,Chapter 01: Evidence-Based Assessment st st st
MULTIPLE CHOICE st
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his
st st st st st st st st st st st st st st st st st st s
pulse is 58 beats per minute. These types of data would be:
t s t s t s t s t s t s t st st s t s t s t
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A st
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating duri
st st st st st st st st st st st st st st
ng the physical examination. Subjective data is what the person says about him or herself during history taking. Th
st st st st st st st st st st st st st st st st st s t
e terms reflective and introspective are not used to describe data.
s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
2. A patient tells the nurse that he is very n e r vNo uUsR, SisIN
st st naGuTsB
ea.CteOdM
, and feels hot. These types of data would be:
st st st st st st st st st st st st st st st st st
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C st
Subjective data are what the person says about him or herself during history taking. Objective data are what the health
st st st st st st st st st st st st st st st st st st st
professional observes by inspecting, percussing, palpating, and auscultating during the physical examinati
s t s t s t s t s t s t s t s t s t s t s t st
on. The terms reflective and introspective are not used to describe data.
s t s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
st st st st st st st st st st st st st
a. Data base. st
b. Admitting data. st
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, c. Financial statement. st
d. Discharge summary. st
ANS: A st
Together with the patients record and laboratory studies, the objective and subjective data form the data base. The
st st st st st st st st st st st st st st st st st
other items are not part of the patients record, laboratory studies, or data.
s t s t s t s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Remembering (Knowledge)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next acti
st st st st st st st st st st st st st st st st st st st st
on should be to:
st st st
a. Immediately notify the patients physician. st st st st
b. Document the sound exactly as it was heard. st st st st st st st
c. Validate the data by asking a coworker to listen to the breath sounds.
st st st st st st st st st st st st
d. Assess again in 20 minutes to note whether the sound is still present.
st st st st st st st st st st st st
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ANS: C st
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accura
st st st st st st st st st st st st st st st st st st st st
cy. If the nurse has less experience in an area, then he or she asks an expert to listen.
s t st s t s t st st s t st st st s t st st s t st s t s t st
DIF: Cognitive Level: Analyzing (Analysis)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep
st st st st st st st st st st st st st st st st st st
in mind that novice nurses, without a background of skills and experience from which to draw, are more likely t
st st st st st st st st st st st st st st st st st st st
o make their decisions using:
st st st st
a. Intuition.
b. A set of rules.
st st st
c. Articles in journals. st st
d. Advice from supervisors. st st
ANS: B st
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF:
st st st st st st st st st st st st st st st st st
Cognitive Level: Understanding (Comprehension) s t st s t
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, MSC: Client Needs: General
st st st
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These res
st st st st st st st st st st st st st st st st st st
ponses are referred to as:
st st st st
a. Intuition.
b. The nursing process. st st
c. Clinical knowledge. st
d. Diagnostic reasoning. st
ANS: A st
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and ac
st st st st st st st st st st st st st st st st st
t without consciously labeling it. The other options are not correct.
s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st st
MSC: Client Needs: General
st st st
7. The nurse is reviewing information about evidence-
st st st st st st
based practice (EBP). Which statement best reflects EBP?
st st st st st st st
a. EBP relies on tradition for supportNoUfR
st beSsItNpGrT
acBt.iC
ceOsM
. st st st st ts
b. EBP is simply the use of best practice techniques for the treatment of patients.
st st st st st st st st st st st st st
c. EBP emphasizes the use of best evidence with the clinicians experience.
st st st st st st st st st st
d. The patients own preferences are not important with EBP. A
st st st st st st st st st
NS: C st
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clin
st st st st st st st st st st st st st st st st st st
icians experience, as well as patient preferences and values, when making decisions about care and treatment.
st st st st st st st st st st st st st st st st
EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is imp
st st st st st st st st st st st st st st st s t s t
ortant when no compelling and supportive research evidence exists.
s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Applying (Application)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a
st st st st st st st st st st st st st st st st st st st st st st
first-level priority problem? st st
a. Patient with postoperative pain st st st
b. Newly diagnosed patient with diabetes who needs diabetic teaching
st st st st st st st st
NURSINGTB.COM
MULTIPLE CHOICE st
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his
st st st st st st st st st st st st st st st st st st s
pulse is 58 beats per minute. These types of data would be:
t s t s t s t s t s t s t st st s t s t s t
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A st
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating duri
st st st st st st st st st st st st st st
ng the physical examination. Subjective data is what the person says about him or herself during history taking. Th
st st st st st st st st st st st st st st st st st s t
e terms reflective and introspective are not used to describe data.
s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
2. A patient tells the nurse that he is very n e r vNo uUsR, SisIN
st st naGuTsB
ea.CteOdM
, and feels hot. These types of data would be:
st st st st st st st st st st st st st st st st st
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C st
Subjective data are what the person says about him or herself during history taking. Objective data are what the health
st st st st st st st st st st st st st st st st st st st
professional observes by inspecting, percussing, palpating, and auscultating during the physical examinati
s t s t s t s t s t s t s t s t s t s t s t st
on. The terms reflective and introspective are not used to describe data.
s t s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
st st st st st st st st st st st st st
a. Data base. st
b. Admitting data. st
NURSINGTB.COM
, c. Financial statement. st
d. Discharge summary. st
ANS: A st
Together with the patients record and laboratory studies, the objective and subjective data form the data base. The
st st st st st st st st st st st st st st st st st
other items are not part of the patients record, laboratory studies, or data.
s t s t s t s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Remembering (Knowledge)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next acti
st st st st st st st st st st st st st st st st st st st st
on should be to:
st st st
a. Immediately notify the patients physician. st st st st
b. Document the sound exactly as it was heard. st st st st st st st
c. Validate the data by asking a coworker to listen to the breath sounds.
st st st st st st st st st st st st
d. Assess again in 20 minutes to note whether the sound is still present.
st st st st st st st st st st st st
NURSINGTB.COM
ANS: C st
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accura
st st st st st st st st st st st st st st st st st st st st
cy. If the nurse has less experience in an area, then he or she asks an expert to listen.
s t st s t s t st st s t st st st s t st st s t st s t s t st
DIF: Cognitive Level: Analyzing (Analysis)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep
st st st st st st st st st st st st st st st st st st
in mind that novice nurses, without a background of skills and experience from which to draw, are more likely t
st st st st st st st st st st st st st st st st st st st
o make their decisions using:
st st st st
a. Intuition.
b. A set of rules.
st st st
c. Articles in journals. st st
d. Advice from supervisors. st st
ANS: B st
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF:
st st st st st st st st st st st st st st st st st
Cognitive Level: Understanding (Comprehension) s t st s t
NURSINGTB.COM
, MSC: Client Needs: General
st st st
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These res
st st st st st st st st st st st st st st st st st st
ponses are referred to as:
st st st st
a. Intuition.
b. The nursing process. st st
c. Clinical knowledge. st
d. Diagnostic reasoning. st
ANS: A st
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and ac
st st st st st st st st st st st st st st st st st
t without consciously labeling it. The other options are not correct.
s t s t s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Understanding (Comprehension)
st st st st st
MSC: Client Needs: General
st st st
7. The nurse is reviewing information about evidence-
st st st st st st
based practice (EBP). Which statement best reflects EBP?
st st st st st st st
a. EBP relies on tradition for supportNoUfR
st beSsItNpGrT
acBt.iC
ceOsM
. st st st st ts
b. EBP is simply the use of best practice techniques for the treatment of patients.
st st st st st st st st st st st st st
c. EBP emphasizes the use of best evidence with the clinicians experience.
st st st st st st st st st st
d. The patients own preferences are not important with EBP. A
st st st st st st st st st
NS: C st
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clin
st st st st st st st st st st st st st st st st st st
icians experience, as well as patient preferences and values, when making decisions about care and treatment.
st st st st st st st st st st st st st st st st
EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is imp
st st st st st st st st st st st st st st st s t s t
ortant when no compelling and supportive research evidence exists.
s t s t s t s t s t s t s t s t
DIF: Cognitive Level: Applying (Application)
st st st st
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
st st st st st st st st st st
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a
st st st st st st st st st st st st st st st st st st st st st st
first-level priority problem? st st
a. Patient with postoperative pain st st st
b. Newly diagnosed patient with diabetes who needs diabetic teaching
st st st st st st st st
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