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1. Evidence-Based Assessment sd
2. Cultural Assessment sd
3. The Interview
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4. The Complete Health History
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5. Mental Status Assessmentsd sd
6. Substance Use Assessment sd sd
7. Family Violence and Human Trafficking
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8. Assessment Techniques and Safety in the Clinical Setting
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9. General Survey and Measurement
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10. Vital Signs sd
11. Pain Assessment
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12. Nutrition Assessment sd
13. Skin, Hair, and Nails
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14. Head, Face, Neck, and Regional Lymphatics
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15. Eyes
16. Ears
17. Nose, Mouth, and Throat
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18. Breasts, Axillae, and Regional Lymphatics
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19. Thorax and Lungs sd sd
20. Heart and Neck Vessels
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21. Peripheral Vascular System and Lymphatic System sd sd sd sd sd
22. Abdomen
23. Musculoskeletal System sd
24. Neurologic System sd
25. Male Genitourinary System
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26. Anus, Rectum, and Prostate
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27. Female Genitourinary System sd sd
28. The Complete Health Assessment: Adult
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29. The Complete Physical Assessment: Infant, Young Child, and Adolescent
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30. Bedside Assessment and Electronic Documentation
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31. Pregnancy
32. Functional Assessment of the Older Adult sd sd sd sd sd
,Chapter 01: Evidence-Based Assessment
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Jarvis: Physical Examination & Health Assessment, 9th Edition
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MULTIPLE CHOICE sd
1. After completing an initial assessment of a patient, the nurse has charted that his respirations a
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re eupneic and his pulse is 58 beats per minute. These types of data would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A s d
Objective data are what the health professional observes by inspecting, percussing, palpating, a
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nd auscultating during the physical examination. Subjective data is what the person says about
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him or herself during history taking. The terms reflective and introspective are not used to descr
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ibe data. sd
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of d
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ata would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C s d
Subjective data are what the person says about him or herself during history taking. Objective d
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ata are what the health professional observes by inspecting, percussing, palpating, and ausculta
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ting during the physical examination. The terms reflective and introspective are not used to des
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cribe data. sd
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form t
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he:
a. Data base. sd
b. Admitting data. sd
c. Financial statement. sd
d. Discharge summary. sd
ANS: A s d
Together with the patient’s record and laboratory studies, the objective and subjective data for
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m the data base. The other items are not part of the patient’s record, laboratory studies, or data.
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4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The n
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urse’s next action should be to:
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a. Immediately notify the patient’s physician. sd sd sd sd
b. Document the sound exactly as it was heard. sd sd sd sd sd sd sd
, c. Validate the data by asking a coworker to listen to the breath sounds.
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d. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C s d
When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates th
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e data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an exp
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ert to listen.sd sd
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nur
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se should keep in mind that novice nurses, without a background of skills and experience fro
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m which to draw, are more likely to make their decisions using:
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a. Intuition.
b. A set of rules. sd sd sd
c. Articles in journals. sd sd
d. Advice from supervisors. sd sd
ANS: B s d
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuiti
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ve links. sd
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously l
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abeling it. These responses are referred to as:sd sd sd sd sd sd sd
a. Intuition.
b... The nursing process. sd sd
c. Clinical knowledge. sd
d. Diagnostic reasoning. sd
ANS: A s d
Intuition is characterized by pattern recognition— sd sd sd sd sd
expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The
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other options are not correct.
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7. The nurse is reviewing information about evidence-
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based practice (EBP). Which statement best reflects EBP?
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a. EBP relies on tradition for support of best practices.
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b. EBP is simply the use of best practice techniques for the treatment of patients.
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c. EBP emphasizes the use of best evidence with the clinician’s experience.
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d... The patient’s own preferences are not important with EBP.
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ANS: C s d
EBP is a systematic approach to practice that emphasizes the use of best evidence in combinati
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on with the clinician’s experience, as well as patient preferences and values, when making decis
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ions about care and treatment. EBP is more than simply using the best practice techniques to tr
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eat patients, and questioning tradition is important when no compelling and supportive researc
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h evidence exists.
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8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which i
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s an example of a first-level priority problem?
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a. Patient with postoperative pain sd sd sd