagnosis. abnormal laboratory values. Second-level priority problems include which of the following? 1. medical diagnosis. 2. 3.g. admission diagnosis. Identifying gaps in data 4. Severely abnormal vital signs ANS: 3 Second-level priority problems are those that require prompt intervention to forestall further deterioration (e. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the: 1. nursing diagnosis. Low self-esteem 2. Validation 2. ANS: 1 An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. DIF: Comprehension REF: Page: 5 MSC: NCLEX: General 11. Lack of knowledge 3. mental status change.15 9. acute pain. DIF: Comprehension REF: Page: 6 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . Distinguishing relevant from irrelevant ANS: 2 Clustering related cues helps the nurse to see relationships among the data. DIF: Comprehension REF: Page: 5 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 10.. Clustering related cues 3. Abnormal laboratory values 4. Which critical thinking skill helps the nurse to see relationships among the data? 1.
diagnosis. evaluation ANS: 4 The nursing process is a method of problem solving that includes assessment. the nursing process calls for a nursing diagnosis. and is having difficulty breathing. Assessment. How should the nurse prioritize these problems? 1.17 12. DIF: Comprehension REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 13. planning. treatment. followed by second-level problems and then third-level problems. diagnosis. pain 4. treatment. Medical diagnosis 3. discharge planning 3. has not been sleeping well lately. Nursing diagnosis 2. planning. The nursing process is a sequential method of problem solving that includes which five steps? 1. diagnosis. pain. sleep 2. breathing. pain 3. discharge planning 4. DIF: Analysis REF: Page: 6 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 14. Admission. follow-up 2. assessment. Admission. implementation. Sleep. Which of the following would be formulated by a nurse using diagnostic reasoning? 1. Breathing. Sleep. Diagnostic assessment ANS: 3 Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis. DIF: Comprehension REF: Page: 2 MSC: NCLEX: General . diagnosis. evaluation. and evaluation. Diagnostic hypothesis 4. sleep. discharge. pain. treatment. evaluation. breathing ANS: 1 First-level priority problems are immediate priorities (remember the ABCs). implementation. Breathing. A newly admitted patient is in acute pain. Assessment.
modify the diagnosis if necessary. 2. continue to reassess. 4. would include underdiagnoses. DIF: Knowledge REF: Page: 7 MSC: NCLEX: General . and identification of strengths. Health is viewed as the absence of disease. predict potential problems. prediction of potential problems. physical examination. 3. diagnoses of actual problems. Health and disease are considered a cyclical process.19 15. check the appropriateness of goals. and interview. Planning 2. Diagnosis 3. A nursing diagnosis made by a critical thinker using a dynamic nursing process would diagnose the actual problem and would also: 1. 3. is the assessment step of the nursing process. Assessment ANS: 4 Data collection. ANS: 2 A dynamic nursing process. including performing the health history. The treatment of disease is nursing’s primary focus. 4. Optimal health is viewed as high-level wellness. ANS: 1 The biomedical model of Western tradition views health as the absence of disease. 2. Evaluation 4. DIF: Comprehension REF: Page: 6 MSC: NCLEX: General 16. DIF: Knowledge REF: Page: 2 MSC: NCLEX: General 17. physical examination. Which statement illustrates the biomedical model of Western traditional views? 1. and interview? 1. as used by a critical thinker. What is the step of the nursing process that includes data collection by health history.
Assessment of health is critical to identifying disease-causing pathogens. evaluate the etiology of disease. Lifestyle. Accurate diagnosis and treatment by a physician are essential for all health care. The majority of deaths among Americans under age 65 years are not preventable. 4.18. are a process based on the medical diagnosis. We have an increasing interest in lifestyle. Which statement about nursing diagnoses is true? They: 1. Why is the concept of prevention essential in describing health? 1. 2. An individual is considered healthy when signs and symptoms of disease have been eliminated. Disease can be prevented by treating the external environment. ANS: 3 . The means to prevention is through treatment provided by primary health care practitioners. DIF: Comprehension REF: Page: 7 MSC: NCLEX: General 19. 4. 2. exercise. personal habits. focus on the function and malfunction of a specific organ system in response to disease. and the social and natural environment. and nutrition are essential to health. 3. personal habits. 2. The public’s concept of health has changed since the 1950s. DIF: Comprehension REF: Page: 7 MSC: NCLEX: General 20. Guidelines to prevention place emphasis on the link between health and personal behavior. evaluate the response of the whole person to actual or potential health problems. Which of the following statements most accurately describes this change? 1. Prevention places emphasis on the link between health and personal behavior. ANS: 1 The accurate diagnosis and treatment of illness are important parts of health care. exercise and nutrition. 4. 3. ANS: 3 A natural progression to prevention now rounds out our concept of health. 3. but the public’s concept of health has expanded since the 1950s.
DIF: Knowledge REF: Page: 6 MSC: NCLEX: General 11 1 or .Nursing diagnoses are used to evaluate the response of the whole person to actual potential health problems.
or community health agency. An example of objective information obtained during the physical assessment includes the: 1. college health service. laboratory studies. complex medical problems of this patient 3. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. independent or group private practice. visiting nurse agency. 3. palpating. A follow-up database to evaluate changes at appropriate intervals 2. A complete health database because of the nurse’s primary responsibility for monitoring the patient’s health 4. patient’s history of allergies. such as a pediatric or family practice clinic. DIF: Application REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 22. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care . patient’s use of medications at home. Which type of database is most appropriate to collect in this setting? 1. and auscultating during the physical examination. 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. percussing. 4.21. ANS: 4 Objective data are the patient’s record. 2. 2 × 5 cm scar present on the right lower forearm. An episodic database because of the continuing. and information that the health professional observes by inspecting. last menstrual period 1 month ago. 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. women’s health care agency.
4. including social support patterns. A patient’s admission to the hospital for surgery the following day 4. ask her to read her health record and indicate any changes since her last visit. strengths. Collect history information first. smaller in scope than the completed database. He is alert and cooperative. obtain a complete health history before checking her blood pressure because much of her history information may have changed. She has been coming to the clinic weekly since she changed medications 2 months ago. A patient has sudden. and coping patterns. Collect all information on the history form.23. How would the nurse proceed with the data collection? 1. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 24. 3. but his injuries are quite severe. one cue complex. ANS: 1 A follow-up database is used in all settings to follow up short-term or chronic health problems. the nurse collects a “mini” database. A patient’s admission to a long-term care facility 2. 3. 2. A patient is at the clinic to have her blood pressure checked. or one body system. A patient in an outpatient clinic has cold and flu-like symptoms 11 3 ANS: 4 In an episodic or problem-centered database. The nurse should: 1. . then perform the physical examination and institute life-saving measures. DIF: Application REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 25. severe shortness of breath 3. Which situation is most appropriate for an episodic history? 1. check only her blood pressure because her complete health history was documented 2 months ago. Simultaneously ask history questions while performing the examination and initiating life-saving measures. It concerns mainly one problem. collect a follow-up database and then check her blood pressure. 2.
4. ANS: 2 The emergency database calls for a rapid collection of the database. The nurse knows that it is important to include cultural information in his health assessment to: 1. DIF: Comprehension MSC: NCLEX: Psychosocial Integrity REF: Page: 10 28. ANS: 4 The age-specific charts for the periodic health examination define a lifetime schedule of health care. A 42-year-old Asian patient is being seen at the clinic for an initial examination. 2. 4. 3. 3. Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit. changing the patient’s perceptions of disease. DIF: Analysis REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 26. often compiled concurrently with life-saving measures. provide cultural health rights for the individual. They are used to help identify the diagnosis of an illness. organized into packages for eight specific age groups. They recommend that every individual receive an annual physical exam. Which statement correctly describes the age-specific charts for the periodic health examination? 1.4. provide culturally sensitive and appropriate care. 2. . 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. the focus of the health professional includes: 1. identify the cause of his illness. DIF: Knowledge REF: Page: 8 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 27. In the health promotion model. They list a frequency schedule for periodic health visits for a specific age group. They are helpful in identifying developmental delays in children. make accurate disease diagnoses.
identifying negative health acts of the consumer. helping the consumer choose a healthier lifestyle. the focus of the health professional is on helping the consumer choose a healthier lifestyle. DIF: Knowledge REF: Page: 7 MSC: NCLEX: Health Promotion and Maintenance 11 5 .2. 3. identification of biomedical model interventions. 4. ANS: 4 In the health promotion model.
Identifying potential problems the individual may develop 4. Evaluate the individual’s condition and compare actual outcomes with expected outcomes. body. Evaluating previous problems and goals 3. and spirit as functioning as a whole within the environment. When nursing diagnoses are being classified. ANS: 3 . A patient’s perception of his or her health status 4. Identifying existing levels of wellness 2. The nurse’s perception of disease related to the patient ANS: 3 Holistic health views the mind. Nursing goals for the patient 2. DIF: Application REF: Page: 5 MSC: NCLEX: General 31. 4.29. Anticipated growth and development patterns 3. not the nurse’s perception or goals. 3. Interpret data and then identify clusters of cues and make inferences. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. DIF: Comprehension REF: Page: 7 MSC: NCLEX: Health Promotion and Maintenance 30. Which would be the next appropriate action? 1. Identify expected outcomes. 2. which of the following would be considered a risk diagnosis? 1. 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. Establish priorities. A holistic model includes the patient’s perception of his or her health status. Which of the following would be included in a holistic model of assessment? 1.
the nurse should evaluate the individual’s condition and compare actual outcomes with expected outcomes. DIF: Application REF: Page: 2 MSC: NCLEX: Safe and Effective Care Environment: Management of Care 11 7 .Evaluation is the next step after the implementation phase of the nursing process. During this step.
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. An older adult with a urinary tract infection is also showing signs of confusion and agitation. with more time and experience than the novice nurse. C = third-level priority problem 1. 1.32. 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 . 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. ANS: MSC: 3. 2. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. A nurse who sees actions in the context of daily plans for patients 4. A = first-level priority problem 2. B = second-level priority problem 3. Which term best describes a proficient nurse? 1. A nurse who has little experience with a specified population and uses rules to guide performance 2. ANS: MSC: 2. A teenager who was stung by a bee during a soccer match is having trouble breathing. 3. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution 3. DIF: Application REF: Page: 3 MSC: NCLEX: General MATCHING Put the following patient situations in order according to level of priority: 1.
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