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Osborn
While conducting a health assessment, the nurse documents a patient's response under the heading "chief
complaint." Which part of the assessment is the nurse conducting?
2. Family history
3. Psychosocial history
Correct Answer: 1
Rationale 1: The history of the present illness includes information about what brought the patient to the health
care provider. The reason is usually written verbatim in the health record and often becomes the chief complaint.
Rationale 2: The patient’s chief complaint is not part of the family history.
Rationale 3: The patient’s chief complaint is not part of the psychosocial history.
Rationale 4: The patient’s chief complaint is not part of the past medical history.
Global Rationale:
Question 2
Type: MCSA
A patient comes to the emergency department and states, "I am having chest pain and I feel short of breath." How
is the data the patient has just given the nurse classified?
1. Nonspecific
2. Objective
4. Subjective
Correct Answer: 4
Rationale 2: Objective data is information collected when the nurse uses the senses: observation, palpation,
auscultation, percussion, and smell.
Global Rationale:
Question 3
Type: MCSA
The nurse has completed the collection and analysis of data from a patient assessment. What is the nurse’s next
action?
2. Plan care.
Correct Answer: 4
Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is the next step of the nursing
process.
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
Global Rationale:
Question 4
Type: MCSA
The nurse asks the patient, "What brings you to the hospital today?" What is the nurse’s rationale for using this
type of question?
Correct Answer: 3
Rationale 1: The question does not acknowledge agreement between the patient and the nurse. The nurse’s
summary at the end of the interview acknowledges agreement.
Rationale 3: The question is an open-ended question and asks for narrative information by stating the topic in
general terms. It is used to introduce a topic.
Global Rationale:
Question 5
Type: MCSA
Correct Answer: 3
Rationale 3: Nodding the head encourages the patient to tell the nurse more and is considered facilitation.
Rationale 4: The use of silence will allow the nurse time to observe the patient's nonverbal cues.
Global Rationale:
Question 6
Type: MCSA
A patient tells the nurse that he has a history of back pain that is controlled with yoga and herbal supplements.
How would the nurse document this information?
Correct Answer: 3
Rationale 2: The strength of the patient’s spiritual beliefs cannot be assessed by this information alone.
Rationale 3: The use of herbal supplements to relieve back pain is a form of complementary or alternative
medicine. The nurse must assess this practice, as some “natural cures” are ineffective and some can interfere with
prescribed medications.
Rationale 4: There is not enough information to make this statement. The patient may use yoga as a strengthening
exercise for back muscles. The herbs may not be taken for stress reduction.
Global Rationale:
Question 7
Type: MCSA
The nurse introduces herself and shakes the patient's hand, then sits so as to maintain eye contact during the health
interview. What do the nurse’s actions demonstrate?
1. Facilitation
4. Empathy
Correct Answer: 3
Rationale 1: Facilitation would occur if the nurse nodded the head to encourage the patient to continue talking.
Rationale 2: Negative nonverbal messages include tense posture, yawning, and avoiding eye contact. The nurse’s
actions are not negative.
Rationale 3: Positive nonverbal messages enhance the relationship with the patient and include eye contact and
equal-status seating.
Question 8
Type: MCSA
During the health history, a patient tells the nurse that she is in an abusive relationship and is fearful of getting
hurt if her husband finds out that she told the nurse. Which response by the nurse is most appropriate for this
patient?
1. "Don't worry. They only strike back when they are angry."
Correct Answer: 2
Rationale 2: The nurse needs to clarify what the patient is explaining, and the best response would be to clarify if
the patient is saying she is in danger.
Rationale 3: The nurse should not offer legal advice to the patient.
Rationale 4: This statement dismisses the patient’s concern for her safety and does not promote her health.
Global Rationale:
Question 9
Type: MCSA
1. Facilitation
2. Empathy
3. Interpretation
4. Summary
Correct Answer: 3
Rationale 1: Facilitation is a technique that would encourage the patient to continue talking.
Rationale 2: Empathy acknowledges the patient's feelings with a statement of understanding to help the patient
feel accepted.
Rationale 3: Interpretation links events or implies a cause, which is what the nurse is doing when responding to
this patient.
Rationale 4: Summary occurs at the end of the interview, when the nurse summarizes the perception of the
patient's health problem from the information gained during the interview.
Global Rationale:
Question 10
Type: MCSA
The nurse notices a patient has a strong, foul body odor. The patient tells the nurse he has trouble getting in and
out of the bathtub. Which areas of the physical assessment does this information address?
Rationale 1: The patient did not say that his inability to use the bathtub was associated with pain, and the nurse
should be careful not to make this assumption.
Rationale 2: An inability to use the bathtub does not speak specifically to nutrition, mental status, or behavior.
Rationale 3: The inability to use the bathtub does affect physical appearance. The patient did not mention that the
tub was too small or that his weight made using it difficult, so these issues cannot currently be considered a factor.
The nurse must be careful not to make assumptions without data.
Rationale 4: The patient states difficulty with using a bathtub, which provides information relevant to functional
assessment, physical appearance, and mobility.
Global Rationale:
Question 11
Type: MCSA
Prior to palpating the abdomen of a patient with several skin lesions, the nurse puts on a pair of gloves. The
patient asks, "What are the gloves for?" Which is the best response the nurse can give the patient?
1. "Gloves are considered a standard precaution to provide protection to the health care provider during an exam."
Correct Answer: 1
Rationale 1: The nurse needs to use standard precautions throughout the entire physical examination and should
explain this to the patient. Gloves are particularly important when skin lesions are present.
Rationale 2: The nurse should not make the patient feel “dirty” or “bad” when answering this question.
Rationale 3: This should not be the reason the nurse is wearing gloves and is not an appropriate answer.
Question 12
Type: MCMA
While performing percussion in a physical examination, the nurse elicits dullness. Which structure is the nurse
likely percussing?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Intestines
2. Lungs
3. Pelvic bone
4. Liver
5. Kidney
Rationale 3: Flatness is the percussion sound heard over muscle and bone.
Rationale 4: Dullness is the percussion sound heard over large, solid organs such as the liver.
Rationale 5: Dullness is the percussion sound heard over large, solid organs such as the kidney.
Global Rationale:
Question 13
Type: MCSA
A patient in the unit has a blood pressure of 55/30, is lethargic, has slurred speech, and is unable to get back to
bed from the bathroom. The nurse calls for a rapid response team. Which component of critical thinking is the
nurse exhibiting?
Correct Answer: 1
Rationale 1: Analysis of the situation is the second component of critical thinking. This component includes the
ability to distinguish normal from abnormal.
Rationale 2: Selection of alternatives is the fourth step in the critical thinking process and is used when
developing outcomes and plans.
Rationale 3: Collection of information is the first step in the critical thinking process and is used during the health
assessment.
Rationale 4: Evaluation of the situation is the last step of the critical thinking process and is used to determine if
the expected outcomes have been achieved.
Global Rationale:
Question 14
Type: MCSA
The nurse and a patient are discussing a variety of options that may help alleviate a health problem. The nurse and
patient are involved in which step of the critical thinking process?
1. Evaluation
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
2. Collection of information
3. Generation of alternatives
Correct Answer: 3
Rationale 1: Evaluation is the last step of the process and is done to determine whether the expected outcomes
have been achieved.
Rationale 2: Collection of information begins with the interview and continues throughout the entire health
assessment.
Rationale 3: Generation of alternatives occurs when options are identified and priorities are established. The
nurse and patient work together to discuss the options so the patient can make an informed decision.
Rationale 4: Analysis of the situation follows the collection of information and helps distinguish normal from
abnormal findings.
Global Rationale:
Question 15
Type: MCMA
The nurse is reviewing the outcomes of a patient's plan of care. Which portions of the critical thinking process are
used in this evaluation?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Revision of cues
2. Generation of alternatives
4. Selection of alternatives
5. Collection of information
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
Correct Answer: 3,4,5
Rationale 1: Cues are bits of information that may hint at the possibility of a health problem. The cues are static
and cannot be revised.
Rationale 2: Each step of the critical thinking process is used in evaluation. The nurse may need to generate new
alternatives to address unmet or undesirable outcomes.
Rationale 3: Each step of the critical thinking process is used in evaluation. The nurse reanalyzes the situation to
see if any omissions or misinterpretations have occurred.
Rationale 4: Each step of the critical thinking process is used in evaluation. The nurse uses critical thinking to
determine if the alternatives selected were appropriate and if any omissions occurred.
Rationale 5: Each step of the critical thinking process is used in evaluation. The nurse uses critical thinking to
determine if all pertinent information was collected and if any misinterpretation occurred.
Global Rationale:
Question 16
Type: FIB
A 54-year-old patient reports that she smokes a pack and a half of cigarettes daily and has been smoking since she
was 16 years old. The nurse would record a smoking history of ______ pack-years.
Standard Text:
Correct Answer: 57
Rationale : This patient has been smoking for 38 years (54-16). 38 × 1.5 = 57 pack-years.
Global Rationale:
Question 17
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
Type: MCMA
The nurse is using the technique of inspection during a patient’s physical examination. Which findings are
possible using this technique?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
4. The patient has difficulty extending the right arm above the head.
Rationale 1: The nurse can see the differences in size using inspection.
Rationale 2: The nurse can see the contours of the abdomen using inspection.
Rationale 3: To assess the radial pulse, the nurse must use palpation.
Rationale 5: Edema can be assessed through inspection, although it must be graded through palpation.
Global Rationale:
Question 18
Type: MCMA
The nurse is preparing to use auscultation as part of a patient’s physical examination. Which techniques should
the nurse use?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
Standard Text: Select all that apply.
1. Pressing the bell of the stethoscope firmly on the skin to hear muffled tones
3. Placing the diaphragm of the stethoscope firmly against the patient’s gown
Rationale 1: The bell of the stethoscope becomes a diaphragm when pressed firmly on the skin. The skin under
the bell stretches, creating a surface that reduces audible vibratory sensations.
Rationale 2: The diaphragm of the stethoscope is best for hearing high-pitched sounds such as normal lung
sounds.
Rationale 3: The stethoscope should be placed on bare skin. The patient’s gown or bed sheets will produce
sounds that interfere with body sounds.
Rationale 4: A variety of sounds can be heard when the nurse listens at each auscultatory landmark. The nurse
should focus on one sound at a time.
Rationale 5: The bell is the best side of the stethoscope for hearing low-pitched sounds such as heart murmurs.
Global Rationale:
Question 19
Type: MCMA
The nurse is using blunt percussion to assess a patient who was involved in a motor vehicle accident. The nurse
would use this technique to assess for injury to which organs?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Kidney
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
2. Liver
3. Lungs
4. Bladder
5. Heart
Rationale 1: Blunt percussion is often used as a quick screen for inflammation or damage to the kidney.
Rationale 2: Blunt percussion over the liver that elicits pain would indicate injury.
Global Rationale:
Question 20
Type: MCSA
Using critical thinking, the nurse assesses that a patient is not a reliable historian. How should the nurse proceed?
Correct Answer: 3
Rationale 1: There are many parts of assessment that do not depend on the patient being an accurate historian.
Rationale 2: Being an unreliable historian does not mean that the patient is not truthful. In some cases it indicates
that the patient has memory or hearing issues.
Osborn, Medical-Surgical Nursing, 2e, Test Bank
Copyright 2014 by Pearson Education, Inc.
Test Bank for Medical-Surgical Nursing, 2nd Edition: Kathleen S. Osborn
Rationale 3: The nurse can assess information in a variety of ways. Asking different questions to elicit
information is a valid technique.
Rationale 4: The nurse should not taint the data set by recording obviously inaccurate data. Further attempts to
verify data should be taken.
Global Rationale: