Chapter 06 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 06

Question 1

Type: MCSA

While conducting a health assessment, the nurse documents a patients response under the heading chief complaint. Which part of the assessment is the nurse conducting?

1. History of present illness

2. Family history

3. Psychosocial history

4. Past medical 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 patients chief complaint is not part of the family history.

Rationale 3: The patients chief complaint is not part of the psychosocial history.

Rationale 4: The patients chief complaint is not part of the past medical history.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

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

3. Factual

4. Subjective

Correct Answer: 4

Rationale 1: Nonspecific is not a term used to describe types of assessment data.

Rationale 2: Objective data is information collected when the nurse uses the senses: observation, palpation, auscultation, percussion, and smell.

Rationale 3: Factual is not a term used to describe types of assessment data.

Rationale 4: Subjective data is information the patient provides to the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

Question 3

Type: MCSA

The nurse has completed the collection and analysis of data from a patient assessment. What is the nurses next action?

1. Evaluate outcomes from care.

2. Plan care.

3. Determine patient care goals.

4. Formulate nursing diagnoses.

Correct Answer: 4

Rationale 1: Evaluation occurs after care is implemented.

Rationale 2: Planning occurs later in the nursing process.

Rationale 3: Determining patient goals is a later step of the nursing process.

Rationale 4: Once data is collected, it is used to formulate nursing diagnoses, which is the next step of the nursing process.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 4

Type: MCSA

The nurse asks the patient, What brings you to the hospital today? What is the nurses rationale for using this type of question?

1. It acknowledges agreement between the patient and the nurse.

2. It elicits specific information.

3. It is useful for introducing a subject in general terms.

4. It helps to clarify information.

Correct Answer: 3

Rationale 1: The question does not acknowledge agreement between the patient and the nurse. The nurses summary at the end of the interview acknowledges agreement.

Rationale 2: Direct questions are used to elicit specific information.

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.

Rationale 4: The question does not help to clarify information.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

Question 5

Type: MCSA

While conducting a health history, the nurse nods her head as the patient is talking. What is the nurses primary rationale for this action?

1. It conveys acknowledgment of the patients feelings.

2. It helps to reduce the patients anxiety level.

3. It encourages the patient to continue talking.

4. It allows the nurse time to observe the patients nonverbal cues.

Correct Answer: 3

Rationale 1: Empathy is used to acknowledge the patients feelings.

Rationale 2: Explanation will reduce the patients anxiety level.

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 patients nonverbal cues.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

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?

1. The patient does not believe in Western medicine.

2. The patient has strong spiritual beliefs.

3. The patient uses some alternative forms of medicine to treat illness.

4. The patient uses stress reduction techniques to control back pain.

Correct Answer: 3

Rationale 1: Western medicine is the type of health care traditionally provided in the United States and includes diagnostic testing, treatments, and medications. There is no indication that the patient does not believe in Western medicine.

Rationale 2: The strength of the patients 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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06-01

Question 7

Type: MCSA

The nurse introduces herself and shakes the patients hand, then sits so as to maintain eye contact during the health interview. What do the nurses actions demonstrate?

1. Facilitation

2. Negative nonverbal messages

3. Positive nonverbal messages

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 nurses actions are not negative.

Rationale 3: Positive nonverbal messages enhance the relationship with the patient and include eye contact and equal-status seating.

Rationale 4: Empathy is acknowledging a patients feelings with a statement of understanding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

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. Dont worry. They only strike back when they are angry.

2. Are you saying that you are in danger?

3. I would get an attorney if I were you.

4. Remember, what goes around comes around.

Correct Answer: 2

Rationale 1: This answer does not promote the patients health.

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 patients concern for her safety and does not promote her health.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-3

Question 9

Type: MCSA

During an assessment, the patient describes shoulder pain. The nurse responds, So, you have this shoulder pain when you eat fried foods or ice cream, is that correct? The nurse is using which interview technique?

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 patients 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 patients health problem from the information gained during the interview.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

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?

1. Behavior and pain

2. Nutritional assessment, mental status, and behavior

3. Physical appearance, height, and weight

4. Functional assessment, physical appearance, and mobility

Correct Answer: 4

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

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.

2. I dont want to catch anything from you.

3. I prefer to wear gloves when touching people.

4. The gloves help me to grip my equipment better.

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.

Rationale 4: This statement is not accurate.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

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.

Standard Text: Select all that apply.

1. Intestines

2. Lungs

3. Pelvic bone

4. Liver

5. Kidney

Correct Answer: 4,5

Rationale 1: Tympany is the percussion sound heard over air-filled intestines.

Rationale 2: Resonance is the percussion sound heard over normal lungs.

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

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?

1. Analysis of situation, distinguishing normal from abnormal

2. Selection of alternative by developing outcomes and plans

3. Collection of information, subjective and objective

4. Evaluation of situation, determination of outcomes achieved

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:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

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

2. Collection of information

3. Generation of alternatives

4. Analysis of the situation

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

Question 15

Type: MCMA

The nurse is reviewing the outcomes of a patients 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.

Standard Text: Select all that apply.

1. Revision of cues

2. Generation of alternatives

3. Analysis of the situation

4. Selection of alternatives

5. Collection of information

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

Question 17

Type: MCMA

The nurse is using the technique of inspection during a patients 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.

Standard Text: Select all that apply.

1. The patients left leg is larger than the right leg.

2. The patients abdomen is scaphoid.

3. The patient has a strong radial pulse.

4. The patient has difficulty extending the right arm above the head.

5. The patient has periorbital edema.

Correct Answer: 1,2,4,5

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 4: Difficulty in movement can be assessed through inspection.

Rationale 5: Edema can be assessed through inspection, although it must be graded through palpation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

Question 18

Type: MCMA

The nurse is preparing to use auscultation as part of a patients physical examination. Which techniques should the nurse use?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pressing the bell of the stethoscope firmly on the skin to hear muffled tones

2. Using the diaphragm of the stethoscope to hear normal lung sounds

3. Placing the diaphragm of the stethoscope firmly against the patients gown

4. Focusing on one sound at a time

5. Using the bell of the stethoscope to hear low-pitched sounds

Correct Answer: 2,4,5

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 patients 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06-04

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.

Standard Text: Select all that apply.

1. Kidney

2. Liver

3. Lungs

4. Bladder

5. Heart

Correct Answer: 1,2

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.

Rationale 3: Blunt percussion is not used to assess the lungs.

Rationale 4: Indirect percussion is used to assess the bladder.

Rationale 5: Blunt percussion is not used to assess the heart.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

Question 20

Type: MCSA

Using critical thinking, the nurse assesses that a patient is not a reliable historian. How should the nurse proceed?

1. Stop the assessment because all data is invalid.

2. Document that the patient is not answering questions truthfully.

3. Ask different questions to assess the same information.

4. Document the information just as the patient reports it.

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.

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-5

 

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