Question 1

The nursing process is a sequential method of problem solving that nurses use and includes which steps?

Accepted Answer

The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

Question 2

Which critical-thinking skill helps the nurse see relationships among the data?

Accepted Answer

Clustering related cues involves clustering, or grouping together, assessment data that appear to be associated, or related, and helps the nurse see relationships among the data. Identifying gaps is looking for missing information and validation involves ensuring accuracy, and distinguishing relevant and irrelevant data involves identifying data the fit, or support the problem, but none of those help the nurse to see relationships.

Question 3

A visiting nurse is making an initial home visit for a patient who has several chronic medical problems. Which type of database is most appropriate to collect in this setting?

Accepted Answer

A complete database is collected in primary care settings, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the person's health care. A follow-up database is performed to follow up, or evaluate changes, on short-term and chronic health problems, but would be collected at appropriate intervals after a complete database was collected at the initial visit. A focused database is conducted for a limited or short-term problem, not for a patient with several chronic problems. An emergency database is an urgent, rapid collection of data often compiled concurrently while lifesaving measures are being performed.

Question 4

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?

Accepted Answer

EBP is a systematic approach to practice that emphasizes the use of research evidence in combination with the clinician's expertise and clinical knowledge (physical assessment), as well as patient values and preferences, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists.

Question 5

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. What type of assessment data is this?

Accepted Answer

Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data.

Question 6

When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?

Accepted Answer

Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent and functioning as a whole within the environment. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. The basis of disease originates from both the external environment and from within the person; the individual human is an open system, continually changing and adapting; and each person is responsible for his or her own personal health state (not the nurse).

Question 7

A patient is brought by ambulance to the emergency department with multiple injuries received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?

Accepted Answer

The emergency database calls for a rapid collection of the database, often concurrently compiled with lifesaving measures. The other responses are not appropriate for the situation. This is an emergency situation and an emergency database with rapid collection of the database compiled concurrently with lifesaving measures.

Question 8

A patient tells the nurse that he is very nervous, nauseous, and "feels hot." What type of assessment data is this?

Accepted Answer

Subjective data is what the person says about him or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data.

Question 9

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Accepted Answer

First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.

Question 10

The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood pressure checks since she changed medications 2 months ago. Which is the most appropriate action for the nurse to take?

Accepted Answer

A follow-up database is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. Asking the patient to read her health history and indicate any changes since her last visit is not appropriate. Just checking the patient's blood pressure without following up on or assessing for any changes in the patient's condition is inappropriate. It is not necessary to conduct a complete health history as one was conducted 2 months ago. Rather a follow-up assessment regarding the patient's blood pressure and factors associated with it are necessary.

Question 11

In which situation is it most appropriate for the nurse to perform a focused or problem-centered history?

Accepted Answer

In a focused or problem-centered database, the nurse collects a "mini" database, which is smaller in scope than the completed database. This mini database primarily concerns one problem, one cue complex, or one body system. A complete database should be conducted for a patient being admitted to a long-term care facility or being admitted for a scheduled surgery. An emergency database should be conducted for a patient with sudden and severe shortness of breath.

Question 12

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?

Accepted Answer

Abnormal laboratory values are a second-level priority problem. Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security). Low self-esteem and lack of knowledge are considered third-level priority as although they are important to a patient's health, they can be addressed after more urgent health problems are addressed. Severely abnormal vital signs would be considered a first-level priority problem.

Question 13

The nurse recognizes that which concept of prevention is essential in describing health?

Accepted Answer

A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. Although treating the environment may help in preventing some diseases, not all diseases can be prevented by treating the external environment. The majority of deaths among Americans under age 65 years are preventable. The means to prevention is achieved through counseling primary care providers designed to change people's unhealthy behaviors r/t smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries, and sexually transmitted infections.

Question 14

What do the patient's record, laboratory studies, objective data, and subjective data combine to form?

Accepted Answer

Together with the patient's record and laboratory studies, the objective and subjective data form the database. The other items are not part of the patient's record, laboratory studies, or data.

Question 15

During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?

Accepted Answer

Facilitating support for EBP includes teaching the nurses how to conduct electronic searches and time to go to the library. However, the best method to help that staff incorporate evidence-based clinical decision making into their practice would be to teach them how to conduct electronic literature searches for pertinent studies may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. Although allowing time for nurses to visit the library may help to support evidence-based questions, time to do so may not be available for many nurses. A better method to facilitate support for EBP would be teaching the nurses how to conduct electronic searches. Just posting published research studies on the unit's bulletin board does not facilitate EBP, as not all published research is valid or pertinent to the nurses' practice. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research.

Question 16

When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard. Which action should the nurse take next?

Accepted Answer

When unsure of a sound heard while listening to a patient's breath sounds, the nurse validates the data to ensure accuracy by either repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse has less experience analyzing breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listening to a patient's breath sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying the patient's physician. To validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to assess the breath sounds.

Question 17

The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on?

Accepted Answer

Novice nurses operate from a set of defined, structured rules to make decisions. It takes time, perhaps a few years, in similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when intuition is included in making clinical decisions. Intuition is included in decision making when functioning at the level of an expert practitioner. While information in journal articles and advice from supervisors may assist in making decisions, novice nurses do not typically base their decisions on them. It would also be important that if information from journal articles and advice from supervisors were used, that they were evidence based.

Question 18

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

Accepted Answer

First-level priority problems are those that are emergent, life-threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority problems.

Question 19

Which is a barrier to incorporating EBP?

Accepted Answer

As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. Lack of significant research studies, insufficient clinical skills of nurses, and inadequate physical assessment skills are not barriers to incorporating EBP. Instead, as individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research which are barriers to incorporating EBP.

Question 20

The nurse is performing a physical assessment on a newly admitted patient. Which is an example of objective information obtained during the physical assessment?

Accepted Answer

Objective data is the patient's record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. A patient's history of allergies, use of medications at home, and date of last menstrual periods are all subjective data.

Quiz 1: Evidence-Based Assessment