11/11/23,w6:40wP TestwBankw-
M wPhysicalwExaminationwandwHealthwAssessmentw8ew(bywJarvis)w1w…
Test wBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w1 w
Chapter w01: wEvidence-Based wAssessment
MULTIPLE w CHOICE
1. After wcompleting wan winitial wassessment wof wawpatient, wthewnursewhas wcharted wthat whis wrespiratio
ns wareweupneic wand w his wpulse wis w58 wbeats wper wminute. wThesewtypes wof wdataw would wbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
w ANS: wA
Objective wdataware wwhat wthe whealth wprofessional wobserves wby winspecting, wpercussing, wpalpating, wa
nd wauscultating w during wthewphysical wexamination. wSubjective wdatawis wwhat wthewperson wsays wabo
ut whim wor wherself wduring whistory
taking. wThe wterms wreflectivewand wintrospective w arewnot wused wtowdescribewdata. wDIF:wCognitivewLevel: wUnderstandi
ng w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
2. A wpatient wtells wthewnursewthat whe wis wverywnervous, wis w nauseated, wand wfeels whot. wThesewtypes w of wdatawwould wbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
w ANS: wC
Subjectivewdatawarewwhat wthe wperson wsays wabout whim wor wherself wduring whistorywtaking. wObjectiv
ewdatawarewwhat wthew health wprofessional wobserves wbyw inspecting, wpercussing, wpalpating, wand wa
uscultating wduring wthewphysical
examination. wThewterms wreflective wand wintrospective warewnot wused wtowdescribe wdata. wDIF: wCognitivewLevel: wUnderstanding
w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
3. Thewpatients wrecord, wlaboratorywstudies, wobjectivewdata, wand wsubjectivewdatawcombinewtowform wthe:
a. Datawbase.
b. Admitting wdata.
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w2
c. Financialw statement.
d. Dischargewsummary
.w ANS: wA
Together wwith wthewpatients wrecord wand wlaboratory wstudies, wthewobjectivewand wsubjectivewdatawform wthewdatawbase. wThe wother wit
ems warewnot wpart wof wthew patients wrecord, wlaboratorywstudies, wor wdata. wDIF: wCognitivewLevel: wRemembering w(Knowledge)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
4. When wlistening wtowa wpatients wbreath wsounds, wthewnursewis wunsure wof wawsound wthat wis wh
eard. wThewnurses wnext w action wshould wbewto:
a. Immediatelywnotifyw thewpatients w physician.
b. Document wthe wsound wexactlywas wit w was wheard.
c. Validatewthewdatawby wasking wa wcoworker wtowlisten wtowthewbreath wsounds.
d. Assess wagain win w20 wminutes wtownotewwhether wthewsound wi
s wstillwpresent. w ANS: wC
When wunsurewof wawsound wheard wwhilewlistening wtowawpatients wbreath wsounds, w thewnursewvalidates wthe wdatawtowensure
accuracy. wIf wthewnursewhas wless wexperiencewin wan warea, wthen whe wor wshewasks wan wexpert wtowlisten. wDIF: wCognitive wL
evel: wAnalyzing w(Analysis) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
5. Thewnursewis wconducting wawclass wfor wnew wgraduatewnurses. wDuring wthewteaching wsession, wthe
wnursewshould wkeep w in wmind wthat wnovicewnurses, wwithout wawbackground wof wskills wand wexperien
cewfrom wwhich wtowdraw, warewmorewlikely
towmake wtheir wdecisions wusing:
a. Intuition.
b. A wset w of w rules.
c. Articles win wjournals.
d. Advicewfrom wsuperviso
rs.w ANS: wB
Novicewnurses woperate wfrom w awset wof wdefined, wstructured wrules. wThewexpert wpractitioner wuses wintuitivewlinks. wDIF:wCognitivewLe
vel: wUnderstanding w (Comprehension)
Test wBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w3 w
MSC: wClient wNeeds: wGeneral
6. Expert wnurses wlearn wtowattend wtowawpattern wof wassessment wdatawand wact wwithout wconsciousl
ywlabeling wit. wThesew responses warewreferred wtow as:
a. Intuition.
b. Thew nursingwprocess.
c. Clinical wknowledge.
d. Diagnostic wreasoning
.w ANS: wA
Intuition wis wcharacterized wbyw pattern wrecognitionexpert wnurses wlearn wtowattend wto wawpattern wof wassessment wdatawand
act wwithout wconsciouslywlabeling wit. wThewother woptions warewnot wcorrect. wDIF: wCognitivewLevel: wUnderstanding w(
Comprehension) w MSC: wClient wNeeds: wGeneral
7. Thewnursewis wreviewing winformation wabout wevidence-based wpracticew(EBP). wW hich wstatement wbest wreflects
EBP?
a. EBP wrelies won wtradition wfor wsupport wof wbest wpractices.
b. EBP wis wsimplywthewusewof w best w practicewtechniques wfor wthewtreatment wof wpatients.
c. EBP wemphasizes wthe wusewof wbest wevidencewwith wthewclinicians w experience.
d. Thewpatients wown wpreferences warewnot wimportant w
with wEBP. w ANS: wC
EBP wis wawsystematic wapproach wtowpracticewthat wemphasizes wthewusewof wbest wevidencewin wcom
bination wwith wthew clinicians wexperience, was wwell was wpatient wpreferences wand wvalues, wwhen wmaki
ng wdecisions wabout wcarewand w treatment. wEBP wis wmorewthan wsimplywusing wthe wbest wpracticewte
chniques wtowtreat wpatients, wand wquestioning
tradition wis wimportant wwhen wnowcompelling wand wsupportive wresearch wevidence wexists. wDIF: wCognitivewLevel: wAp
plying w(Application) w MSC: wClient wNeeds: wSafewand wEffectivewCare wEnvironment: wManagement wof wCare
8. Thewnursewis wconducting wawclass won wprioritywsetting wfor wawgroup wof wnew wgraduatewnurses.
wW hich wis wan wexamplew of wawfirst-level wprioritywproblem?
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a. Patient wwith wpostoperative wpain
b. Newlywdiagnosed wpatient wwith wdiabetes wwhowneeds wdiabetic wt
eaching w TestwBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w4
c. Individual wwith wawsmall wlaceration won wthewsolewof wthewfoot
d. Individual wwith wshortness wof wbreath wand wrespiratory
wdistress w ANS: wD
First-level wprioritywproblems ware wthosewthat ware wemergent, wlifewthreatening, wand wimmediate w(e.g., westablishing wan
airway, wsupporting wbreathing, wmaintaining wcirculation, wmonitoring wabnormal wvital wsigns). wDIF: wCognitivewLevel: wUnderstanding w(Co
mprehension) w MSC: wClient wNeeds: wSafewand wEffectivew CarewEnvironment: wManagement wof wCare
9. When wconsidering wprioritywsetting wof wproblems, wthewnursewkeeps win wmind wthat wsecond-
level wprioritywproblems w includewwhich wof wthesewaspects?
a. Low wself-esteem
b. Lack wof w knowledge
c. Abnormalwlaboratoryw values
d. Severelywabnormal wvital ws
igns w ANS: wC
Second-
level wprioritywproblems warewthose wthat wrequirewprompt wintervention wtowforestall wfurther wdeterioration w(e.g., wmental wstatus wchange, w
acute wpain, w abnormal wlaboratory wvalues, wrisks wtowsafetywor wsecurity). wDIF: wCognitivewLevel: wUnderstanding w(Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
10. Which wcritical wthinking wskill whelps wthewnursewsee wrelationships wamong wthe wdata?
a. Validation
b. Clusteringw relatedw cues
c. Identifying wgaps win wdata
d. Distinguishingwrelevantwfromwirrelev
antw ANS: wB
Clustering wrelated wcues whelps wthewnursewsee wrelationships wamong wthe wdata. wDIF: wCognitivewLevel: wUnderstanding
w(Comprehension) w MSC: wClient wNeeds: wSafew and wEffective wCarewEnvironment: wManagement wof wCare
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w5
11. Thewnursewknows wthat wdeveloping wappropriatewnursing winterventions wfor wa wpatien
twrelies won wthew appropriateness wof wthew diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
w ANS: wA
An waccuratewnursing wdiagnosis wprovides wthewbasis wfor wthe wselection wof wnursing winterventions wto
wachieve woutcomes w for wwhich wthewnursewis waccountable. wThewother witems wdownot wcontributewt
owthewdevelopment wof wappropriate wnursing w interventions. wDIF: wCognitivewLevel: wUnderstanding w(
Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
12. Thewnursing wprocess wis wawsequential wmethod wof wproblem wsolving wthat wnurses wusewand wincludes wwhich wsteps?
a. Assessment, wtreatment, wplanning, wevaluation, wdischarge, wand wfollow-up
b. Admission, wassessment, wdiagnosis, wtreatment, wand wdischargewplanning
c. Admission, w diagnosis, w treatment, w evaluation, w andw dischargew planning
d. Assessment, wdiagnosis, woutcome widentification, wplanning, wimplementation, wand w
evaluation w ANS: wD
Thewnursing wprocess wis wawmethod wof wproblem wsolving wthat wincludes wassessment, wdiagnosis, wo
utcomew identification, wplanning, wimplementation, wand wevaluation. wDIF: wCognitive wLevel: wUnderstan
ding w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagemen
twof wCare
13. A wnewlyw admitted wpatient wis win wacutewpain, whas wnot wbeen wsleeping wwell wlately, wan
d wis whaving wdifficultyw breathing. wHow wshould wthewnursewprioritizewthesewproblems?
a. Breathing, w pain,w andw sleep
b. Breathing, w sleep,w andwpain
c. Sleep,w breathing,w andw pain
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w6
d. Sleep,wpain,w andwbreat
hingw ANS: wA
First-levelw priorityw problems w arew immediatew priorities,w rememberingwthew ABCs w (airway,w breathing, w and
circulation), wfollowed wbywsecond-level wproblems, wand wthen wthird-
level wproblems. wDIF: wCognitivewLevel: wAnalyzing w(Analysis) w MSC: wClient wNeeds: wSafewand wEffectivewCar
ewEnvironment: wManagement wof wCare
14. Which wof wthesewwould wbewformulated wbywawnursewusing wdiagnostic wreasoning?
a. Nursingw diagnosis
b. Medical wdiagnosis
c. Diagnostic whypothesis
d. Diagnostic wassessme
ntw ANS: wC
Diagnostic wreasoning wcalls wfor wthe wnursewtowformulatewa wdiagnostic whypothesis; wthewnursing wproc
ess wcalls wfor waw nursing wdiagnosis. wDIF: wCognitivewLevel:wUnderstanding w(Comprehension)
MSC: w ClientwNeeds: wGeneral
15. Barriers w towincorporatingw EBP w include:
a. Nurses wlack wof wresearch wskills win wevaluating wthewqualityw of wresearch wstudies.
b. Lack wof wsignificant wresearch wstudies.
c. Insufficient w clinical wskills w of w nurses.
d. Inadequatewphysical wassessment ws
kills. w ANS: wA
As windividuals, wnurses wlack wresearch wskills win wevaluating wthewqualitywof wresearch wstudies, warewis
olated wfrom wother w colleagues wwhoware wknowledgeable win wresearch, wand woften wlack wthewtimewto
wvisitwthewlibrarywtowread wresearch. wThew other wresponses warewnot wconsidered wbarriers. wDIF: wC
ognitivewLevel: wUnderstanding w(Comprehension)
MSC: w ClientwNeeds: wGeneral
16. What wstep wof wthewnursing wprocess wincludes wdatawcollection wbywhealth whistory, wphysical w
examination, wand w interview?
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TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w7
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
w ANS: wD
Datawcollection, wincluding wperforming wthe whealth whistory, wphysical wexamination, wand winterview, wis wthe wassessment
step wof wthe wnursing wprocess. wDIF: wCognitivewLevel: wRemembering w(
Knowledge) w MSC: wClient wNeeds: wGeneral
17. During wawstaff wmeeting, wnurses wdiscuss wthewproblems wwith waccessing wresearch wstudies w
towincorporatew evidence-
based wclinical wdecision wmaking wintowtheir wpractice. wW hichwsuggestion wby wthe wnursewmanager
wwould w best w help wthesewproblems?
a. Form wa wcommitteewtowconduct wresearch wstudies.
b. Postwpublished wresearch wstudies won wthewunits wbulletin wboards.
c. Encouragewthewnurses wtowvisit wthewlibraryw towreview wstudies.
d. Teach wthewnurses whow wtowconduct welectronic wsearches wfor wrese
arch wstudies. w ANS: wD
Facilitating wsupport wfor wEBP wwould wincludewteaching wthewnurses whow wtowconduct welectronic ws
earches; wtime wtow visitwthewlibrarywmaywnot wbe wavailablewfor wmanywnurses. wActuallywconductin
g wresearch wstudies wmaywbe whelpful win
thewlong-
run wbut wnot wan wimmediatewsolution wtowreviewing wexisting wresearch. wDIF: wCognitivewLevel: wApplying w(Appli
cation) w MSC: wClient wNeeds: wSafewand wEffectivewCarew Environment: wManagement wof wCare
18. When wreviewing wthewconcepts wof whealth, wthewnursewrecalls wthat wthewcomponents wof wholi
stic whealth wincludew which wof wthese?
a. Disease woriginates wfrom wthewexternal wenvironment.
b. Thewindividual whuman wis wawclosed wsystem.
c. Nurses ware wresponsiblewfor wawpatients w health wstate.
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w8
d. Holistic whealth wviews wthewmind, wbody, wand wspirit was winte
rdependent. w ANS: wD
Consideration wof wthewwholewperson wis wthewessencewof w holistic whealth, wwhich wviews wthewmind, wbody, w and wspirit w as
interdependent. wThewbasis wof wdisease woriginates wfrom wboth wthewexternal wenvironment wand wfrom wwithin wthewperson.wBoth wthewin
dividual whuman wand wthew external wenvironment warewopen wsystems, wcontinuallywchanging wand wadapting, wand weach wperson wis wres
ponsiblewfor whis wor wher wown wpersonal whealth wstate. w DIF:wCognitivewLevel: wUnderstanding w(Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
19. Thewnursewrecognizes wthat wthewconcept wof wprevention win wdescribing whealth wis w essential wbecause:
a. Diseasewcan wbe wprevented wby wtreating wthewexternal wenvironment.
b. Thewmajorityw of wdeaths wamong wAmericans wunder wage w65 wyears warewnot wpreventable.
c. Prevention wplaces wthewemphasis won wthe wlink wbetween whealth wand wpersonal wbehavior.
d. Thewmeans wto wprevention wis wthrough wtreatment wprovided wbywprimarywhealth wcar
ewpractitioners. w ANS: wC
A wnatural wprogression wto wprevention wrounds wout wthewpresent wconcept wof whealth. wGuidelines wtowprevention wplace
thewemphasis won wthewlink wbetween whealth wand wpersonal wbehavior. wDIF: wCognitive wLevel: wUnderstanding w(
Comprehension) w MSC: wClient wNeeds: wGeneral
20. Thewnursewis wperforming wa wphysical wassessment won wa w newlyw admitted wpatient. wAn wex
amplewof wobjectivew information wobtained wduring wthewphysical wassessment w includes wthe:
a. Patients whistoryw of wallergies.
b. Patients wusewof wmedications wat whome.
c. Last wmenstrual wperiod w1 wmonth wago.
d. 2 w5 wcm wscar won wthe wright wlower
wforearm. w ANS: wD
Objective wdatawarewthe wpatients wrecord, wlaboratorywstudies, wand wcondition wthat wthewhealth wprofess
ional wobserves wbyw inspecting, wpercussing, wpalpating, wand wauscultating wduring wthewphysical wexami
nation. wThewother wresponses wreflect w subjectivewdata. wDIF: wCognitivewLevel: wApplying w(Application)
Test w Bank w-
wPhysical wExamination wand wHealth wAssessment w 8e w(byw Jarvis) w9 w
MSC: wClient wNeeds: wSafewand wEffectivewCare wEnvironment: wManagem
ent wof wCare
21. A wvisiting wnursewis wmaking wan winitial whome wvisit wfor wawpatient wwho whas wmany wchronic wmedical wproblems. wW hich wtype wof wd
atawbasewis w most w appropriatew towcollect win wthis wsetting?
a. A wfollow-up wdata wbasewtowevaluate wchanges wat wappropriatewintervals
b. An wepisodic wdatawbasewbecause wof wthewcontinuing, wcomplexwmedical wproblems wof wthis wpatient
c. A wcompletewhealth wdatawbase wbecausewof wthe wnurses wprimarywresponsibility wfor
wmonitoring wthew patients whealth
d. An wemergencywdatawbasewbecause wof wthewneed wtowcollect winformation wand wmake wac
curatewdiagnoses w rapidly
ANS: wC
Thewcompletewdatawbasewis wcollected win wawprimarywcare wsetting, wsuch was wa wpediatric wor wfam
ilywpracticewclinic, w independent wor wgroup wprivatewpractice, wcollegewhealth wservice, wwomens whea
lth wcarewagency, wvisiting wnurse w agency, wor wcommunitywhealth wagency. wIn wthesewsettings, wthe
wnursewis wthewfirstwhealth wprofessional wto wseewthe
patient wand whas wthewprimarywresponsibility wfor wmonitoring wthewpersons whealth wcare. wDIF: wCognitivewLevel: wApplying w(Application)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
22. Which wsituation wis wmost wappropriate wduring wwhich wthewnursewperforms wawfocused wor w
problem-centered w history?
a. Patient wis wadmitted wto wa wlong-term wcarewfacility.
b. Patient whas wa wsudden wand wseverewshortness wof wbreath.
c. Patient wis wadmitted wtowthe whospital wfor wsurgery wthewfollowing wday.
d. Patient win wan woutpatient wclinic whas wcold wand winfluenza-
likewsymptoms. w ANS: wD
In wawfocused wor wproblem-
centered wdata wbase, wthe wnurse wcollects wa wmini wdata wbase, wwhich wis wsmaller win wscopewthan w t
hewcompleted wdatawbase. wThis wmini wdatawbasewprimarily wconcerns wonewproblem, wone wcuewcom
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M wPhysical
plex, wor wonewbodyw system. wExamination
wDIF: wCognitive wLevel: wApplying wwandwHealthwAssessmentw8ew(bywJarvis)w1w…
(Application)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
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Test wBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w1 w
Chapter w01: wEvidence-Based wAssessment
MULTIPLE w CHOICE
1. After wcompleting wan winitial wassessment wof wawpatient, wthewnursewhas wcharted wthat whis wrespiratio
ns wareweupneic wand w his wpulse wis w58 wbeats wper wminute. wThesewtypes wof wdataw would wbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
w ANS: wA
Objective wdataware wwhat wthe whealth wprofessional wobserves wby winspecting, wpercussing, wpalpating, wa
nd wauscultating w during wthewphysical wexamination. wSubjective wdatawis wwhat wthewperson wsays wabo
ut whim wor wherself wduring whistory
taking. wThe wterms wreflectivewand wintrospective w arewnot wused wtowdescribewdata. wDIF:wCognitivewLevel: wUnderstandi
ng w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
2. A wpatient wtells wthewnursewthat whe wis wverywnervous, wis w nauseated, wand wfeels whot. wThesewtypes w of wdatawwould wbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
w ANS: wC
Subjectivewdatawarewwhat wthe wperson wsays wabout whim wor wherself wduring whistorywtaking. wObjectiv
ewdatawarewwhat wthew health wprofessional wobserves wbyw inspecting, wpercussing, wpalpating, wand wa
uscultating wduring wthewphysical
examination. wThewterms wreflective wand wintrospective warewnot wused wtowdescribe wdata. wDIF: wCognitivewLevel: wUnderstanding
w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
3. Thewpatients wrecord, wlaboratorywstudies, wobjectivewdata, wand wsubjectivewdatawcombinewtowform wthe:
a. Datawbase.
b. Admitting wdata.
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w2
c. Financialw statement.
d. Dischargewsummary
.w ANS: wA
Together wwith wthewpatients wrecord wand wlaboratory wstudies, wthewobjectivewand wsubjectivewdatawform wthewdatawbase. wThe wother wit
ems warewnot wpart wof wthew patients wrecord, wlaboratorywstudies, wor wdata. wDIF: wCognitivewLevel: wRemembering w(Knowledge)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
4. When wlistening wtowa wpatients wbreath wsounds, wthewnursewis wunsure wof wawsound wthat wis wh
eard. wThewnurses wnext w action wshould wbewto:
a. Immediatelywnotifyw thewpatients w physician.
b. Document wthe wsound wexactlywas wit w was wheard.
c. Validatewthewdatawby wasking wa wcoworker wtowlisten wtowthewbreath wsounds.
d. Assess wagain win w20 wminutes wtownotewwhether wthewsound wi
s wstillwpresent. w ANS: wC
When wunsurewof wawsound wheard wwhilewlistening wtowawpatients wbreath wsounds, w thewnursewvalidates wthe wdatawtowensure
accuracy. wIf wthewnursewhas wless wexperiencewin wan warea, wthen whe wor wshewasks wan wexpert wtowlisten. wDIF: wCognitive wL
evel: wAnalyzing w(Analysis) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
5. Thewnursewis wconducting wawclass wfor wnew wgraduatewnurses. wDuring wthewteaching wsession, wthe
wnursewshould wkeep w in wmind wthat wnovicewnurses, wwithout wawbackground wof wskills wand wexperien
cewfrom wwhich wtowdraw, warewmorewlikely
towmake wtheir wdecisions wusing:
a. Intuition.
b. A wset w of w rules.
c. Articles win wjournals.
d. Advicewfrom wsuperviso
rs.w ANS: wB
Novicewnurses woperate wfrom w awset wof wdefined, wstructured wrules. wThewexpert wpractitioner wuses wintuitivewlinks. wDIF:wCognitivewLe
vel: wUnderstanding w (Comprehension)
Test wBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w3 w
MSC: wClient wNeeds: wGeneral
6. Expert wnurses wlearn wtowattend wtowawpattern wof wassessment wdatawand wact wwithout wconsciousl
ywlabeling wit. wThesew responses warewreferred wtow as:
a. Intuition.
b. Thew nursingwprocess.
c. Clinical wknowledge.
d. Diagnostic wreasoning
.w ANS: wA
Intuition wis wcharacterized wbyw pattern wrecognitionexpert wnurses wlearn wtowattend wto wawpattern wof wassessment wdatawand
act wwithout wconsciouslywlabeling wit. wThewother woptions warewnot wcorrect. wDIF: wCognitivewLevel: wUnderstanding w(
Comprehension) w MSC: wClient wNeeds: wGeneral
7. Thewnursewis wreviewing winformation wabout wevidence-based wpracticew(EBP). wW hich wstatement wbest wreflects
EBP?
a. EBP wrelies won wtradition wfor wsupport wof wbest wpractices.
b. EBP wis wsimplywthewusewof w best w practicewtechniques wfor wthewtreatment wof wpatients.
c. EBP wemphasizes wthe wusewof wbest wevidencewwith wthewclinicians w experience.
d. Thewpatients wown wpreferences warewnot wimportant w
with wEBP. w ANS: wC
EBP wis wawsystematic wapproach wtowpracticewthat wemphasizes wthewusewof wbest wevidencewin wcom
bination wwith wthew clinicians wexperience, was wwell was wpatient wpreferences wand wvalues, wwhen wmaki
ng wdecisions wabout wcarewand w treatment. wEBP wis wmorewthan wsimplywusing wthe wbest wpracticewte
chniques wtowtreat wpatients, wand wquestioning
tradition wis wimportant wwhen wnowcompelling wand wsupportive wresearch wevidence wexists. wDIF: wCognitivewLevel: wAp
plying w(Application) w MSC: wClient wNeeds: wSafewand wEffectivewCare wEnvironment: wManagement wof wCare
8. Thewnursewis wconducting wawclass won wprioritywsetting wfor wawgroup wof wnew wgraduatewnurses.
wW hich wis wan wexamplew of wawfirst-level wprioritywproblem?
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M wPhysicalwExaminationwandwHealthwAssessmentw8ew(bywJarvis)w1w…
a. Patient wwith wpostoperative wpain
b. Newlywdiagnosed wpatient wwith wdiabetes wwhowneeds wdiabetic wt
eaching w TestwBank w-
wPhysical wExamination wand wHealth wAssessment w8e w(bywJarvis) w4
c. Individual wwith wawsmall wlaceration won wthewsolewof wthewfoot
d. Individual wwith wshortness wof wbreath wand wrespiratory
wdistress w ANS: wD
First-level wprioritywproblems ware wthosewthat ware wemergent, wlifewthreatening, wand wimmediate w(e.g., westablishing wan
airway, wsupporting wbreathing, wmaintaining wcirculation, wmonitoring wabnormal wvital wsigns). wDIF: wCognitivewLevel: wUnderstanding w(Co
mprehension) w MSC: wClient wNeeds: wSafewand wEffectivew CarewEnvironment: wManagement wof wCare
9. When wconsidering wprioritywsetting wof wproblems, wthewnursewkeeps win wmind wthat wsecond-
level wprioritywproblems w includewwhich wof wthesewaspects?
a. Low wself-esteem
b. Lack wof w knowledge
c. Abnormalwlaboratoryw values
d. Severelywabnormal wvital ws
igns w ANS: wC
Second-
level wprioritywproblems warewthose wthat wrequirewprompt wintervention wtowforestall wfurther wdeterioration w(e.g., wmental wstatus wchange, w
acute wpain, w abnormal wlaboratory wvalues, wrisks wtowsafetywor wsecurity). wDIF: wCognitivewLevel: wUnderstanding w(Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
10. Which wcritical wthinking wskill whelps wthewnursewsee wrelationships wamong wthe wdata?
a. Validation
b. Clusteringw relatedw cues
c. Identifying wgaps win wdata
d. Distinguishingwrelevantwfromwirrelev
antw ANS: wB
Clustering wrelated wcues whelps wthewnursewsee wrelationships wamong wthe wdata. wDIF: wCognitivewLevel: wUnderstanding
w(Comprehension) w MSC: wClient wNeeds: wSafew and wEffective wCarewEnvironment: wManagement wof wCare
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w5
11. Thewnursewknows wthat wdeveloping wappropriatewnursing winterventions wfor wa wpatien
twrelies won wthew appropriateness wof wthew diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
w ANS: wA
An waccuratewnursing wdiagnosis wprovides wthewbasis wfor wthe wselection wof wnursing winterventions wto
wachieve woutcomes w for wwhich wthewnursewis waccountable. wThewother witems wdownot wcontributewt
owthewdevelopment wof wappropriate wnursing w interventions. wDIF: wCognitivewLevel: wUnderstanding w(
Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
12. Thewnursing wprocess wis wawsequential wmethod wof wproblem wsolving wthat wnurses wusewand wincludes wwhich wsteps?
a. Assessment, wtreatment, wplanning, wevaluation, wdischarge, wand wfollow-up
b. Admission, wassessment, wdiagnosis, wtreatment, wand wdischargewplanning
c. Admission, w diagnosis, w treatment, w evaluation, w andw dischargew planning
d. Assessment, wdiagnosis, woutcome widentification, wplanning, wimplementation, wand w
evaluation w ANS: wD
Thewnursing wprocess wis wawmethod wof wproblem wsolving wthat wincludes wassessment, wdiagnosis, wo
utcomew identification, wplanning, wimplementation, wand wevaluation. wDIF: wCognitive wLevel: wUnderstan
ding w(Comprehension) w MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagemen
twof wCare
13. A wnewlyw admitted wpatient wis win wacutewpain, whas wnot wbeen wsleeping wwell wlately, wan
d wis whaving wdifficultyw breathing. wHow wshould wthewnursewprioritizewthesewproblems?
a. Breathing, w pain,w andw sleep
b. Breathing, w sleep,w andwpain
c. Sleep,w breathing,w andw pain
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w6
d. Sleep,wpain,w andwbreat
hingw ANS: wA
First-levelw priorityw problems w arew immediatew priorities,w rememberingwthew ABCs w (airway,w breathing, w and
circulation), wfollowed wbywsecond-level wproblems, wand wthen wthird-
level wproblems. wDIF: wCognitivewLevel: wAnalyzing w(Analysis) w MSC: wClient wNeeds: wSafewand wEffectivewCar
ewEnvironment: wManagement wof wCare
14. Which wof wthesewwould wbewformulated wbywawnursewusing wdiagnostic wreasoning?
a. Nursingw diagnosis
b. Medical wdiagnosis
c. Diagnostic whypothesis
d. Diagnostic wassessme
ntw ANS: wC
Diagnostic wreasoning wcalls wfor wthe wnursewtowformulatewa wdiagnostic whypothesis; wthewnursing wproc
ess wcalls wfor waw nursing wdiagnosis. wDIF: wCognitivewLevel:wUnderstanding w(Comprehension)
MSC: w ClientwNeeds: wGeneral
15. Barriers w towincorporatingw EBP w include:
a. Nurses wlack wof wresearch wskills win wevaluating wthewqualityw of wresearch wstudies.
b. Lack wof wsignificant wresearch wstudies.
c. Insufficient w clinical wskills w of w nurses.
d. Inadequatewphysical wassessment ws
kills. w ANS: wA
As windividuals, wnurses wlack wresearch wskills win wevaluating wthewqualitywof wresearch wstudies, warewis
olated wfrom wother w colleagues wwhoware wknowledgeable win wresearch, wand woften wlack wthewtimewto
wvisitwthewlibrarywtowread wresearch. wThew other wresponses warewnot wconsidered wbarriers. wDIF: wC
ognitivewLevel: wUnderstanding w(Comprehension)
MSC: w ClientwNeeds: wGeneral
16. What wstep wof wthewnursing wprocess wincludes wdatawcollection wbywhealth whistory, wphysical w
examination, wand w interview?
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TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w7
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
w ANS: wD
Datawcollection, wincluding wperforming wthe whealth whistory, wphysical wexamination, wand winterview, wis wthe wassessment
step wof wthe wnursing wprocess. wDIF: wCognitivewLevel: wRemembering w(
Knowledge) w MSC: wClient wNeeds: wGeneral
17. During wawstaff wmeeting, wnurses wdiscuss wthewproblems wwith waccessing wresearch wstudies w
towincorporatew evidence-
based wclinical wdecision wmaking wintowtheir wpractice. wW hichwsuggestion wby wthe wnursewmanager
wwould w best w help wthesewproblems?
a. Form wa wcommitteewtowconduct wresearch wstudies.
b. Postwpublished wresearch wstudies won wthewunits wbulletin wboards.
c. Encouragewthewnurses wtowvisit wthewlibraryw towreview wstudies.
d. Teach wthewnurses whow wtowconduct welectronic wsearches wfor wrese
arch wstudies. w ANS: wD
Facilitating wsupport wfor wEBP wwould wincludewteaching wthewnurses whow wtowconduct welectronic ws
earches; wtime wtow visitwthewlibrarywmaywnot wbe wavailablewfor wmanywnurses. wActuallywconductin
g wresearch wstudies wmaywbe whelpful win
thewlong-
run wbut wnot wan wimmediatewsolution wtowreviewing wexisting wresearch. wDIF: wCognitivewLevel: wApplying w(Appli
cation) w MSC: wClient wNeeds: wSafewand wEffectivewCarew Environment: wManagement wof wCare
18. When wreviewing wthewconcepts wof whealth, wthewnursewrecalls wthat wthewcomponents wof wholi
stic whealth wincludew which wof wthese?
a. Disease woriginates wfrom wthewexternal wenvironment.
b. Thewindividual whuman wis wawclosed wsystem.
c. Nurses ware wresponsiblewfor wawpatients w health wstate.
TestwBank w- wPhysical wExamination wand wHealth wAssessment w8ew(bywJarvis) w8
d. Holistic whealth wviews wthewmind, wbody, wand wspirit was winte
rdependent. w ANS: wD
Consideration wof wthewwholewperson wis wthewessencewof w holistic whealth, wwhich wviews wthewmind, wbody, w and wspirit w as
interdependent. wThewbasis wof wdisease woriginates wfrom wboth wthewexternal wenvironment wand wfrom wwithin wthewperson.wBoth wthewin
dividual whuman wand wthew external wenvironment warewopen wsystems, wcontinuallywchanging wand wadapting, wand weach wperson wis wres
ponsiblewfor whis wor wher wown wpersonal whealth wstate. w DIF:wCognitivewLevel: wUnderstanding w(Comprehension)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
19. Thewnursewrecognizes wthat wthewconcept wof wprevention win wdescribing whealth wis w essential wbecause:
a. Diseasewcan wbe wprevented wby wtreating wthewexternal wenvironment.
b. Thewmajorityw of wdeaths wamong wAmericans wunder wage w65 wyears warewnot wpreventable.
c. Prevention wplaces wthewemphasis won wthe wlink wbetween whealth wand wpersonal wbehavior.
d. Thewmeans wto wprevention wis wthrough wtreatment wprovided wbywprimarywhealth wcar
ewpractitioners. w ANS: wC
A wnatural wprogression wto wprevention wrounds wout wthewpresent wconcept wof whealth. wGuidelines wtowprevention wplace
thewemphasis won wthewlink wbetween whealth wand wpersonal wbehavior. wDIF: wCognitive wLevel: wUnderstanding w(
Comprehension) w MSC: wClient wNeeds: wGeneral
20. Thewnursewis wperforming wa wphysical wassessment won wa w newlyw admitted wpatient. wAn wex
amplewof wobjectivew information wobtained wduring wthewphysical wassessment w includes wthe:
a. Patients whistoryw of wallergies.
b. Patients wusewof wmedications wat whome.
c. Last wmenstrual wperiod w1 wmonth wago.
d. 2 w5 wcm wscar won wthe wright wlower
wforearm. w ANS: wD
Objective wdatawarewthe wpatients wrecord, wlaboratorywstudies, wand wcondition wthat wthewhealth wprofess
ional wobserves wbyw inspecting, wpercussing, wpalpating, wand wauscultating wduring wthewphysical wexami
nation. wThewother wresponses wreflect w subjectivewdata. wDIF: wCognitivewLevel: wApplying w(Application)
Test w Bank w-
wPhysical wExamination wand wHealth wAssessment w 8e w(byw Jarvis) w9 w
MSC: wClient wNeeds: wSafewand wEffectivewCare wEnvironment: wManagem
ent wof wCare
21. A wvisiting wnursewis wmaking wan winitial whome wvisit wfor wawpatient wwho whas wmany wchronic wmedical wproblems. wW hich wtype wof wd
atawbasewis w most w appropriatew towcollect win wthis wsetting?
a. A wfollow-up wdata wbasewtowevaluate wchanges wat wappropriatewintervals
b. An wepisodic wdatawbasewbecause wof wthewcontinuing, wcomplexwmedical wproblems wof wthis wpatient
c. A wcompletewhealth wdatawbase wbecausewof wthe wnurses wprimarywresponsibility wfor
wmonitoring wthew patients whealth
d. An wemergencywdatawbasewbecause wof wthewneed wtowcollect winformation wand wmake wac
curatewdiagnoses w rapidly
ANS: wC
Thewcompletewdatawbasewis wcollected win wawprimarywcare wsetting, wsuch was wa wpediatric wor wfam
ilywpracticewclinic, w independent wor wgroup wprivatewpractice, wcollegewhealth wservice, wwomens whea
lth wcarewagency, wvisiting wnurse w agency, wor wcommunitywhealth wagency. wIn wthesewsettings, wthe
wnursewis wthewfirstwhealth wprofessional wto wseewthe
patient wand whas wthewprimarywresponsibility wfor wmonitoring wthewpersons whealth wcare. wDIF: wCognitivewLevel: wApplying w(Application)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
22. Which wsituation wis wmost wappropriate wduring wwhich wthewnursewperforms wawfocused wor w
problem-centered w history?
a. Patient wis wadmitted wto wa wlong-term wcarewfacility.
b. Patient whas wa wsudden wand wseverewshortness wof wbreath.
c. Patient wis wadmitted wtowthe whospital wfor wsurgery wthewfollowing wday.
d. Patient win wan woutpatient wclinic whas wcold wand winfluenza-
likewsymptoms. w ANS: wD
In wawfocused wor wproblem-
centered wdata wbase, wthe wnurse wcollects wa wmini wdata wbase, wwhich wis wsmaller win wscopewthan w t
hewcompleted wdatawbase. wThis wmini wdatawbasewprimarily wconcerns wonewproblem, wone wcuewcom
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plex, wor wonewbodyw system. wExamination
wDIF: wCognitive wLevel: wApplying wwandwHealthwAssessmentw8ew(bywJarvis)w1w…
(Application)
MSC: wClient wNeeds: wSafewand wEffectivewCarewEnvironment: wManagement wof wCare
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