h1 h1 h1 h1 h1 h1 h1 h1
Being Assessment 1st Edition Test Bank h1 h1 h1 h1 h1
Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
h1 h1 h1 h1 h1 h1 h1 h1 h1
BEING
h1
MULTIPLE CHOICE h1
1. After completing an initial assessment of a patient, the nurse has charted that his respirati
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
ons are eupneic and his pulse is 58 beats per minute. These types of data would be:
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
, a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A h1
Objective data are what the health professional observes by inspecting, percussing, palpating,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h
and auscultating during the physical examination. Subjective data is what the person says abo
1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
ut him or herself during history taking. The terms reflective and introspective are not used to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h
describe data.
1 h1
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
h1 h1 h1 h1 h1 h1 h1
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
of data would be:
h1 h1 h1 h1
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C h1
Subjective data are what the person says about him or herself during history taking. Objective
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
,data are what the health professional observes by inspecting, percussing, palpating, and auscu
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
ltating during the physical examination. The terms reflective and introspective are not used to
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
describe data. h1
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
h1 h1 h1 h1 h1 h1 h1
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
3. The patients record, laboratory studies, objective data, and subjective data combine to for
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
m the:
h1
a Data base. h1
.
b Admitting data. h1
.
c Financial statement. h1
.
d Discharge summary. h1
.
ANS: A h1
Together with the patients record and laboratory studies, the objective and subjective data for
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
m the data base. The other items are not part of the patients record, laboratory studies, or dat
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
a.
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
h1 h1 h1 h1 h1 h1 h1
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
The nurses next action should be to:
h1 h1 h1 h1 h1 h1
a Immediately notify the patients physician. h1 h1 h1 h1
.
b Document the sound exactly as it was heard. h1 h1 h1 h1 h1 h1 h1
.
c Validate the data by asking a coworker to listen to the breath sounds.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
.
d Assess again in 20 minutes to note whether the sound is still present.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
.
ANS: C h1
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates t
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
he data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
expert to listen.
h 1 h1
, DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
h1 h1 h1 h1 h1 h1 h1
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
5. The nurse is conducting a class for new graduate nurses. During the teaching session,
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
the nurse should keep in mind that novice nurses, without a background of skills and exp
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
erience from which to draw, are more likely to make their decisions using:
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h 1
a Intuition.
.
b A set of rules.
h1 h1 h1
.
c Articles in journals. h1 h1
.
d Advice from supervisors. h1 h1
.
ANS: B h1
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intu
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
itive links.
h1
DIF: Cognitive Level: Understanding (Comprehension) REF: z.
h1 h1 h1 h1 h1 h1 h1
3 MSC: Client Needs: General
h1 h1 h1 h1
6. Expert nurses learn to attend to a pattern of assessment data and act without consciou
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
sly labeling it. These responses are referred to as:
h1 h1 h1 h1 h1 h1 h1 h1
a Intuition.
.
b The nursing process.
h1 h1
.
c Clinical knowledge. h1
.
d Diagnostic reasoning. h1
.
ANS: A h1
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of ass
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
essment data and act without consciously labeling it. The other options are not correct.
h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1 h1
DIF: Cognitive Level: Understanding (Comprehension) REF: z.
h1 h1 h1 h1 h1 h1 h1
4 MSC: Client Needs: General
h1 h1 h1 h1
7. The nurse is reviewing information about evidence-
h1 h1 h1 h1 h1 h1
based practice (EBP). Which statement best reflects EBP?
h1 h1 h1 h1 h1 h1 h1