Evidence-Based Assessment: Nursing Process and Critical Thinking, Exams of Nursing

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Chapter 01: Evidence-Based Assessment

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 datawould be: a. Objective.
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.”These types of data would be: a. Subjective.
3. The patient’s record, laboratory studies, objective data, and subjective datacombine to form the: a. Data base.
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that isheard. The nurse’s next action should be to: a. Validate the data by asking a coworker to listen to the breath sounds.
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 backgroundof skills and experience from which to draw, are more likely to make their decisions using: a. A set of rules.
6. Expert nurses learn to attend to a pattern of assessment data and act withoutconsciously labeling it. These responses are referred to as: a. Intuition.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP emphasizes the use of best evidence with the clinician’s experience.
8. The nurse is conducting a class on priority setting for a group of new graduatenurses. Which is an example of a first-level priority problem? a. Individual with shortness of breath and respiratory distress
9. When considering priority setting of problems, the nurse keeps in mind thatsecond-level priority problems include which of these aspects? a. Abnormal laboratory values
10. Which critical thinking skill helps the nurse see relationships among the data? a. Clustering related cues
11. The nurse knows that developing appropriate nursing interventions for a patientrelies on the appropriateness of the diagnosis. a. Nursing
12. The nursing process is a sequential method of problem solving that nurses use andincludes which steps? a. Assessment, diagnosis, outcome identification, planning, implementation,and evaluation
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and ishaving difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep
14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Diagnostic hypothesis

15. Barriers to incorporating EBP include: a. Nurses’ lack of research skills in evaluating the quality of research studies.
16. What step of the nursing process includes data collection by health history,physical examination, and interview? a. Assessment
17. 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? a. Teach the nurses how to conduct electronic searches for research studies.
18. When reviewing the concepts of health, the nurse recalls that the components ofholistic health include which of these? a. Holistic health views the mind, body, and spirit as interdependent.
19. The nurse recognizes that the concept of prevention in describing health isessential because: a. Prevention places the emphasis on the link between health and personalbehavior.
20. The nurse is performing a physical assessment on a newly admitted patient. Anexample of objective information obtained during the physical assessment includes the: a. 2 5 cm scar on the right lower forearm.
21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collectin this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medicalproblems of this patient c. A complete health data base because of the nurse’s primary responsibilityfor monitoring the patient’s health d. An emergency data base because of the need to collect information andmake accurate diagnoses rapidly
22. Which situation is most appropriate during which the nurse performs a focused orproblem-centered history? a. Patient is admitted to the hospital for surgery the following day. b. Patient in an outpatient clinic has cold and influenza-like symptoms.
23. A patient is at the clinic to have her blood pressure checked. She has been comingto the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure.
24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but hisinjuries are quite severe. How would the nurse proceed with data collection? a. Simultaneously ask history questions while performing the examinationand initiating life-saving measures.

25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his healthassessment is important to:

a. Provide culturally sensitive and appropriate care.

26. In the health promotion model, the focus of the health professional includes: a. Helping the consumer choose a healthier lifestyle.
27. The nurse has implemented several planned interventions to address the nursingdiagnosis of acute pain. Which would be the next appropriate action? a. Evaluate the individual’s condition, and compare actual outcomes withexpected outcomes.
28. Which statement best describes a proficient nurse? A proficient nurse is one who: a. Understands a patient situation as a whole rather than a list of tasks andrecognizes the long-term goals for the patient.

31. MULTIPLE RESPONSE32.

1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered togetherduring data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Nonproductive cough c. Patient reports dyspnea upon exertion d. Rate of respirations 16 breaths per minute

3. MATCHING 4. Put the following patient situations in order according to the level of priority. a. .A teenager who was stung by a bee during a soccer match is havingtrouble breathing. b. An older adult with a urinary tract infection is also showing signs of confusion and agitation. c. A patient newly diagnosed with type 2 diabetes mellitus does not knowhow to check his own blood glucose levels with a glucometer

8. Chapter 04: The Complete Health History

1. The nurse is preparing to conduct a health history. Which of thesestatements best describes the purpose of a health history? a. To provide a database of subjective information about the patient’spast and current health
2. When the nurse is evaluating the reliability of a patient’s responses, whichof these statements would be correct? The patient: a. Provided consistent information and therefore is reliable.
3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse bestdocument his reason for seeking care?

a. J.M. is a 59 - year-old man who states that he has been having“black stools” for the past 24 hours.

4. A patient tells the nurse that she has had abdominal pain for the past week.What would be the nurse’s best response? a. “Can you point to where it hurts?”
5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’sstatement? a. “How would you say the pain affects your ability to do your daily activities?”
6. In recording the childhood illnesses of a patient who denies having hadany, which note by the nurse would be most accurate? a. Patient denies measles, mumps, rubella, chickenpox, pertussis, andstrep throat.
7. A female patient tells the nurse that she has had six pregnancies, with fourlive births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a. Grav 6, Term 4, (S)Ab-2, Living 4
8. A patient tells the nurse that he is allergic to penicillin. What would be thenurse’s best response to this information? a. “Describe what happens to you when you take penicillin.”
9. The nurse is taking a family history. Important diseases or problems aboutwhich the patient should be specifically asked include: a. Mental illness.
10. The review of systems provides the nurse with: a. Information regarding health promotion practices.
11. Which of these statements represents subjective data the nurse obtainedfrom the patient regarding the patient’s skin? a. Patient denies any color change.
12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for thispatient? a. “Do you perform testicular self-examinations?”
13. Which of these responses might the nurse expect during a functionalassessment of a patient whose leg is in a cast? a. “I’m able to transfer myself from the wheelchair to the bedwithout help.”
14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response bythe nurse is most appropriate? a. “What did you do to cope with the loss of both your husband andmother?”
15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing thisinformation?

a. Alcohol can interact with all medications and can make somediseases worse.

16. The mother of a 16-month-old toddler tells the nurse that her daughter hasan earache. What would be an appropriate response? a. “Describe what she is doing to indicate she is having pain.”
17. During an assessment of a patient’s family history, the nurse constructs agenogram. Which statement best describes a genogram? a. Graphic family tree that uses symbols to depict the gender,relationship, and age of immediate family members
18. A 5-year-old boy is being admitted to the hospital to have his tonsilsremoved. Which information should the nurse collect before this procedure? a. Child’s reactions to previous hospitalizations
19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15months of age. What recommendation should the nurse make? a. MMR vaccination needs to be repeated at 4 to 6 years of age.
20. In obtaining a review of systems on a “healthy” 7-year-old girl, the healthcare provider knows that it would be important to include the: a. Limitations related to her involvement in sports activities.
21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of theassessment is being performed? a. Functional assessment
22. The nurse is obtaining a health history on an 87-year-old woman. Whichof the following areas of questioning would be most useful at this time? a. Current health promotion activities
23. The nurse is performing a review of systems on a 76-year-old patient.Which of these statements is correct for this situation? a. Questions that are reflective of the normal effects of aging areadded.
24. A 90-year-old patient tells the nurse that he cannot remember the names ofthe medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a. “Would you have a family member bring in your medications?”
25. The nurse is performing a functional assessment on an 82-year-old patientwho recently had a stroke. Which of these questions would be most important to ask? a. “Are you able to dress yourself?”
26. The nurse is preparing to do a functional assessment. Which statementbest describes the purpose of a functional assessment? a. It helps determine how a person is managing day-to-day activities.

27. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is anexample of a symptom?

a. Chest pain

28. A patient is describing his symptoms to the nurse. Which of thesestatements reflects a description of the setting of his symptoms? a. “This pain happens every time I sit down to use the computer.”
29. During an assessment, the nurse uses the CAGE test. The patient answers“yes” to two of the questions. What could this be indicating? a. The nurse should suspect alcohol abuse and continue with a morethorough substance abuse assessment.
30. The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion ofthe FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a. “Are you a part of any religious or spiritual congregation?”
31. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction wouldbe appropriate for the parents before the interview begins? a. “While I interview your daughter, will you step out to the waitingroom and complete these family health history questionnaires?”
32. The nurse is assessing a new patient who has recently immigrated to theUnited States. Which question is appropriate to add to the health history? a. “When did you come to the United States and from whatcountry?” 33. MULTIPLE RESPONSE
33. The nurse is assessing a patient’s headache pain. Which questions reflect oneor more of the critical characteristics of symptoms that should be assessed? Select all that apply. a. “Where is the headache pain?” b. “On a scale of 1 to 10, how bad is the pain?” c. “How often do the headaches occur?” d. “What makes the headaches feel better?”
34. The nurse is conducting a developmental history on a 5-year-old child. Whichquestions a. “How many teeth has he lost, and when did he lose them?” b. “Is he able to tie his shoelaces?” c. “Can he tell time?”

36. Chapter 05: Mental Status Assessment

1. During an examination, the nurse can assess mental status by which activity? a. Observing the patient and inferring health or dysfunction
2. The nurse is assessing the mental status of a child. Which statement aboutchildren and mental status is true?

a. All aspects of mental status in children are interdependent.

3. The nurse is assessing a 75-year-old man. As the nurse begins the mentalstatus portion of the assessment, the nurse expects that this patient:

a. May take a little longer to respond, but his general knowledge and abilitiesshould not have declined.

4. When assessing aging adults, the nurse knows that one of the first things thatshould be assessed before making judgments about their mental status is: a. Sensory-perceptive abilities
5. The nurse is preparing to conduct a mental status examination. Whichstatement is true regarding the mental status examination? a. Gathering mental status information during the health history interview isusually sufficient.
6. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse’s bestcourse of action? a. Perform a complete mental status examination.
7. The nurse is conducting a patient interview. Which statement made by thepatient should the nurse more fully explore during the interview? a. “I never did too good in school.”
8. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthricspeech and is lethargic. The nurse’s best approach regarding this examinationis to: a. Plan to defer the rest of the mental status examination.
9. A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of herother clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that: a. More information should be gathered to decide whether her dress isappropriate.
10. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. During the tests of cognitive function,the nurse would expect that he: a. Will be oriented to place and person, but the patient may not be certain ofthe date.
11. During a mental status examination, the nurse wants to assess a patient’saffect. The nurse should ask the patient which question? a. “How do you feel today?”
12. The nurse is planning to assess new memory with a patient. The best way forthe nurse to do this would be to: a. Give him the Four Unrelated Words Test.
13. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she couldnot four unrelated words. a. Recall; after a 30 - minute delay

14. During a mental status assessment, which question by the nurse would bestassess a person’s judgment? a. “Tell me what you plan to do once you are discharged from the hospital.”
15. Which of these individuals would the nurse consider at highest risk for asuicide attempt? a. Older adult man who tells the nurse that he is going to “join his wife inheaven” tomorrow and plans to use a gun
16. The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to beconcerned about the girl’s mental status? a. Her mother states that her daughter prefers to play with toddlers instead ofkids her own age while in daycare.
17. The nurse is assessing orientation in a 79-year-old patient. Which of theseresponses would lead the nurse to conclude that this patient is oriented? a. “I know my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010.”
18. The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant’s parents thatthe Denver II: a. Is a screening instrument designed to detect children who are slow indevelopment.
19. A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy duringthe conversation. The best description of this patient’s level of consciousnesswould be: a. Lethargic
20. A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding andtake my train.” What is the best description of this patient’s problem? a. Wernicke’s aphasia
21. A patient repeatedly seems to have difficulty coming up with a word. He says,“I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing: a. Circumlocution
22. During an examination, the nurse notes that a patient is exhibiting flight ofideas. Which statement by the patient is an example of flight of ideas? a. “Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby’s bottom.”
23. A patient describes feeling an unreasonable, irrational fear of snakes. His fearis so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: a. Has a snake phobia.

24. A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. Thisbehavior is a display of: a. Inappropriate affect
25. During reporting, the nurse hears that a patient is experiencing hallucinations.Which is an example of a hallucination? a. Man believes that his dead wife is talking to him.
26. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse shouldfirst assess the patient’s: a. Level of consciousness and cognitive abilities
27. A patient states, “I feel so sad all of the time. I can’t feel happy even doingthings I used to like to do.” He also states that he is tired, sleeps poorly, andhas no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? a. “How long have you been feeling this way?”
28. A 26-year-old woman was robbed and beaten a month ago. She is returning tothe clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? a. “Are you having any disturbing dreams?” 29. The nurse is performing a mental status examination. Which statement is true

regarding the assessment of mental status? a. Mental status functioning is inferred through the assessment of anindividual’s behaviors.

30. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statementswould be most appropriate for the nurse to use in this situation to assess attention span? a. “Pick up the pencil in your left hand, move it to your right hand, andplace it on the table.”
31. The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient? a. “Please point to articles in the room and parts of the body as I namethem.”
32. A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds inthe past month. Which of these statements or questions is the nurse’s best response in this situation? a. “Are you feeling so hopeless that you feel like hurting yourself now?”

33. The nurse is providing instructions to newly hired graduates for the mini–mental state examination (MMSE). Which statement best describes this examination?

a. This examination is a good tool to detect delirium and dementia and todifferentiate these from psychiatric mental illness.

34. The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global
35. A patient repeats, “I feel hot. Hot, cot, rot, tot, got. I’m a spot.” The nursedocuments this as an illustration of: a. Clanging
36. During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of: a. Compulsive disorder
37. The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock withthe numbers out of order and with an incorrect time. This result indicates which finding? a. Cognitive impairment
38. During morning rounds, the nurse asks a patient, “How are you today?” The patient responds, “You today, you today, you today!” and mumbles the words.This speech pattern is an example of: a. Echolalia

40. MULTIPLE RESPONSE 1. The nurse is assessing a patient who is admitted with possible delirium. Whichof these are manifestations of delirium? Select all that apply a. Develops over a short period. b. Person is exhibiting memory impairment or deficits. c. Occurs as a result of a medical condition, such as systemic infection.

8. Chapter 08: Assessment Techniques and Safety in

the Clinical Setting

1. When performing a physical assessment, the first technique the nurse willalways use is: 9. Inspection.
2. The nurse is preparing to perform a physical assessment. Which statementis true about the physical assessment? The inspection phase: 10. Takes time and reveals a surprising amount of information.
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature? 11. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.
4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? 12. Palpation
5. The nurse is preparing to assess a patient’s abdomen by palpation. Howshould the nurse proceed? 13. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.
6. The nurse would use bimanual palpation technique in which situation?
   14. Palpating the kidneys and uterus
7. The nurse is preparing to percuss the abdomen of a patient. The purpose ofthe percussion is to assess the of the underlying tissue. a. Density
8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that morereview is needed? a. Percussing once over each area
9. When percussing over the liver of a patient, the nurse notices a dull sound.The nurse should: