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CHAPTER 1FoundationsforClinicalProficiency
MULTIPLE CHOICE
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1. Aftercompletinganinitial assessmentofa patient,the nursehaschartedthat his respirations are v0 v0 v0 v0 v0 v0 v0
eupneic and his pulse is 58 beats per minute. These types of data would be:
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a Objective.
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b Reflective.
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c Subjective.
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d Introspective.
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ANS:A v0
Objective data are what the health professional observes by inspecting, percussing, palpating, and
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auscultatingduring the physical examination. Subjective data is what the person says about him or
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herselfduringhistorytaking.Thetermsreflectiveandintrospectivearenot usedtodescribedata.
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DIF:Cognitive Level: Understanding(Comprehension)REF: p. 2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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2. Apatienttellsthenursethatheisverynervous,isnauseated,and feelshot.Thesetypesof data
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would be:
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a Objective.
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b Reflective.
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c Subjective.
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d Introspective.
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ANS:C v0
Subjective data are what the person says about him or herself during history taking. Objectivedata
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arewhatthehealthprofessionalobservesbyinspecting,percussing,palpating, and
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auscultatingduringthephysicalexamination.Theterms reflectiveandintrospectivearenotused v0 v0 v0 v0 v0 v0 v0 v0 v0 v0
todescribedata.
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DIF:Cognitive Level: Understanding(Comprehension)REF: p. 2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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3. Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombineto
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formthe:
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a Database. v0
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b Admittingdata.
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c Financialstatement. v0
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d Dischargesummary. v0
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ANS:A v0
Togetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataform the data
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base. The other items are not part of the patients record, laboratory studies, or data.
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DIF:Cognitive Level:Remembering(Knowledge)REF:p. 2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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4. Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard. The
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nurses next action should be to:
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a Immediatelynotifythepatientsphysician. v0 v0 v0
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b Documentthesoundexactlyasitwasheard. v0 v0 v0 v0 v0 v0
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c Validatethedatabyaskingacoworkertolistentothebreathsounds. v0 v0 v0 v0 v0 v0 v0 v0 v0 v0
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d Assessagainin20minutestonotewhetherthesoundisstillpresent. v0 v0 v0 v0 v0 v0 v0 v0 v0 v0 v0
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ANS:C v0
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the datato
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ensureaccuracy. Ifthenursehaslessexperienceinanarea,thenheorsheasksanexpert to listen.
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DIF:CognitiveLevel:Analyzing(Analysis)REF:p.2
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, MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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