(Test Bank) Canadian Nursing Health Assessment: A Best Practice Approach

Stephen,Skillen, 2

Nursing

Test Bank

2nd Edition

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Test Bank for Canadian Nursing Health Assessment: A Best Practice Approach, The downloadable file consists of 313 pages, and the total size of the file is 1.93 MB. Purchase now only for highly discounted price.

Author(s): Stephen, Skillen

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Study Note Preview

Chapter 1: The Nurse's Role in Health Assessment Multiple Choice 1. What is one of the priority goals of nursing practice? A) To influence private policy B) To further the interests of the nursing profession C) To promote privacy in health care D) To advocate for patients and communities Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Moderate Objective: 1 Page and Header: 5, Advocacy Taxonomic Level: Knowledge Feedback: Nurses engage in many activities in the course of nursing practice. Among the most important goals of the nurse is the advocacy role of the nurse. This role supersedes the importance of promoting the profession and promoting privacy, even though both are laudable goals. Nurses normally aim to influence public, not private, policy. 2. What do nursing activities that promote health and prevent disease primarily accomplish? A) Reduce an individual's risk of illness B) Reduce recovery times C) Optimize self-care abilities D) Create home care safety Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: Nursing activities that promote health and prevent illness reduce the risk of disease. These activities are not primarily focused on reducing recovery times, optimizing self-care, or creating home safety, though each of these outcomes is congruent with the philosophy of health promotion. 3. The purpose of a health assessment includes what? A) Identifying the patient's major disease process B) Collecting information about the health status of the patient C) Clarifying the patient's extended health care benefits D) Explaining the patient's overall health to him or her Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. The patient's health care coverage is not a component of health assessment, and it is not normally the nurse's role to explain the patient's overall health or identify particular diseases. 4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending primarily on what factor? A) How much time the nurse has B) The patient's acuity C) The patient's cooperation D) Onset of current symptoms Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Comprehension Feedback: Data that nurses collect during a physical assessment vary depending on a patient's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the patient is, or the onset of the current symptoms. 5. A nursing instructor is discussing the purposes of health assessment. What is a priority purpose of health assessment? A) To establish a database against which subsequent assessments can be measured B) To establish rapport with the patient and family C) To gather information for specialists to whom the patient might be referred D) To quantify the degree of pain a patient may be experiencing Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 2 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Analysis Feedback: Health assessment is the collection of subjective and objective data to develop a database about a patient's health status (past and present), health concerns, and usual coping mechanisms so that an individualized care plan can be created. Rapport is important but is not a priority goal of health assessment. It is not normally the nurse's role to gather data for specialists. Pain assessment is an important component of most assessments but is not a primary purpose for assessment. 6. How do nurses primarily facilitate the achievement of high-level wellness with a patient? A) By encouraging the patient to keep appointments B) By providing information on alternative treatments C) By promoting patients' health D) By providing efficient patient care Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Easy Objective: 3 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Analysis Feedback: High-level wellness is a process by which people maintain balance and direction in the most favourable environment. The role of nurses is to facilitate this achievement through health promotion and teaching. Nurses do not necessarily facilitate the achievement of high-level wellness by encouraging patients to keep appointments, providing information on alternative treatments, or providing “efficienct” patient care. 7. The nurse is caring for a patient who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true? A) The patient stops doing wellness-promoting activities. B) The patient develops signs and symptoms. C) The patient begins exercising. D) The patient verbalizes anxiety over the cost of medications. Ans: B Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 6, Wellness and Health Promotion Taxonomic Level: Evaluation Feedback: The person who moves toward illness and premature death develops signs, symptoms, and disability, which, unfortunately, is when most treatment occurs in the current health care system. The patient who stops performing wellness-promoting activities is not necessarily moving toward death. A patient who begins exercising is moving toward wellness, not illness. The verbalization of anxiety over financial matters is not an indication of illness. 8. Nurses collaborate with individuals, families, groups, and communities to implement health promotion, risk reduction, and disease prevention strategies. What is an example of primary prevention? A) Conducting a public blood glucose monitoring campaign B) Administering antibiotics to a patient with sepsis C) Providing immunizations to school children D) Screening for high blood pressure Ans: C Age Group: Child and Adolescent Chapter: 1 Client Type: Population Competency Category: Health and Wellness Difficulty: Difficult Objective: 3 Page and Header: 7, Risk Assessment and Health Promotion Taxonomic Level: Analysis Feedback: Immunizations are an example of primary prevention, while BP and diabetes screening are secondary prevention measures. Active treatment of illness is associated with tertiary prevention. 9. A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse primarily use? A) Rationales B) Canadian Nurses Association recommendations C) Physical assessment skills D) Clinical reasoning Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 4 Page and Header: 9, Clinical Reasoning Taxonomic Level: Analysis Feedback: Nurses use clinical reasoning and critical thinking to formulate diagnostic statements. Rationale, CNA recommendations, and physical assessment skills are not central to the process of formulating diagnostic statements, though each may be integrated into the process. 10. A nurse is caring for three patients whose care involves complex situations and multiple responsibilities. What is most important to resolving problems for this nurse? A) Intuition B) Physical assessment C) Critical thinking D) Nursing care plan Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Group Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 9, Critical Thinking Taxonomic Level: Application Feedback: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems and is more important than intuition. Care plans and physical assessments are not useful in the absence of critical thinking. 11. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Community Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 5, Purposes of Health Assessment Taxonomic Level: Application Feedback: The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are integrated into nursing but are not frameworks for providing individualized care to a community. 12. Which of the following is a recognized type of nursing assessment? A) Physical B) Implied C) Mental D) Emergency Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 5 Page and Header: 10, Types of Health Assessments Taxonomic Level: Knowledge Feedback: Three types of nursing assessments are common—emergency, focused, and comprehensive. 13. A nurse performs a comprehensive assessment on a patient. What is a unique component of this assessment? A) Circulatory assessment B) Assessment of the airway C) Complete health history D) Disability assessment Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Comprehensive Assessment Taxonomic Level: Application Feedback: The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or every 8 hours for patients in intensive care. Focused assessments and emergency assessments do not include a complete health history. 14. The nurse is admitting a patient to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A) It covers the body from head to toe. B) It occurs only in the clinic area. C) It involves all body systems. D) It is more in-depth on specific issues. Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 11, Focused Assessment Taxonomic Level: Analysis Feedback: A focused assessment is based on the patient's issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health. It usually involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in-depth on the specific issue(s). 15. A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will primarily provide what type of data? A) Concrete B) Subjective C) Realistic D) Objective Ans: D Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Easy Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Comprehension Feedback: The physical assessment follows the history and focused interview and includes objective data, which are measurable. Subjective data are gathered during the health history. Concrete and realistic data are distracters for this question. 16. The nurse is performing a health assessment on a new patient. While taking the detailed history, the nurse knows to include what information? A) Functional status B) Only data involving the patient complaint C) A focused assessment of the patient complaint D) Family history for the past three generations Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 6 Page and Header: 13, Components of the Health Assessment Taxonomic Level: Knowledge Feedback: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Family histories generally go back only to grandparents, not great-grandparents. 17. When documenting the results of a health assessment, what principle must the nurse follow? A) Documentation must be kept secure and private. B) Documentation must be freely shared with all stakeholders. C) Documentation becomes a publically accessible record after 7 years. D) Documentation should be expressed according to the nurse's preferences. Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Professional Practice Difficulty: Difficult Objective: 7 Page and Header: 14, Documentation and Communication Taxonomic Level: Synthesis Feedback: Legislation regulates the security and privacy of information that is contained in nursing documentation. Accordingly, it does not become a publically accessible record and is not necessarily shared with all stakeholders. It should be performed in a standardized manner, not guided by the nurse's individual preferences. 18. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment? A) Body systems B) Head to toe C) Functional D) Comprehensive Ans: C Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Health and Wellness Difficulty: Moderate Objective: 6 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: A functional assessment focuses on the patterns that all humans share—health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs. 19. A clinical instructor is teaching a group about organizing data when documenting and communicating findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? A) Body systems B) Comprehensive C) Head to toe D) Functional Ans: A Age Group: All Age Groups Chapter: 1 Client Type: Individual Competency Category: Changes in Health Difficulty: Moderate Objective: 7 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Evaluation Feedback: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data. 20. A nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what? A) Body systems B) Functional C) Focused D) Head to toe Ans: D Age Group: Child and Adolescent Chapter: 1 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 5 Page and Header: 15, Organizing Frameworks for Health Assessment Taxonomic Level: Analysis Feedback: The head-to-toe method is efficient and provides more modesty for patients than other modes of assessment. Chapter 2: Interviewing and Therapeutic Communication Multiple Choice 1. A nursing instructor is explaining and analyzing nonverbal communication with the nursing class. The instructor explains that facial expressions should be A) humourous. B) stoic. C) relaxed. D) detached. Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Comprehension Feedback: Facial expressions should be relaxed, caring, and interested. Detached and stoic expressions are likely to hinder partnership, and humourous expressions are inappropriate in many circumstances. 2. A nurse is admitting a new patient who is currently lying in bed. Where should the nurse be positioned? A) Seated in a chair at eye level with the patient B) Sitting on the side of the bed, looking down at the patient C) Leaning on the nightstand at eye level with the patient D) Standing beside the bed, looking down at the patient Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 1 Page and Header: 22, Nonverbal Communication Skills Taxonomic Level: Application Feedback: To facilitate optimal eye contact, the nurse needs to be at eye level with the patient. Those who stand while patients are in bed will be taller than patients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level with patients who are in bed during interviews. 3. In some situations, a way to apply nonverbal communication effectively is through silence. The purposeful use of silence during the interview allows patients to do what? A) Rest and improve health B) Provide accurate answers C) Compensate for decreased levels of consciousness D) Withdraw from the nurse Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 2 Page and Header: 24, Silence Taxonomic Level: Analysis Feedback: The nurse uses silence purposefully during the interview to allow patients time to gather their thoughts and provide accurate answers. He or she also uses silence therapeutically to communicate nonverbal concern. Silence also gives patients a chance to decide how much information to disclose. Silence is not intended to allow withdrawal from the therapeutic relationship. 4. A nurse is interviewing a patient who uses a verbal expression with which the nurse is unfamiliar. What is the most appropriate statement for the nurse to use to clarify the expression's meaning from the patient? A) Tell me what you mean by ________? B) I think that expression means ____________. C) That expression is unclear to me. D) Where did you hear that expression? Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 2 Page and Header: 24, Clarification Taxonomic Level: Synthesis Feedback: Clarification is important when the patient's word choice or ideas are unclear. For example, the nurse states, “Tell me what you mean by _____?” Another way to clarify is to ask, “What happens when you _____?” Such questions prompt patients to identify other symptoms or give more information, so that the nurse better understands. The nurse also can use clarification when the patient's history of illness is confusing. This is superior to guessing or asking the patient where he or she heard the expression. 5. The patient tells the nurse that he is sorry he fell off the roof and broke his leg. The nurse responds by saying, “Oh, you poor thing! I've had injuries too, so I know how you're feeling.” What type of response is this? A) Empathetic B) Therapeutic C) Sympathetic D) Supportive Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Difficult Objective: 3 Page and Header: 25, Sympathy Taxonomic Level: Analysis Feedback: Sympathy is feeling what a patient feels from the viewpoint of the nurse. When the nurse is being sympathetic, he or she is not being therapeutic, because the nurse is interpreting the situation as he or she perceives it. Because this response is nontherapeutic, it is also nonsupportive. 6. A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic? A) Clarification B) Using technical language C) Summarizing D) Focusing Ans: B Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 3 Page and Header: 6, Technical or Overwhelming Language Taxonomic Level: Comprehension Feedback: Using technical language often contributes to nontherapeutic communication. The other given options are therapeutic responses. 7. A nurse is preparing to admit a new patient to the unit and is reviewing the patient's record chronologically. In what phase of the interview process are the nurse and the patient? A) Preinteraction B) Beginning C) Working D) Ending Ans: A Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Easy Objective: 4 Page and Header: 27, Preinteraction Phase Taxonomic Level: Analysis Feedback: In the preinteraction phase, the nurse reviews the record chronologically to detect patterns of illness, such as declining functional status, and to identify how things fit together. This precedes the other listed phases. 8. During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? A) Preinteraction B) Beginning C) Working D) Ending Ans: C Age Group: All Age Groups Chapter: 2 Client Type: Individual Competency Category: Nurse-Client Partnership Difficulty: Moderate Objective: 4 Page and Header: 28, Working Phase Taxonomic Level: Comprehension Feedback: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. 9. The nurse is interviewing a patient from a culture different from that of the nurse. The nurse works to preserve the code of conduct that shows respect for others. What