Health Assessment 1 Comprehensive Q&A with detailed explanations Final

Health Assessment 1 Comprehensive Q&A with detailed explanations Final 1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse i s 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. - ✔✔ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physica l examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. 2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. The se types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. - ✔✔ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data. 7. The nurse is reviewing information about evidence -based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinicians experience. d. The patients own preferences are not important with EBP. - ✔✔ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making d ecisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. 15. Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills. - ✔✔ANS: A As individuals, nurses lack research s kills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. 3. The patients reco rd, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary. - ✔✔ANS: A Together with the patients record and laboratory studies, the objective and subjectiv e data form the data base. The other items are not part of the patients record, laboratory studies, or data. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors. - ✔✔ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. 10. Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps i n data d. Distinguishing relevant from irrelevant - ✔✔ANS: B Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding (Comprehension) 8. The nurse is conducting a class on priority setting for a group o f new graduate nurses. Which is an example of a first -level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 4 c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress - ✔✔ANS: D First -level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs). 9. When considering priority setting of problems, the nurse keeps in mind that second -level priority problems include which of these aspects? a. Low self -esteem b. Lack of k nowledge c. Abnormal laboratory values d. Severely abnormal vital signs - ✔✔ANS: C Second -level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security). 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, dischar ge, and follow -up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation - ✔✔ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. 24. A patient is brought by ambulance to the emergency department with multiple traumas receive d in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life -saving measures. b. Simultaneously ask history questions while performing the examination and initiating life -saving measures.