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PTS: 1 DIF: Cognitive Level: Applying Application REF: 124 OBJ: Discuss approaches to data collection in nursing assessment.. PTS: 1 DIF: Cognitive Level: Analyzing Analysis REF: 126 OBJ

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Nursing Practice 8th Edition by Potter and Perry

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https://getbooksolutions.com/download/test-bank-for-essentials-for-Chapter 09: Nursing Process

Potter: Essentials for Nursing Practice, 8th Edition

MULTIPLE CHOICE

1 A nurse is collecting data on a patient who is being admitted into hospice care The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained The nurse is currently involved in which step of the nursing process?

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Assessment is the deliberate and systematic collection of data about a patient The data will reveal a patient’s current and past health status,

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functional status, and present and past coping patterns A nursing diagnosis is

a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat Implementation is the performance of nursing

interventions necessary for achieving the goals and expected outcomes of nursing care Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: 124 OBJ: Describe each step of the nursing process TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

2 The nurse is admitting a patient to the unit and asks the

patient about the health history The nurse is engaged in

which component of the nursing process?

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The nurse is in the assessment phase An assessment database includes a

patient’s comprehensive health history, which includes information about a patient’s physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system The database also includes physical examination findings and a

summary of results from laboratory and diagnostic testing A nursing

diagnosis is a clinical judgment about individual, family, or community

responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat Evaluation is crucial to deciding

whether, after interventions have been delivered, a patient’s condition or being improves Planning involves setting priorities, identifying patient-

well-centered goals and expected outcomes, and prescribing nursing interventions

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: 124 OBJ: Discuss approaches to data collection in nursing assessment

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

3 A postoperative patient is continuing to have incisional pain As part

of the nurse’s assessment, the nurse notes that the patient is grimacing when he or she changes position The patient’s grimace can be useful

in the assessment and can be described as which of the following?

b Inference

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PTS: 1 DIF: Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis

4 A postoperative patient has denied the need for pain medication The nurse has noted that the patient describes the pain as a “1” on a 0 to

10 scale The nurse also notes that the patient grimaces when he or she changes position and guards the incision The nurse believes that the patient is experiencing pain based on the information gathered in the assessment What is this phenomenon known as?

b Inference

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licensed and competent to treat such as impaired tissue perfusion

PTS: 1 DIF: Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis

5 A nurse is collecting data during the assessment of a patient During the assessment, the nurse collects both subjective and objective data Which information should the nurse consider as subjective data?

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b Incisional erythema

c Emesis of 150 mL

d Sharp, burning pain

ANS: D

Sharp, burning pain is subjective Subjective data are patients’ verbal

descriptions of their health problems Only patients provide subjective data Heart rate, incisions, and emesis are all objective data Objective

data are observations or measurements of a patient’s health status

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data

6 The nurse has just completed an assessment on a patient with a

fractured right femur Which data will the nurse categorize as objective?

a The patient’s toes of right foot are

warm and pink

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b The patient reports a dull ache in

the right hip

c The patient says feels tired all the time

d The patient is concerned about

insurance coverage

ANS: A

Toes pink and warm are objective data Objective data are observations or measurements of a patient’s health status Subjective data are patients’ verbal descriptions of their health problems Only patients provide subjective data

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data

7 A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse As the student nurse charts the interaction, which

statement is the best way to document what happened?

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a Appears to be in pain as

evidenced by grouchy behavior

registered nurse do the assessment

c States, “I want a registered nurse to

do my assessment”

d Is grumpy, registered nurse notified

ANS: C

When a nurse collects objective data, he or she should apply critical

thinking intellectual standards (e.g., clear, precise, and consistent) Nurses

do not include personal interpretive statements The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care If you do not report or record an

assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)

REF: 126 | 131

OBJ: Explain the relationship between critical thinking and

steps of the nursing process

TOP: Nursing Process: Implementation MSC: NCLEX:

Management of Care

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8 A mother of five children is admitted to the hospital for abdominal pain The nurse asks a series of questions before performing a physical assessment The patient answers the questions When asking the

patient some other questions, the patient’s spouse starts to answer As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions What is the rationale for the nurse’s behavior?

a The patient is exhibiting confusion

b The spouse is being obnoxious

c The patient is the best source of information

d The spouse is too controlling

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REF: 127 OBJ: Discuss approaches to data collection in

patient is too young The patient’s chart is a source but not a primary

source The parents are a better source than the surgeon

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introduces self and explains that will be gathering some

information The nurse is in which phase of the interview?

information will remain confidential and will be used only by health care professionals who provide his or her care During the working phase you gather information about a patient’s health status When the interview comes to an end, this is called termination Assessment is the first step in the nursing process, not the first step in an interview

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11 A nurse is teaching the staff about the phases of the interview process Which information should the nurse include in the teaching session?

a Orientation, working, termination

b Orientation, assessment, evaluation

c Planning, assessment, termination

d Planning, assessment, evaluation

ANS: A

The three phases of the interview process are orientation,

working, and termination Assessment, evaluation, and planning are phases in the nursing process

nursing assessment

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TOP: Nursing Process: Implementation MSC: NCLEX:

Management of Care

12 Which question or comment should the nurse

initially use that would best gather the most information

during a health history assessment?

a “Let us help you.”

b “Did you seek help when it first started?”

c “Tell me about the problems

you are having.”

d “Do you have a family history

of this problem?”

ANS: C

Initially use open-ended questions/comments The use of open-ended

questions/comments prompts patients to describe a situation in more than one

or two words This technique leads to a discussion in which patients actively describe their health status Once patients tell their story, focus on the

symptoms that the patient identifies and ask closed-ended questions that limit his or her answers to one or two words such as “yes” or “no” or a number or frequency of a symptom The questions that start with “Do” and “Did” are closed-ended “Let us help you” will not get the patient’s perspective

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uses comments such as “go on.” Which technique is the nurse using?

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Care

hospital after a grand mal seizure took place at a shopping mall The patient’s spouse accompanied the patient to the hospital

and is being interviewed by the nurse Which question should the nurse ask to quickly focus on the patient’s symptoms?

a “What made you choose this hospital?”

b “How long did the seizure last?”

c “Tell me how the seizure

disorder has affected the family.”

d “Tell me why you brought your spouse

to the hospital today.”

ANS: B

“How long did the seizure last?” is the question that will quickly focus on the patient’s symptoms Once patients tell their story, use a problem-seeking interview technique This approach takes the information provided in the patient’s story and then more fully describes and identifies specific problem areas For example, focus on the symptoms the patient identifies and ask closed-ended questions that limit the patient’s answers to one or two words such as “yes” or “no” or a number or frequency of a symptom What made you

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choose this hospital does not focus on the seizure “Tell me”

will not get information quickly as these are open-ended

PTS: 1 DIF: Cognitive Level: Applying (Application)

TOP: Nursing Process: ImplementationMSC: NCLEX: Safety and

Infection Control

accident The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems What is the nurse doing?

a Making a medical diagnosis

b Performing a physical examination

c Making an evaluation

d Performing data validation

ANS: B

A physical examination involves use of the techniques of inspection,

palpation, percussion, auscultation, and smell A complete examination

includes a patient’s height, weight, vital signs, general appearance and

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behavior, and a head-to-toe examination of all body systems Nurses

make nursing diagnoses, not medical diagnoses, after assessment of

data Evaluation is the last step of the nursing process Evaluation is

crucial to deciding whether, after interventions have been delivered, a

patient’s condition or well-being improves Validation of assessment

data is the comparison of data with another source to confirm accuracy

problems eating since the patient had a stroke The patient denies any problems and states that does not require assistance After lunch, the nurse notes that the patient has not eaten most of the food and has

spilled much of the food These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission The nurse is using which type of information to make this deduction?

a Verbal behavior

b Physical assessment

c Nursing diagnosis

d Nonverbal behavior

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ANS: D

Observation of the level of function is different from what a nurse learns about function during the interview A nurse observes what the patient does, such as self-feeding or making a decision, rather than what the

patient says he or she can do The level of function involves a person’s

ability to perform during everyday activities Observation of the patient’s behavior for level of function differs from a physical assessment The

hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength Verbal behavior is what the patient says A nursing diagnosis would be self-care deficit

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: 129-130 OBJ: Discuss approaches to data collection in nursing assessment

hospital The patient is interviewed by a nurse from a Korean family The nurse did not make eye contact with the patient while conducting the interview This disturbed the patient because the patient thought that the nurse might be trying to hide something Which factor most likely influenced the behavior of the nurse and patient?

a Culture

b Validation

c Collaborative problem

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d Defining characteristics

ANS: A

Communication and culture are interrelated in the way individuals

express feelings verbally and nonverbally When a nurse learns the

variations in how people of different cultures communicate, he or she will likely gather more accurate information from patients Validation of assessment data is the comparison of data with another source to confirm accuracy A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a

patient’s status Defining characteristics are the clinical criteria or

assessment findings that support an actual nursing diagnosis

PTS: 1 DIF: Cognitive Level: Analyzing (Analysis) REF: 130 OBJ: Discuss approaches to data collection in nursing assessment

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

18 A nurse wants to provide patient-centered care to a patient of another culture Which question is the most

culturally sensitive when talking about a patient’s illness?

a “What do you call your problem?”

b “How long has your child had the runs?”

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