Evidence-Based Physical Examination Best Practices for Health & b
. Reflective.
Well-Being Assessment 1st Edition Test Bank A+
c
Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND
. Subjective.
WELL- BEING
d
MULTIPLE CHOICE
. Introspective.
1. After completing an initial assessment of a patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
ANS: C
Subjective data are what the person says about him or herself during history taking. Objective
a
. Objective.
data are what the health professional observes by inspecting, percussing, palpating, and
b
auscultating during the physical examination. The terms reflective and introspective are not used
. Reflective.
to describe data.
c
. Subjective.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
d
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
. Introspective.
3. The patients record, laboratory studies, objective data, and subjective data combine to
form the:
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
a
and auscultating during the physical examination. Subjective data is what the person says about
. Data base.
him or herself during history taking. The terms reflective and introspective are not used to
b
describe data.
. Admitting data.
c
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
. Financial statement.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
. Discharge summary.
of data would be:
ANS: A
a
Together with the patients record and laboratory studies, the objective and subjective data form
. Objective.
the data base. The other items are not part of the patients record, laboratory studies, or data.
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. Articles in journals.
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2 d
MSC: Client Needs: Safe and Effective Care Environment: Management of Care . Advice from supervisors.
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
The nurses next action should be to: ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
a intuitive links.
. Immediately notify the patients physician.
b DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3 MSC: Client Needs: General
. Document the sound exactly as it was heard. 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
c labeling it. These responses are referred to as:
. Validate the data by asking a coworker to listen to the breath sounds.
d a
. Assess again in 20 minutes to note whether the sound is still present. . Intuition.
b
ANS: C . The nursing process.
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the c
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert . Clinical knowledge.
to listen. d
. Diagnostic reasoning.
DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care ANS: A
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
nurse should keep in mind that novice nurses, without a background of skills and experience assessment data and act without consciously labeling it. The other options are not correct.
from which to draw, are more likely to make their decisions using:
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4 MSC: Client Needs: General
a 7. The nurse is reviewing information about evidence-based practice (EBP). Which
. Intuition. statement best reflects EBP?
b
. A set of rules.
c a
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. EBP relies on tradition for support of best practices. First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
b establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
. EBP is simply the use of best practice techniques for the treatment of patients. signs) (see Table 1-1).
c
. EBP emphasizes the use of best evidence with the clinicians experience. DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
d MSC: Client Needs: Safe and Effective Care Environment: Management of Care
. The patients own preferences are not important with EBP. 9. When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects?
ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination a
with the clinicians experience, as well as patient preferences and values, when making decisions . Low self-esteem
about care and treatment. EBP is more than simply using the best practice techniques to treat b
patients, and questioning tradition is important when no compelling and supportive research . Lack of knowledge
evidence exists. c
. Abnormal laboratory values
DIF: Cognitive Level: Applying (Application) REF: z. 5 d
MSC: Client Needs: Safe and Effective Care Environment: Management of Care . Severely abnormal vital signs
8. The nurse is conducting a class on priority setting for a group of new graduate nurses.
Which is an example of a first-level priority problem? ANS: C
Second-level priority problems are those that require prompt intervention to forestall further
a deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety
. Patient with postoperative pain or security) (see Table 1-1).
b
. Newly diagnosed patient with diabetes who needs diabetic teaching DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
c MSC: Client Needs: Safe and Effective Care Environment: Management of Care
. Individual with a small laceration on the sole of the foot 10. Which critical thinking skill helps the nurse see relationships among the data?
d
. Individual with shortness of breath and respiratory distress
ANS: D
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