Chapter 01: Evidence-Based Assessment
MULTIPLE CHOICE
After completing an initial assessment of a patient, the nurse has charted that
his respirations are eupneic and his pulse is 58 beats per minute. These types
of data would be:
Objective.
Reflective.
Subjective.
Introspective.
ANS: A
Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination.
Subjective data is what the person says ab ut him or herself during history
taking. The terms reflective and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
A patient tells the nurse that he is very nervous, is na seated, and feels hot.
These types of data would be:
Objective.
Reflective.
Subjective.
Introspective.
ANS: C
Subjective data are what the person says about him or herself during history
taking. Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. The
terms reflective and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
The patients record, laboratory studies, objective data, and subjective data
combine to form the:
Data base.
Admitting data.
,
,Financial statement.
Discharge summary.
ANS: A
Together with the patients record and laboratory studies, the objective and
subjective data form the data base.
The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
When listening to a patients breath sounds, the nurse is unsure of a sound
that is heard. The nurses next action should be to:
Immediately notify the patients physician.
Document the sound exactly as it was heard.
Validate the data by asking a coworker to listen to the breath sounds.
Assess again in 20 minutes to note whether the ound is still present.
ANS: C
When unsure of a sound heard while listening to a patients breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in
n rea, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analy i )
MSC: Client Needs: Safe and Eff ctive Care Environment: Management of Care
The nurse is conducting a class for new graduate nurses. During the teaching
session, the nurse should keep in mind that novice nurses, without a
background of skills and experience from which to draw, are more likely to
make their decisions using:
Intuition.
A set of rules.
Articles in journals.
Advice from supervisors.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links.
DIF: Cognitive Level: Understanding (Comprehension)
,
MULTIPLE CHOICE
After completing an initial assessment of a patient, the nurse has charted that
his respirations are eupneic and his pulse is 58 beats per minute. These types
of data would be:
Objective.
Reflective.
Subjective.
Introspective.
ANS: A
Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination.
Subjective data is what the person says ab ut him or herself during history
taking. The terms reflective and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
A patient tells the nurse that he is very nervous, is na seated, and feels hot.
These types of data would be:
Objective.
Reflective.
Subjective.
Introspective.
ANS: C
Subjective data are what the person says about him or herself during history
taking. Objective data are what the health professional observes by inspecting,
percussing, palpating, and auscultating during the physical examination. The
terms reflective and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
The patients record, laboratory studies, objective data, and subjective data
combine to form the:
Data base.
Admitting data.
,
,Financial statement.
Discharge summary.
ANS: A
Together with the patients record and laboratory studies, the objective and
subjective data form the data base.
The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
When listening to a patients breath sounds, the nurse is unsure of a sound
that is heard. The nurses next action should be to:
Immediately notify the patients physician.
Document the sound exactly as it was heard.
Validate the data by asking a coworker to listen to the breath sounds.
Assess again in 20 minutes to note whether the ound is still present.
ANS: C
When unsure of a sound heard while listening to a patients breath sounds, the
nurse validates the data to ensure accuracy. If the nurse has less experience in
n rea, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analy i )
MSC: Client Needs: Safe and Eff ctive Care Environment: Management of Care
The nurse is conducting a class for new graduate nurses. During the teaching
session, the nurse should keep in mind that novice nurses, without a
background of skills and experience from which to draw, are more likely to
make their decisions using:
Intuition.
A set of rules.
Articles in journals.
Advice from supervisors.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert
practitioner uses intuitive links.
DIF: Cognitive Level: Understanding (Comprehension)
,
