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