ISBN: 9780826155313 TEST BANK FOR Evidence-Based Physical Examination Best Practices for Health & Well-Being Assessment 2nd Edition ;All Chapters / Full Complete

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BeingAssessment 1st Edition Test Bank b
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Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
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BEING
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MULTIPLE CHOICE bv




1. After completing an initial assessment of a patient, the nurse has charted that his
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respirationsare 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 bv




Objective data are what the health professional observes by inspecting, percussing, palpating,
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and auscultating during the physical examination. Subjective data is what the person says
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abouthim or herself during history taking. The terms reflective and introspective are not used to
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describe data.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
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ofdata would be:
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a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.

ANS: C bv




Subjective data are what the person says about him or herself during history taking. Objective
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,data are what the health professional observes by inspecting, percussing, palpating, and
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auscultating during the physical examination. The terms reflective and introspective are not
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usedto describe data.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to
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formthe:
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a Data base. bv




.
b Admitting data. bv




.
c Financial statement. bv




.
d Discharge summary. bv




.

ANS: A bv




Together with the patients record and laboratory studies, the objective and subjective data
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formthe data 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: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
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Thenurses next action should be to:
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a Immediately notify the patients physician. bv bv bv bv




.
b Document the sound exactly as it was heard. bv bv bv bv bv bv bv




.
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 bv




When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
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data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an
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expertto listen.
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,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
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nurse should keep in mind that novice nurses, without a background of skills and
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experiencefrom which to draw, are more likely to make their decisions using:
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a Intuition.
.
b A set of rules.
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.
c Articles in journals. bv bv




.
d Advice from supervisors. bv bv




.

ANS: B bv




Novice nurses operate from a set of defined, structured rules. The expert practitioner usesintuitive
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links.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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3MSC: Client Needs: General
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6. Expert nurses learn to attend to a pattern of assessment data and act without
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consciouslylabeling it. These responses are referred to as:
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a Intuition.
.
b The nursing process. bv bv




.
c Clinical knowledge. bv




.
d Diagnostic reasoning. bv




.

ANS: A bv




Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern
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ofassessment data and act without consciously labeling it. The other options are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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4MSC: Client Needs: General
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7. The nurse is reviewing information about evidence-based practice (EBP). Which
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statementbest 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 clinicians experience.
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.
d The patients own preferences are not important with EBP.
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.

ANS: C bv




EBP is a systematic approach to practice that emphasizes the use of best evidence in
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combinationwith the clinicians experience, as well as patient preferences and values, when
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making decisions about care and treatment. EBP is more than simply using the best practice
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techniques to treat patients, and questioning tradition is important when no compelling and
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supportive research evidence exists.
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DIF: Cognitive Level: Applying (Application) REF: z. 5
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Whichis
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an example of a first-level priority problem?
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a Patient with postoperative pain bv bv bv




.
b Newly diagnosed patient with diabetes who needs diabetic teaching
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.
c Individual with a small laceration on the sole of the foot bv bv bv bv bv bv bv bv bv bv




.
d Individual with shortness of breath and respiratory distress bv bv bv bv bv bv bv




.

ANS: D bv




First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
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establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
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vitalsigns) (see Table 1-1).
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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9. When considering priority setting of problems, the nurse keeps in mind that second-
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levelpriority problems include which of these aspects?
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