Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
BEING
MUL PLE CHOICE
1. After comple ng an ini al assessment of a pa ent, the nurse has charted that his respira ons are
eupneic and his pulse is 58 beats per minute. These types of data would be:
a Objec ve.
.
b Reflec ve.
.
, c Subjec ve.
.
d Introspec ve.
.
ANS: A
Objec ve data are what the health professional observes by inspec ng, percussing, palpa ng, and
ausculta ng during the physical examina on. Subjec ve data is what the person says about him or
herself during history taking. The terms reflec ve and introspec ve are not used to describe data.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
2. A pa ent tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a Objec ve.
.
b Reflec ve.
.
c Subjec ve.
.
d Introspec ve.
.
ANS: C
Subjec ve data are what the person says about him or herself during history taking. Objec ve
,data are what the health professional observes by inspec ng, percussing, palpa ng, and ausculta ng
during the physical examina on. The terms reflec ve and introspec ve are not used to describe
data.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
3. The pa ents record, laboratory studies, objec ve data, and subjec ve data combine to form
the:
a Data base.
.
b Admit ng data.
.
c Financial statement.
.
d Discharge summary.
.
ANS: A
Together with the pa ents record and laboratory studies, the objec ve and subjec ve data form the
data base. The other items are not part of the pa ents record, laboratory studies, or data.
DIF: Cogni ve Level: Remembering (Knowledge) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
4. When listening to a pa ents breath sounds, the nurse is unsure of a sound that is heard. The
nurses next ac on should be to:
a Immediately no fy the pa ents physician.
.
b Document the sound exactly as it was heard.
.
c Validate the data by asking a coworker to listen to the breath sounds.
.
d Assess again in 20 minutes to note whether the sound is s ll present.
.
ANS: C
When unsure of a sound heard while listening to a pa ents breath sounds, the nurse validates the
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
to listen.
, DIF: Cogni ve Level: Analyzing (Analysis) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
5. The nurse is conduc ng 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:
a Intui on.
.
b A set of rules.
.
c Ar cles in journals.
.
d Advice from supervisors.
.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert prac oner uses intui ve
links.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 3
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a Intui on.
.
b The nursing process.
.
c Clinical knowledge.
.
d Diagnos c reasoning.
.
ANS: A
Intui on is characterized by pattern recogni onexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other op ons are not correct.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 4
MSC: Client Needs: General
7. The nurse is reviewing informa on about evidence-based prac ce (EBP). Which statement
best reflects EBP?
BEING
MUL PLE CHOICE
1. After comple ng an ini al assessment of a pa ent, the nurse has charted that his respira ons are
eupneic and his pulse is 58 beats per minute. These types of data would be:
a Objec ve.
.
b Reflec ve.
.
, c Subjec ve.
.
d Introspec ve.
.
ANS: A
Objec ve data are what the health professional observes by inspec ng, percussing, palpa ng, and
ausculta ng during the physical examina on. Subjec ve data is what the person says about him or
herself during history taking. The terms reflec ve and introspec ve are not used to describe data.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
2. A pa ent tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a Objec ve.
.
b Reflec ve.
.
c Subjec ve.
.
d Introspec ve.
.
ANS: C
Subjec ve data are what the person says about him or herself during history taking. Objec ve
,data are what the health professional observes by inspec ng, percussing, palpa ng, and ausculta ng
during the physical examina on. The terms reflec ve and introspec ve are not used to describe
data.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
3. The pa ents record, laboratory studies, objec ve data, and subjec ve data combine to form
the:
a Data base.
.
b Admit ng data.
.
c Financial statement.
.
d Discharge summary.
.
ANS: A
Together with the pa ents record and laboratory studies, the objec ve and subjec ve data form the
data base. The other items are not part of the pa ents record, laboratory studies, or data.
DIF: Cogni ve Level: Remembering (Knowledge) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
4. When listening to a pa ents breath sounds, the nurse is unsure of a sound that is heard. The
nurses next ac on should be to:
a Immediately no fy the pa ents physician.
.
b Document the sound exactly as it was heard.
.
c Validate the data by asking a coworker to listen to the breath sounds.
.
d Assess again in 20 minutes to note whether the sound is s ll present.
.
ANS: C
When unsure of a sound heard while listening to a pa ents breath sounds, the nurse validates the
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
to listen.
, DIF: Cogni ve Level: Analyzing (Analysis) REF: z. 2
MSC: Client Needs: Safe and Effec ve Care Environment: Management of Care
5. The nurse is conduc ng 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:
a Intui on.
.
b A set of rules.
.
c Ar cles in journals.
.
d Advice from supervisors.
.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert prac oner uses intui ve
links.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 3
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a Intui on.
.
b The nursing process.
.
c Clinical knowledge.
.
d Diagnos c reasoning.
.
ANS: A
Intui on is characterized by pattern recogni onexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other op ons are not correct.
DIF: Cogni ve Level: Understanding (Comprehension) REF: z. 4
MSC: Client Needs: General
7. The nurse is reviewing informa on about evidence-based prac ce (EBP). Which statement
best reflects EBP?
