Description
Bates Nursing Guide to Physical Examination and History Taking Hogan-Quigley Test Bank
Chapter 2- Critical Thinking in Health Assessment
| 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) | Assessment |
| B) | Diagnosis |
| C) | Planning |
| D) | Evaluation |
| 2. | The nurse is changing a patient’s plan of care because identified goals have not been achieved. The nurse is working within which phase of the nursing process? |
| A) | Assessment |
| B) | Planning |
| C) | Implementation |
| D) | Evaluation |
| 3. | During an assessment, the nurse asks a patient with low back pain what has been used to try to alleviate the pain. The nurse is asking questions to determine which category of the mnemonic OLD CART? |
| A) | Treatments |
| B) | Duration |
| C) | Location |
| D) | Onset |
| 4. | The nurse is completing an assessment of a patient with cardiac and respiratory problems. Which data would the nurse categorize as subjective? |
| A) | Blood pressure 168/94 mm Hg |
| B) | Respiratory rate 28 and shallow |
| C) | Heart rate 94 and irregular |
| D) | Palpitations every morning |
| 5. | After completing an assessment, the nurse is generating the patient’s problem list. Which problem would have the highest priority for the patient? |
| A) | Shoulder pain |
| B) | Insomnia |
| C) | Anxiety about work |
| D) | Lack of appetite |
| 6. | The nurse has identified that a patient has 24 health issues to be included on the problem list. What can the nurse do to help focus on the patient’s most acute health care needs first? |
| A) | Place the problems in alphabetical order. |
| B) | Separate the list into active and inactive problems. |
| C) | List the problems according to body system. |
| D) | Ask the patient which problem is the highest priority. |
| 7. | The nurse is determining diagnoses that would be appropriate for a patient with heart failure. Which diagnosis would have the highest priority for the patient? |
| A) | Activity intolerance related to shortness of breath and fatigue |
| B) | Ineffective health maintenance related to last mammogram being 2 years ago |
| C) | Knowledge deficit related to lack of information regarding low-sodium diet |
| D) | Anxiety related to hospitalization and inability to attend to home and work needs |
| 8. | The nurse is developing nursing diagnosis for a patient. Which health concerns would be appropriate for the nurse to identify as health maintenance problems? (Select all that apply.) |
| A) | Prescribed medication to treat prostate cancer |
| B) | Instruction needed on newly prescribed renal diet |
| C) | Importance of having pneumococcal pneumonia vaccination |
| D) | Exercises for range of motion and mobility due to arthritis |
| E) | Schedule for hemodialysis to start three times each week |
| 9. | The nurse has completed a plan of care for a patient having a total knee replacement. What should the nurse do prior to implementing this plan of care? |
| A) | Discuss the plan of care with the nurse manager. |
| B) | Share the assessment and plan with the admitting health care provider. |
| C) | Ask the patient for opinions and willingness to proceed with the interventions. |
| D) | Identify which quality improvement activities will be included in the plan of care. |
| 10. | After reassessing a patient with a foot wound, the nurse identifies a new health problem of reduced breath sounds in both lung bases. What should the nurse do with this information? (Select all that apply.) |
| A) | Notify the nurse manager. |
| B) | Formulate a nursing diagnosis. |
| C) | Add interventions to the care plan. |
| D) | Add the new problem to the problem list. |
| E) | Nothing because this is an expected finding. |
Answer Key
| 1. | C |
| 2. | D |
| 3. | A |
| 4. | D |
| 5. | A |
| 6. | B |
| 7. | A |
| 8. | B, C, D |
| 9. | C |
| 10. | B, C, D |
