Evidence-Based xPhysical xExamination xBest xPractices
xfor xHealth x& xWell-Being xAssessment x1st xEdition xTest
, xBank
Chapter x1. xAPPROACH xTO xEVIDENCE-BASED xASSESSMENT xOF xHEALTH xAND xWELL-
xBEING
MULTIPLE xCHOICE
1. After xcompleting xan xinitial xassessment xof xa xpatient, xthe xnurse xhas xcharted xthat xhis
xrespirations xare xeupneic xand xhis xpulse xis x58 xbeats xper xminute. xThese xtypes xof xdata
xwould xbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: xA
Objective xdata xare xwhat xthe xhealth xprofessional xobserves xby xinspecting, xpercussing,
xpalpating, xand xauscultating xduring xthe xphysical xexamination. xSubjective xdata xis xwhat xthe
xperson xsays xabout xhim xor xherself xduring xhistory xtaking. xThe xterms xreflective xand
xintrospective xare xnot xused xto xdescribe xdata.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
2. A xpatient xtells xthe xnurse xthat xhe xis xvery xnervous, xis xnauseated, xand xfeels xhot.
xThese xtypes xof xdata xwould xbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: xC
Subjective xdata xare xwhat xthe xperson xsays xabout xhim xor xherself xduring xhistory xtaking.
xObjective
,data xare xwhat xthe xhealth xprofessional xobserves xby xinspecting, xpercussing, xpalpating, xand
xauscultating xduring xthe xphysical xexamination. xThe xterms xreflective xand xintrospective xare
xnot xused xto xdescribe xdata.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
3. The xpatients xrecord, xlaboratory xstudies, xobjective xdata, xand xsubjective xdata xcombine
xto xform xthe:
a Data xbase.
.
b Admitting xdata.
.
c Financial xstatement.
.
d Discharge xsummary.
.
ANS: xA
Together xwith xthe xpatients xrecord xand xlaboratory xstudies, xthe xobjective xand xsubjective
xdata xform xthe xdata xbase. xThe xother xitems xare xnot xpart xof xthe xpatients xrecord, xlaboratory
xstudies, xor xdata.
DIF: xCognitive xLevel: xRemembering x(Knowledge) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
4. When xlistening xto xa xpatients xbreath xsounds, xthe xnurse xis xunsure xof xa xsound xthat xis
xheard. xThe xnurses xnext xaction xshould xbe xto:
a Immediately xnotify xthe xpatients xphysician.
.
b Document xthe xsound xexactly xas xit xwas xheard.
.
c Validate xthe xdata xby xasking xa xcoworker xto xlisten xto xthe xbreath xsounds.
.
d Assess xagain xin x20 xminutes xto xnote xwhether xthe xsound xis xstill xpresent.
.
ANS: xC
When xunsure xof xa xsound xheard xwhile xlistening xto xa xpatients xbreath xsounds, xthe xnurse
xvalidates xthe xdata xto xensure xaccuracy. xIf xthe xnurse xhas xless xexperience x in xan xarea, xthen
xhe xor xshe xasks xan xexpert x to xlisten.
, DIF: xCognitive xLevel: xAnalyzing x(Analysis) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
5. The xnurse xis xconducting xa xclass xfor xnew xgraduate xnurses. xDuring xthe xteaching
xsession, xthe xnurse xshould xkeep xin xmind xthat xnovice xnurses, xwithout xa xbackground xof
xskills xand xexperience xfrom xwhich xto xdraw, xare xmore xlikely xto xmake xtheir xdecisions
x using:
a Intuition.
.
b A xset xof xrules.
.
c Articles xin xjournals.
.
d Advice xfrom xsupervisors.
.
ANS: xB
Novice xnurses xoperate xfrom xa xset xof xdefined, xstructured xrules. xThe xexpert xpractitioner
xuses xintuitive xlinks.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF:
xz. x3 xMSC: xClient xNeeds: xGeneral
6. Expert xnurses xlearn xto xattend xto xa xpattern xof xassessment xdata xand xact xwithout
xconsciously xlabeling xit. xThese xresponses xare xreferred xto xas:
a Intuition.
.
b The xnursing xprocess.
.
c Clinical xknowledge.
.
d Diagnostic xreasoning.
.
ANS: xA
Intuition xis xcharacterized xby xpattern xrecognitionexpert xnurses xlearn xto xattend xto xa xpattern
xof xassessment xdata xand xact xwithout xconsciously xlabeling xit. xThe xother xoptions xare xnot
xcorrect.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF:
xz. x4 xMSC: xClient xNeeds: xGeneral
7. The xnurse xis xreviewing xinformation xabout xevidence-based xpractice x(EBP). xWhich
xstatement xbest xreflects xEBP?
xfor xHealth x& xWell-Being xAssessment x1st xEdition xTest
, xBank
Chapter x1. xAPPROACH xTO xEVIDENCE-BASED xASSESSMENT xOF xHEALTH xAND xWELL-
xBEING
MULTIPLE xCHOICE
1. After xcompleting xan xinitial xassessment xof xa xpatient, xthe xnurse xhas xcharted xthat xhis
xrespirations xare xeupneic xand xhis xpulse xis x58 xbeats xper xminute. xThese xtypes xof xdata
xwould xbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: xA
Objective xdata xare xwhat xthe xhealth xprofessional xobserves xby xinspecting, xpercussing,
xpalpating, xand xauscultating xduring xthe xphysical xexamination. xSubjective xdata xis xwhat xthe
xperson xsays xabout xhim xor xherself xduring xhistory xtaking. xThe xterms xreflective xand
xintrospective xare xnot xused xto xdescribe xdata.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
2. A xpatient xtells xthe xnurse xthat xhe xis xvery xnervous, xis xnauseated, xand xfeels xhot.
xThese xtypes xof xdata xwould xbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: xC
Subjective xdata xare xwhat xthe xperson xsays xabout xhim xor xherself xduring xhistory xtaking.
xObjective
,data xare xwhat xthe xhealth xprofessional xobserves xby xinspecting, xpercussing, xpalpating, xand
xauscultating xduring xthe xphysical xexamination. xThe xterms xreflective xand xintrospective xare
xnot xused xto xdescribe xdata.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
3. The xpatients xrecord, xlaboratory xstudies, xobjective xdata, xand xsubjective xdata xcombine
xto xform xthe:
a Data xbase.
.
b Admitting xdata.
.
c Financial xstatement.
.
d Discharge xsummary.
.
ANS: xA
Together xwith xthe xpatients xrecord xand xlaboratory xstudies, xthe xobjective xand xsubjective
xdata xform xthe xdata xbase. xThe xother xitems xare xnot xpart xof xthe xpatients xrecord, xlaboratory
xstudies, xor xdata.
DIF: xCognitive xLevel: xRemembering x(Knowledge) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
4. When xlistening xto xa xpatients xbreath xsounds, xthe xnurse xis xunsure xof xa xsound xthat xis
xheard. xThe xnurses xnext xaction xshould xbe xto:
a Immediately xnotify xthe xpatients xphysician.
.
b Document xthe xsound xexactly xas xit xwas xheard.
.
c Validate xthe xdata xby xasking xa xcoworker xto xlisten xto xthe xbreath xsounds.
.
d Assess xagain xin x20 xminutes xto xnote xwhether xthe xsound xis xstill xpresent.
.
ANS: xC
When xunsure xof xa xsound xheard xwhile xlistening xto xa xpatients xbreath xsounds, xthe xnurse
xvalidates xthe xdata xto xensure xaccuracy. xIf xthe xnurse xhas xless xexperience x in xan xarea, xthen
xhe xor xshe xasks xan xexpert x to xlisten.
, DIF: xCognitive xLevel: xAnalyzing x(Analysis) xREF: xz. x2
MSC: xClient xNeeds: xSafe xand xEffective xCare xEnvironment: xManagement xof xCare
5. The xnurse xis xconducting xa xclass xfor xnew xgraduate xnurses. xDuring xthe xteaching
xsession, xthe xnurse xshould xkeep xin xmind xthat xnovice xnurses, xwithout xa xbackground xof
xskills xand xexperience xfrom xwhich xto xdraw, xare xmore xlikely xto xmake xtheir xdecisions
x using:
a Intuition.
.
b A xset xof xrules.
.
c Articles xin xjournals.
.
d Advice xfrom xsupervisors.
.
ANS: xB
Novice xnurses xoperate xfrom xa xset xof xdefined, xstructured xrules. xThe xexpert xpractitioner
xuses xintuitive xlinks.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF:
xz. x3 xMSC: xClient xNeeds: xGeneral
6. Expert xnurses xlearn xto xattend xto xa xpattern xof xassessment xdata xand xact xwithout
xconsciously xlabeling xit. xThese xresponses xare xreferred xto xas:
a Intuition.
.
b The xnursing xprocess.
.
c Clinical xknowledge.
.
d Diagnostic xreasoning.
.
ANS: xA
Intuition xis xcharacterized xby xpattern xrecognitionexpert xnurses xlearn xto xattend xto xa xpattern
xof xassessment xdata xand xact xwithout xconsciously xlabeling xit. xThe xother xoptions xare xnot
xcorrect.
DIF: xCognitive xLevel: xUnderstanding x(Comprehension) xREF:
xz. x4 xMSC: xClient xNeeds: xGeneral
7. The xnurse xis xreviewing xinformation xabout xevidence-based xpractice x(EBP). xWhich
xstatement xbest xreflects xEBP?
