chapter 2- critical thinking in health assessment

8/20/2019 Chapter 2- Critical Thinking in Health Assessment

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1.The nurse is working with a patient to identify health goals and interventions to achieve

the goals. In which phase of the nursing process are the nurse and patient participating?

A) AssessmentB) Diagnosis

) !lanning

D) "valuation

#.The nurse is changing a patient$s plan of care %ecause identified goals have not %eenachieved. The nurse is working within which phase of the nursing process?

A) Assessment

B) !lanning

) ImplementationD) "valuation

&.During an assessment' the nurse asks a patient with low %ack pain what has %een used totry to alleviate the pain. The nurse is asking (uestions to determine which category of the

mnemonic *D A+T?A) Treatments

B) Duration

) *ocationD) nset

,.The nurse is completing an assessment of a patient with cardiac and respiratory pro%lems.-hich data would the nurse categorie as su%/ective?

A) Blood pressure 1023, mm 4gB) +espiratory rate # and shallow) 4eart rate 3, and irregular

D) !alpitations every morning

5.After completing an assessment' the nurse is generating the patient$s pro%lem list. -hich

pro%lem would have the highest priority for the patient?

A) 6houlder painB) Insomnia

) An7iety a%out work

D) *ack of appetite

0.The nurse has identified that a patient has #, health issues to %e included on the pro%lemlist. -hat can the nurse do to help focus on the patient$s most acute health care needs

first?

A) !lace the pro%lems in alpha%etical order.

B) 6eparate the list into active and inactive pro%lems.) *ist the pro%lems according to %ody system.

D) Ask the patient which pro%lem is the highest priority.

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8.The nurse is determining diagnoses that would %e appropriate for a patient with heartfailure. -hich diagnosis would have the highest priority for the patient?

A) Activity intolerance related to shortness of %reath and fatigue

B) Ineffective health maintenance related to last mammogram %eing # years ago) 9nowledge deficit related to lack of information regarding low:sodium diet

D) An7iety related to hospitaliation and ina%ility to attend to home and work needs

.The nurse is developing nursing diagnosis for a patient. -hich health concerns would %e

appropriate for the nurse to identify as health maintenance pro%lems? ;6elect all that

apply.)A) !rescri%ed medication to treat prostate cancer

B) Instruction needed on newly prescri%ed renal diet

) Importance of having pneumococcal pneumonia vaccination

D) "7ercises for range of motion and mo%ility due to arthritis") 6chedule for hemodialysis to start three times each week

3.The nurse has completed a plan of care for a patient having a total knee replacement.

-hat should the nurse do prior to implementing this plan of care?A) Discuss the plan of care with the nurse manager.

B) 6hare the assessment and plan with the admitting health care provider.

) Ask the patient for opinions and willingness to proceed with the interventions.

D) Identify which (uality improvement activities will %e included in the plan of care.

1<.After reassessing a patient with a foot wound' the nurse identifies a new health pro%lemof reduced %reath sounds in %oth lung %ases. -hat should the nurse do with this

information? ;6elect all that apply.)

A) =otify the nurse manager.B) >ormulate a nursing diagnosis.

) Add interventions to the care plan.

D) Add the new pro%lem to the pro%lem list.

") =othing %ecause this is an e7pected finding.

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Answer Key

1.#.D

&.A

,.D5.A

0.B

8.A.B' ' D

3.

1<.B' ' D

!age &

chapter 2- critical thinking in health assessment

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