FUNDAMENTALS End Chapter Exam 1

Which of the following data sets are examples of subjective data?

• Heart rate of 22 breaths/min and chest congestion

• Lung sounds revealing crackles and use of intercostal muscles to breathe

• Patient statement, “It’s hard for me to get a breath”

• Slumped posture and previous respiratory rate of 16 breaths/min

• Patient report of sore throat and hoarseness

The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?

• Orientation

• Working phase

• Data interpretation

• Termination

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:

• Reflection

• Clinical inference

• Cue

• Validation

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?

• Current medications

• Patient expectations of planned surgery

• Review of patient’s family support system

• History of allergies

• Patient’s explanation for what might be the cause of symptoms that require surgery

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time?

• Recognize normal changes associated with aging

• Avoid direct eye contact

• Lean forward and smile as you pose questions

• Allow for pauses as patient tells his story

• Use the list of questions from the clinic assessment form to complete all data

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment to the abdomen, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?

• Incorrect clustering of data

• Wrong diagnosis

• Condition is a collaborative problem

• Premature ending assessment

Answer explanation

Skin is clean and intact

Review the following nursing diagnoses and identify the diagnoses that are stated correctly

• Offer frequent skin care because of Impaired Skin Integrity

• Risk for Infection

• Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion

• Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea

• Lack of Knowledge related to laser surgery

Answer explanation

Option 3 has a medical diagnosis as a related factor

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of:

• Collaborative data set

• Diagnostic label

• Related factors

• Data cluster

• Validated data set

Answer explanation

A data cluster consists of the data elements about a patient that form a meaningful pattern, in this case a pattern of impaired mobility.

A nurse reviews data gathered regarding a patient’s response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following?

• Data collection

• Data clustering

• Data interpretation

• Making a diagnostic statement

• Outcome setting

Setting priorities for a patient’s nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care?

• Priority setting establishes a preferential order for nursing interventions

• In most cases wellness problems take priority over problem-focused problems

• Recognition of symptom patterns helps in understanding when to plan interventions

• Longer-term chronic needs require priority over short-term problems

• Priority setting involves creating a list of care tasks