ckEdition ckby ckBickley
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,Bates’ ckGuide ckTo ckPhysical ckExamination ckand ckHistory ckTaking, ck13th
ckEdition ckby ckBickley
PlusBay.Plus
,Bates’ ckGuide ckTo ckPhysical ckExamination ckand ckHistory ckTaking, ck13th ckEdition
ckby ckBickley
Bates' ckGuide ckto ckPhysical ckExamination ckand ckHistory ckTaking ck13th ckEdition ckBickley
ckTest ckBank ckCHAPTER ck1 Approach ckto ckthe ckClinical ckEncounter
After ckcompleting ckan ckinitial ckassessment ckof cka ckpatient, ckthe cknurse ckhas ckcharted
ckthat ckhis ckrespirations ckare ckeupneic ckand ckhis ckpulse ckis ck58 ckbeats ckper ckminute.
ckThese cktypes ckof ckdata ckwould ckbe:
a
Objective.
b
Reflective.
c
Subjective.
d
Introspective.
ANS: ckA
Objective ckdata ckare ckwhat ckthe ckhealth ckprofessional ckobserves ckby ckinspecting,
ckpercussing, ckpalpating, ckand ckauscultating ckduring ckthe ckphysical ckexamination.
ckSubjective ckdata ckis ckwhat ckthe ckperson cksays ckabout ckhim ckor ckherself ckduring
ckhistory cktaking. ckThe ckterms ckreflective ckand ckintrospective ckare cknot ckused ckto
ckdescribe ckdata.
DIF: ckCognitive ck Level: ck Understanding ck(Comprehension) ck REF: ck p. ck2
MSC: ckClient ck Needs: ckSafe ckand ckEffective ckCare ckEnvironment: ck Management ckof ckCare
• A ckpatient cktells ckthe cknurse ckthat ckhe ckis ckvery cknervous, ckis cknauseated,
ckand ckfeels ckhot. ckThese cktypes ckof ckdata ckwould ckbe:
a
Objective.
b
Reflective.
c
Subjective.
d
Introspective.
ANS: ckC
Subjective ckdata ckare ckwhat ckthe ckperson cksays ckabout ckhim ckor ckherself ckduring
ckhistory cktaking. ckObjective ckdata ckare ckwhat ckthe ckhealth ckprofessional ckobserves ckby
ckinspecting, ckpercussing, ckpalpating, ckand ckauscultating ckduring ckthe ckphysical
ckexamination. ckThe ckterms ckreflective ckand ckintrospective ckare cknot ckused
to ckdescribe ck data.
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, Bates’ ckGuide ckTo ckPhysical ckExamination ckand ckHistory ckTaking, ck13th ckEdition
ckby ckBickley
DIF: ckCognitive ck Level: ck Understanding ck(Comprehension) ck REF: ck p. ck2
MSC: ckClient ck Needs: ckSafe ckand ckEffective ckCare ckEnvironment: ck Management ckof ckCare
• The ckpatients ckrecord, cklaboratory ckstudies, ckobjective ckdata, ckand
cksubjective ckdata ckcombine ckto ckform ckthe:
a
Data ckbase.
b
Admitting ckdata.
c
Financial ckstatement.
d
Discharge cksummary.
ANS: ckA
Together ckwith ckthe ckpatients ckrecord ckand cklaboratory ckstudies, ckthe ckobjective ckand
cksubjective ckdata ckform ckthe ckdata ckbase. ckThe ckother ckitems ckare cknot ckpart ckof ckthe
ckpatients ckrecord, cklaboratory ckstudies, ckor ckdata.
DIF: ckCognitive ck Level: ckRemembering ck (Knowledge) ckREF: ck p. ck2
MSC: ckClient ck Needs: ckSafe ckand ckEffective ckCare ckEnvironment: ck Management ckof ckCare
• When cklistening ckto cka ckpatients ckbreath cksounds, ckthe cknurse ckis ckunsure ckof cka
cksound ckthat ckis ckheard. ckThe cknurses cknext ckaction ckshould ckbe ckto:
a
Immediately ck notify ckthe ck patients ck physician.
b
Document ckthe cksound ckexactly ckas ckit ckwas
ck heard.
c Validate ckthe ckdata ckby ckasking cka
ckcoworker ckto cklisten ckto ckthe ckbreath
cksounds.
d Assess ckagain ckin ck20 ckminutes ckto cknote
ckwhether ckthe cksound ckis ckstill ckpresent.
ANS: ckC
When ckunsure ckof cka cksound ckheard ckwhile cklistening ckto cka ckpatients ckbreath cksounds, ckthe
cknurse ckvalidates ckthe ckdata ckto ckensure ckaccuracy. ckIf ckthe cknurse ckhas ckless ckexperience ckin
ckan ckarea, ckthen ckhe ckor ckshe ckasks ckan ckexpert ckto cklisten.
DIF: ckCognitive ck Level: ckAnalyzing ck(Analysis) ckREF: ck p. ck2
MSC: ckClient ck Needs: ckSafe ckand ckEffective ckCare ckEnvironment: ck Management ckof ckCare
• The cknurse ckis ckconducting cka ckclass ckfor cknew ckgraduate cknurses. ckDuring
ckthe ckteaching cksession, ckthe cknurse ckshould ckkeep ckin ckmind ckthat cknovice
cknurses, ckwithout cka
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