Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 1 Health Assessment

1. A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound on the left foot states to the nurse, "I am healthy, I don't know why I have to be here to get a check-up." Which statement by the nurse is the most appropriate?

1. "I feel that you are in denial about your health status."

2. "Tell me about your definition of being healthy."

3. "Do you understand what diabetes is?"

4. "Is there anything else you are not telling me?"

Page Ref: 4

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Illness Management

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is preparing to provide teaching to a client at risk for diabetes. During which time should the nurse recognize is the most effective moment for teaching?

1. During health promotion.

2. When the client is ready to learn.

3. During the discussion of disease prevention.

4. When a knowledge deficit has been identified.

Page Ref: 2

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health; communicate information effectively; and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.

1. The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives?

1. "It will allow healthcare providers to lobby legislators for more funding."

2. "The primary goal of Healthy People 2020 is to assist healthcare providers in determining risk factors for premature birth."

3. "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death."

4. "The initiatives will outline standards of care for providers in managing diseases."

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care; patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is reviewing the advanced practice roles in nursing. Which role should the nurse recognize is most likely to provide indirect patient care?

1. Nurse Researcher.

2. Nurse Administrator.

3. Nurse Educator.

4. Nurse Anesthetist.

Page Ref: 2

Cognitive Level: Applying

Client Need & Sub: Management of Care; Concepts of Management

Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals; function competently within one's own scope of practice as leader or member of the healthcare team; and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare.

MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.

1. The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which source should the nurse use?

1. The client's physical assessment.

2. The client's self-reports.

3. The client's healthcare provider.

4. The client's significant other.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.2: Explain evidence-based practice and its significance in nursing.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The nurse is reviewing a client's medical records. Which should the nurse recognize as subjective data?

1. The client tells the nurse their abdomen hurts on the left side after eating.

2. The client's abdomen is tender on the left side during palpation.

3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen.

4. The client's hemoglobin is 14.1 gm/dL.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is reviewing a client's medical record. Which documented data should the nurse recognize is objective?

1. The client states, "fell and hurt myself."

2. The client states, "I am six years old."

3. "Six-year-old child observed holding a towel to her forehead."

4. "Client states that she was running and fell at the playground."

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action should the nurse take?

1. Report the lack of achievement of the goals to the healthcare provider.

2. Review the data and modify the plan.

3. Reformulate the nursing diagnosis to a more realistic one.

4. Request a consult for the client to be seen by a pulmonologist.

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Illness Management

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The preceptor has created a teaching plan about the concepts of health and wellness for a new nurse. Which statement by the nurse indicates an understanding of health?

1. "Health is the absence of illness, disease, and symptoms."

2. "Health is a state of well-being and when the client feels good."

3. "Health is the state when a person is viewed as a holistic being."

4. "Health is a state of complete physical, mental, and social well-being."

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.5; IX.7. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Knowledge and Practice: Health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is caring for a client who is recovering from abdominal surgery. Which goal should the nurse include in this client's plan of care?

1. The client will verbalize pain relief using an intensity rating in 1 hour.

2. The client will state that they feel fine in 1 hour.

3. The nurse will observe fewer signs of pain in the client's every 1 hour.

4. The nurse will re-evaluate the client's pain level every 1 hour.

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention should the nurse implement to address this client's pain?

1. The healthcare provider will prescribe additional analgesics.

2. The client will have reduced pain after administration of analgesics.

3. The client will vocalize reduced levels of pain within 1 hour.

4. The client will be assisted with guided imagery to manage pain levels.

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Non-Pharmacological Comfort Interventions

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. A new nurse asks the preceptor how the Healthy People 2020 goals can affect a hospitalized client. Which response by the educator is the most appropriate?

1. "Healthy People 2020 is a tool for the healthcare providers to offer information to their clients."

2. "Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death."

3. "The purpose of Healthy People 2020 is to reduce healthcare costs for hospitalized clients."

4. "Healthy People 2020 is seen as a tool by hospitals to reduce length of stay."

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Knowledge and Practice: Health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1.7: Examine how national health policy is structured to enhance individual and population health.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The preceptor is reviewing a new nurse's goal statement of, "The client will resume normal bowel elimination patterns," created for the care plan of a client with irritable bowel syndrome. Which feedback should the preceptor provide the nurse?

1. "This plan of care has an appropriate goal statement which meets criteria."

2. "This goal statement requires a time frame to be appropriate."

3. "This goal statement is not reflective of the client's diagnosis."

4. "This care plan is accurate and should be entered in the client's medical record."

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Elimination

Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input; initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which goals should the nurse include in the initial health assessment? Select all that apply.

1. Determine the client's current state of health.

2. Predict risks to current health status.

3. Use only objective data to determine client allergies.

4. Identify the client's ongoing health activities.

5. Identify the client's ability to adhere to treatment.

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. During a physical assessment of a client, the nurse notes wheezing and documents the findings in the medical record. Which phase of critical thinking is represented by the nurse's actions?

1. Collection of information.

2. Evaluation.

3. Generation of alternatives.

4. Analysis of the situation.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based on new knowledge. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The nurse is obtaining an admission assessment. Which should the nurse document as subjective data? Select all that apply.

1. The client's mother informs the nurse that her daughter has not been sleeping due to pain.

2. The client states, "I have pain in my belly that is 7 out of 10."

3. Abdominal assessment reveals a firm, hard abdomen.

4. The client is weak and looks pale.

5. The client appears nervous during the data collection period.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is admitting a client to the unit. Which should the nurse consider when regarding the confidentiality of the client?

1. Information sharing is limited to those directly involved in the client care.

2. All members of the unit's healthcare team may have access to the chart.

3. The Health Insurance Portability and Accountability Act (HIPAA) determines who can communicate with the client.

4. The medical records are open to any hospital employee, including administration.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Confidentiality/Information Security

Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VIII.10. Protect patient privacy and confidentiality of patient records and other privileged communications. | NLN Competencies: Context and Environment: Act in accordance with legal and regulatory requirements, including HIPAA, for faculty's students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The preceptor is reviewing the effective use of the nursing process with a new nurse. Which statement by the nurse indicates an understanding of the information?

1. "The correct order of the nursing process is diagnosis, assessment, planning, implementation, and evaluation."

2. "The correct order of the nursing process is assessment, diagnosis, planning, implementation, and evaluation."

3. "The correct order of the nursing process is planning, assessment, diagnosis, implementation, and evaluation."

4. "The correct order of the nursing process is assessment, planning, diagnosis, implementation, and evaluation."

Page Ref: 5

Cognitive Level: Remembering

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The nurse is reviewing the role of the nurse practitioner. Which should the nurse recognize is the primary role?

1. Manage complex patient care areas.

2. Attend to the health of women of all ages.

3. Engagement in quality improvement.

4. Provide primary care in acute settings.

Page Ref: 3

Cognitive Level: Understanding

Client Need & Sub: Safe and Effective Care Environment; Concepts of Management

Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively and clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare.

MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.

1. The nurse recognizes that there needs to be a change in practice on the unit to improve the client outcomes. Which is the quickest method the nurse should consider to change current practice?

1. Research.

2. Literature review.

3. Quality improvement project.

4. Document patient outcomes.

Page Ref: 3

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Performance Improvement (Quality Improvement)

Standards: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based on new knowledge | AACN Essentials Competencies: III.5. Participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes. | NLN Competencies: Quality and Safety: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.2: Explain evidence-based practice and its significance in nursing.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is reviewing the advanced practice roles of the nurse. Which should the nurse recognize as the primary responsibility of the clinical nurse specialist?

1. Identify problems in regards to patient care, designs plans of study, and develops tools.

2. Provide generalized healthcare services, such as family planning, obstetric, and gynecological care.

3. Provide direct patient care, direct and teach other team members providing care, and conduct research within an area of specialization.

4. Combine expertise in diagnosis and illness with a nurse's understanding of health promotion and prevention.

Page Ref: 3

Cognitive Level: Understanding

Client Need & Sub: Safe and Effective Care Environment; Concepts of Management

Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare.

MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.

1. The nurse is preparing to conduct a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which initial action should the nurse take?

1. Obtain a urine sample.

2. Monitor the client's vital signs.

3. Assess the client's about dietary preferences.

4. Assess the characteristics of the client's pain.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is preparing to obtain a health history. Which should the nurse understand is the main purpose of obtaining a health history before a physical assessment?

1. Allows the nurse to gather objective data.

2. Provides a systematic means of gathering information.

3. Enables a nursing diagnosis to be generated.

4. Assists the examiner in accurately conducting a physical assessment.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.4: Define health assessment and identify key components.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is reviewing the goal statements for a postoperative client. Which goal statements should the nurse recognize needs further development? Select all that apply.

1. The nurse will assess the vital signs every 2 hours.

2. The client will ambulate every 6 hours on the first postoperative day.

3. The client will report feeling better by the end of the day.

4. The client will begin a clear liquid diet on the first postoperative day.

5. The nurse will administer oral analgesics as prescribed.

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse administrator is explaining their role to a new nurse. Which statement made by the new nurse indicates further teaching is required?

1. "You are available for consultation."

2. "You will be conducting research."

3. "You are responsible for staffing."

4. "You will be monitoring the goals of the organization."

Page Ref: 2

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Concepts of Management

Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively. Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.

1. The new nurse is reviewing a client's plan of care with the preceptor. Which statement made by the nurse should the preceptor be concerned with?

1. "I have created one goal per nursing diagnosis."

2. "I have created my goals based on the nursing diagnosis."

3. "I identified measurable goals during the planning."

4. "I have written the interventions based on my goals."

Page Ref: 5

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, and Supervision

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The nurse is reviewing a client's care plan. Which part of the nursing process should the nurse use to determine if new problems exist?

1. Assessment.

2. Evaluation.

3. Implementation.

4. Planning.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Personal and Professional Development: Identify problems. Apply decision-making skills, particularly in the context of uncertainty and ambiguity. | Nursing/Integrated Concepts: Nursing Process: Evaluating

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.

1. The preceptor is assessing a new nurse's ability to critically think. Which should the preceptor include in the assessment? Select all that apply.

1. Application of logic.

2. Use of resources.

3. Ability to problem solving.

4. Use of the nursing process.

5. Use of cognitive skills.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Personal and Professional Development: Identify problems and apply decision-making skills, particularly in the context of uncertainty and ambiguity. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The nurse is developing a client's plan of care. Which should the nurse base the plan of care on?

1. The nursing diagnosis.

2. The objective data.

3. The subjective data.

4. Client goals.

Page Ref: 5

Cognitive Level: Remembering

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is preparing to focus on the third step of the nursing process. Which should the nurse anticipate obtaining?

1. Statement of client goals.

2. Collection of subjective data.

3. Performance of care activities.

4. Review of client's achievement of goals.

Page Ref: 5

Cognitive Level: Remembering

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1.3: Explain the steps of the nursing process.

MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.

1. The nurse is reviewing the client's record for reports of pain. Which should the nurse consider subjective data? Select all that apply.

1. The client's leg is red and swollen.

2. The client complains of leg tenderness.

3. The client's white blood cell count is elevated

4. The client demonstrates guarding behavior during the assessment

5. The client states they have leg cramps.

Page Ref: 6

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.B.3. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.4: Define health assessment and identify key components.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. The nurse is evaluating the risk factors for health disparity. Which social determinant should the nurse consider places the clients in the community at risk?

1. Lack of access to healthcare services.

2. Nonadherence to health prevention.

3. Lack of participation in exercise.

4. Chronic substance abuse.

Page Ref: 7

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context of Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities.

MNL Learning Outcome: 1.4: Examine the components of health assessment.

1. Which should the nurse understand is the main focus of the Agency for Health Research and Quality?

1. Nursing practice guidelines.

2. Health promotion.

3. Produce evidence-based reports.

4. Address healthcare disparity.

Page Ref: 3

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context of Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1.7: Examine how national health policy is structured to enhance individual and population health.

MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its use in nursing.