Evidence Based Assessment (Chapter 1)

Question 1

what is data collection

Answer 1

the collection of data about an individuals health state

Question 2

what is required for sound diagnostic reasoning and clinical judgment

Answer 2

critical thinking

Question 3

what is the purpose of an assessment

Answer 3

to make a judgment or diagnosis

Question 4

what type of diagnosis do nurses make

Answer 4

nursing diagnosis (not medical)

Question 5

what are cues

Answer 5

pieces of data that help the nurse make diagnosis

Question 6

what form the database

Answer 6

subjective data
objective data
patients record
lab studies

Question 7

subjective data

Answer 7

what the patient tells you during interaction

Question 8

objective data

Answer 8

info from assessment

Question 9

what type of data would this be
- 76 bpm
- 3.8 Potassium
- 129 Sodium

Answer 9

objective

Question 10

what type of data would this be
- “I have not been able to put weight on my left leg for 4 days now”

Answer 10

subjective

Question 11

what type of data is typically pain

Answer 11

subjective

Question 12

what type of data would this be
- double mastectomy (found in chart)

Answer 12

objective

Question 13

what are the 3 dimensions of critical thinking

Answer 13

theory and experiential knowledge to preform that nursing process
commitment to learning to think critically
psychomotor and manual skill development

Question 14

what is always the first step of the nursing process

Answer 14

assessment

Question 15

why is assessment always the first step of the nursing process

Answer 15

build on data we collect

Question 16

steps of nursing process in order

Answer 16

assessment
diagnosis
outcome identification
planning
implementation
evaluation

Question 17

what do outcome identification and planning do

Answer 17

the outcome we want to see happen
goals

Question 18

what does implementation do

Answer 18

things to implement or take away to reach goal

Question 19

what does evaluation do

Answer 19

did we reach the goals

Question 20

why is important to preform a consultation when collecting data

Answer 20

to see if there is a reason or trend with abnormal finding

Question 21

what are first level priorities

Answer 21

airway
breathing
circulation

Question 22

what are second level priorities

Answer 22

acute pain
change in mental status
infection

Question 23

what are third level priorities

Answer 23

lack of knowledge
family coping
activity
rest

Question 24

what are clusters

Answer 24

groups of cues of abnormal values to help make a diagnosis

Question 25

how would we validate not being able to feel a pulse on a patient who is fully aware

Answer 25

use a doppler to feel use stethoscope to listen to apical pulse

Question 26

how would we validate a patient who looks out of breath

Answer 26

use a pulse ox to determine oxygen saturation

Question 27

is validating information always a numerical value

Answer 27

no

Question 28

complete (total health) database

Answer 28

focus on all body systems

Question 29

Emergency database (or problem centered database)

Answer 29

focus only on one system

Question 30

follow up data base

Answer 30

made after a diagnosis

Question 31

what is EBP

Answer 31

systematic approach to practice that emphasizes the use of best evidence

Question 32

5 steps to evidence based practice

Answer 32

ask the clinical question acquire sources of evidence appraise and synthesize evidence apply relevant evidence in practice assess the outcomes

Question 33

validation of data entails 1. distinguishing normal from abnormal 2. making interferences 3. using an organized and comprehensive approach 4. checking the accuracy and reliability of the data

Answer 33

4. checking the accuracy and reliability of the data

Question 34

which critical thinking skill helps the nurse to see relationships among the data 1. validation 2. clustering related cues 3. identifying gaps in data 4. distinguishing relevant from irrelevant

Answer 34

2. clustering related cues

Question 35

an example of subjective data is 1. decreased range of motion 2. crepitation in the left knee joint 3. left knee has been swollen and hot for the past 3 days 4. arthritis

Answer 35

3. left knee has been swollen and hot for the past 3 days (this could be objective if the 3 days was not said since hot and swollen is objective data)

Question 36

which of the following is considered an example of objective data 1. alert and oriented 2. dizziness 3. an earache 4. sore throat

Answer 36

1. alert and oriented (cannot assess dizziness, earache, sore throat, cannot assess pain)

Question 37

first level priority AKA

Answer 37

life threatening

Question 38

second level priority AKA

Answer 38

urgent

Question 39

third level priority AKA

Answer 39

can wait

Question 40

what priority would be a BP of 60/40

Answer 40

first level priority

Question 41

what priority would be difficulty breathing, pulse oximeter 88 on room air

Answer 41

first level priority

Question 42

what priority would be hunger and thirst

Answer 42

third priority

Question 43

what priority is anxiety

Answer 43

second priority (could be first if patient is having extreme anxiety attack with hyperventilating)

Question 44

what priority would a temp of 103 F

Answer 44

second priority

Question 45

an adult with a temp of 103 in an adult would be a second priority but if that infant had that same temp what would be the priority

Answer 45

first priority