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Health Assessment Exam -1 Questions and Complete Solutions Graded A+.
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Health Assessment Exam -1 Questions and Complete Solutions Graded A+.
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Health AssessmentExam #1
Questions and
Complete Solutions
Graded A+
Denning [Date] [Course title]
,1. 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. These types of data would be: - Answer: Objective
Objective data are 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.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data
would be: - Answer: Subjective
Subjective data are what the person says about him or herself during history taking. Objective data are
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.
3. The patients record, laboratory studies, objective data, and subjective data combine to form the: -
Answer: Data Base
Together with the patients record and laboratory studies, the objective and subjective data form the
data base. The other items are not part of the patients record, laboratory studies, or data.
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses
next action should be to - Answer: Validate the data by asking a coworker to listen to the breath
sounds.
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data
to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
,5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse
should keep in mind that novice nurses, without a background of skills and experience from which to
draw, are more likely to make their decisions using: - Answer: A set of rules
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
links.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it.
These responses are referred to as: - Answer: Intuition.
Intuition is characterized by pattern recognition expert nurses learn to attend to a pattern of assessment
data and act without consciously labeling it. The other options are not correct.
The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects
EBP? - Answer: EBP emphasizes the use of best evidence with the clinicians experience.
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with
the clinicians experience, as well as patient preferences and values, 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.
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? - Answer: Individual with shortness of breath and respiratory
distress
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).
, When considering priority setting of problems, the nurse keeps in mind that second-level priority
problems include which of these aspects? - Answer: Abnormal laboratory values
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).
10. Which critical thinking skill helps the nurse see relationships among the data? - Answer: .Clustering
related cues
Clustering related cues helps the nurse see relationships among the data.
The nurse knows that developing appropriate nursing interventions for a patient relies on the
appropriateness of the __________ diagnosis. - Answer: Nursing
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve
outcomes for which the nurse is accountable. The other items do not contribute to the development of
appropriate nursing interventions.
The nursing process is a sequential method of problem solving that nurses use and includes which
steps? - Answer: Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
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? - Answer: Breathing, pain, and sleep
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