Evidence-Based Physical Examination Best Practices for Health & Well- bv bv bv bv bv bv bv bv
BeingAssessment 1st Edition Test Bank b
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Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
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BEING
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MULTIPLE CHOICE bv
1. After completing an initial assessment of a patient, the nurse has charted that his
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respirationsare eupneic and his pulse is 58 beats per minute. These types of data would be:
bv v
b bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A bv
Objective data are what the health professional observes by inspecting, percussing, palpating,
bv bv bv bv bv bv bv bv bv bv bv
and auscultating during the physical examination. Subjective data is what the person says
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abouthim or herself during history taking. The terms reflective and introspective are not used to
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
describe data.
bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
ofdata would be:
bv bv bv bv
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C bv
Subjective data are what the person says about him or herself during history taking. Objective
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,data are what the health professional observes by inspecting, percussing, palpating, and
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auscultating during the physical examination. The terms reflective and introspective are not
bv bv bv bv bv bv bv bv bv bv bv bv
usedto describe data.
bv bv bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to
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formthe:
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a Data base. bv
.
b Admitting data. bv
.
c Financial statement. bv
.
d Discharge summary. bv
.
ANS: A bv
Together with the patients record and laboratory studies, the objective and subjective data
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formthe data base. The other items are not part of the patients record, laboratory studies, or data.
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
Thenurses next action should be to:
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a Immediately notify the patients physician. bv bv bv bv
.
b Document the sound exactly as it was heard. bv bv bv bv bv bv bv
.
c Validate the data by asking a coworker to listen to the breath sounds.
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.
d Assess again in 20 minutes to note whether the sound is still present.
bv bv bv bv bv bv bv bv bv bv bv bv
.
ANS: C bv
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
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data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
expertto listen.
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,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
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nurse should keep in mind that novice nurses, without a background of skills and
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experiencefrom which to draw, are more likely to make their decisions using:
bv v
b bv bv bv bv bv bv bv bv bv bv b v
a Intuition.
.
b A set of rules.
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.
c Articles in journals. bv bv
.
d Advice from supervisors. bv bv
.
ANS: B bv
Novice nurses operate from a set of defined, structured rules. The expert practitioner usesintuitive
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links.
bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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3MSC: Client Needs: General
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6. Expert nurses learn to attend to a pattern of assessment data and act without
bv bv bv bv bv bv bv bv bv bv bv bv bv
consciouslylabeling it. These responses are referred to as:
bv v
b bv bv bv bv bv bv bv
a Intuition.
.
b The nursing process. bv bv
.
c Clinical knowledge. bv
.
d Diagnostic reasoning. bv
.
ANS: A bv
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
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ofassessment data and act without consciously labeling it. The other options are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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4MSC: Client Needs: General
bv bv bv bv bv
7. The nurse is reviewing information about evidence-based practice (EBP). Which
bv bv bv bv bv bv bv bv bv
statementbest reflects EBP?
bv bv bv bv
, a EBP relies on tradition for support of best practices.
bv bv bv bv bv bv bv bv
.
b EBP is simply the use of best practice techniques for the treatment of patients.
bv bv bv bv bv bv bv bv bv bv bv bv bv
.
c EBP emphasizes the use of best evidence with the clinicians experience.
bv bv bv bv bv bv bv bv bv bv bv
.
d The patients own preferences are not important with EBP.
bv bv bv bv bv bv bv bv
.
ANS: C bv
EBP is a systematic approach to practice that emphasizes the use of best evidence in
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combinationwith the clinicians experience, as well as patient preferences and values, when
bv v
b bv bv bv bv bv bv bv bv bv bv bv
making decisions about care and treatment. EBP is more than simply using the best practice
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techniques to treat patients, and questioning tradition is important when no compelling and
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supportive research evidence exists.
bv bv bv bv
DIF: Cognitive Level: Applying (Application) REF: z. 5
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Whichis
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
an example of a first-level priority problem?
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a Patient with postoperative pain bv bv bv
.
b Newly diagnosed patient with diabetes who needs diabetic teaching
bv bv bv bv bv bv bv bv
.
c Individual with a small laceration on the sole of the foot bv bv bv bv bv bv bv bv bv bv
.
d Individual with shortness of breath and respiratory distress bv bv bv bv bv bv bv
.
ANS: D bv
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
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establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
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vitalsigns) (see Table 1-1).
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
9. When considering priority setting of problems, the nurse keeps in mind that second-
bv bv bv bv bv bv bv bv bv bv bv bv
levelpriority problems include which of these aspects?
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BeingAssessment 1st Edition Test Bank b
v bv bv bv bv
Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
bv bv bv bv bv bv bv bv bv
BEING
bv
MULTIPLE CHOICE bv
1. After completing an initial assessment of a patient, the nurse has charted that his
bv bv bv bv bv bv bv bv bv bv bv bv bv
respirationsare eupneic and his pulse is 58 beats per minute. These types of data would be:
bv v
b bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A bv
Objective data are what the health professional observes by inspecting, percussing, palpating,
bv bv bv bv bv bv bv bv bv bv bv
and auscultating during the physical examination. Subjective data is what the person says
bv bv bv bv bv bv bv bv bv bv bv bv bv
abouthim or herself during history taking. The terms reflective and introspective are not used to
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
describe data.
bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
ofdata would be:
bv bv bv bv
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C bv
Subjective data are what the person says about him or herself during history taking. Objective
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
,data are what the health professional observes by inspecting, percussing, palpating, and
bv bv bv bv bv bv bv bv bv bv bv
auscultating during the physical examination. The terms reflective and introspective are not
bv bv bv bv bv bv bv bv bv bv bv bv
usedto describe data.
bv bv bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
3. The patients record, laboratory studies, objective data, and subjective data combine to
bv bv bv bv bv bv bv bv bv bv bv
formthe:
bv bv
a Data base. bv
.
b Admitting data. bv
.
c Financial statement. bv
.
d Discharge summary. bv
.
ANS: A bv
Together with the patients record and laboratory studies, the objective and subjective data
bv bv bv bv bv bv bv bv bv bv bv bv
formthe data base. The other items are not part of the patients record, laboratory studies, or data.
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
Thenurses next action should be to:
bv bv bv bv bv bv bv
a Immediately notify the patients physician. bv bv bv bv
.
b Document the sound exactly as it was heard. bv bv bv bv bv bv bv
.
c Validate the data by asking a coworker to listen to the breath sounds.
bv bv bv bv bv bv bv bv bv bv bv bv
.
d Assess again in 20 minutes to note whether the sound is still present.
bv bv bv bv bv bv bv bv bv bv bv bv
.
ANS: C bv
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
expertto listen.
bv bv bv
,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
nurse should keep in mind that novice nurses, without a background of skills and
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
experiencefrom which to draw, are more likely to make their decisions using:
bv v
b bv bv bv bv bv bv bv bv bv bv b v
a Intuition.
.
b A set of rules.
bv bv bv
.
c Articles in journals. bv bv
.
d Advice from supervisors. bv bv
.
ANS: B bv
Novice nurses operate from a set of defined, structured rules. The expert practitioner usesintuitive
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
links.
bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z.
bv bv bv bv bv bv
3MSC: Client Needs: General
bv bv bv bv bv
6. Expert nurses learn to attend to a pattern of assessment data and act without
bv bv bv bv bv bv bv bv bv bv bv bv bv
consciouslylabeling it. These responses are referred to as:
bv v
b bv bv bv bv bv bv bv
a Intuition.
.
b The nursing process. bv bv
.
c Clinical knowledge. bv
.
d Diagnostic reasoning. bv
.
ANS: A bv
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
bv bv bv bv bv bv bv bv bv bv bv bv
ofassessment data and act without consciously labeling it. The other options are not correct.
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z.
bv bv bv bv bv bv
4MSC: Client Needs: General
bv bv bv bv bv
7. The nurse is reviewing information about evidence-based practice (EBP). Which
bv bv bv bv bv bv bv bv bv
statementbest reflects EBP?
bv bv bv bv
, a EBP relies on tradition for support of best practices.
bv bv bv bv bv bv bv bv
.
b EBP is simply the use of best practice techniques for the treatment of patients.
bv bv bv bv bv bv bv bv bv bv bv bv bv
.
c EBP emphasizes the use of best evidence with the clinicians experience.
bv bv bv bv bv bv bv bv bv bv bv
.
d The patients own preferences are not important with EBP.
bv bv bv bv bv bv bv bv
.
ANS: C bv
EBP is a systematic approach to practice that emphasizes the use of best evidence in
bv bv bv bv bv bv bv bv bv bv bv bv bv bv
combinationwith the clinicians experience, as well as patient preferences and values, when
bv v
b bv bv bv bv bv bv bv bv bv bv bv
making decisions about care and treatment. EBP is more than simply using the best practice
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
techniques to treat patients, and questioning tradition is important when no compelling and
bv bv bv bv bv bv bv bv bv bv bv bv bv
supportive research evidence exists.
bv bv bv bv
DIF: Cognitive Level: Applying (Application) REF: z. 5
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Whichis
bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv bv
an example of a first-level priority problem?
bv bv bv bv bv bv bv
a Patient with postoperative pain bv bv bv
.
b Newly diagnosed patient with diabetes who needs diabetic teaching
bv bv bv bv bv bv bv bv
.
c Individual with a small laceration on the sole of the foot bv bv bv bv bv bv bv bv bv bv
.
d Individual with shortness of breath and respiratory distress bv bv bv bv bv bv bv
.
ANS: D bv
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
bv bv bv bv bv bv bv bv bv bv bv bv
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
bv bv bv bv bv bv bv bv bv
vitalsigns) (see Table 1-1).
bv bv bv bv bv
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
bv bv bv bv bv bv bv
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
bv bv bv bv bv bv bv bv bv bv
9. When considering priority setting of problems, the nurse keeps in mind that second-
bv bv bv bv bv bv bv bv bv bv bv bv
levelpriority problems include which of these aspects?
bv bv bv bv bv bv b v
