Solution
Evidence-Based Physical Examination Best Practices for Health
nd nd nd nd nd nd
nd& Well-Being Assessment 2nd Edition Test Bank A+
nd nd nd nd nd nd nd nd
Chapter nd1. ndAPPROACH ndTO ndEVIDENCE-BASED ndASSESSMENT ndOF ndHEALTH
AND ndWELL- ndBEING
nd
MULTIPLE ndCHOICE
1. After ndcompleting ndan ndinitial ndassessment ndof nda ndpatient, ndthe ndnurse ndhas ndcharted
nd that ndhis ndrespirations ndare ndeupneic ndand ndhis ndpulse ndis nd58 ndbeats ndper ndminute. ndThese ndtypes
nd of nddata ndwould ndbe:
a
. Objective.
nd b
. Reflective.
nd c
. Subjective.
nd d
. Introspective.
ANS: ndA
Objective nddata ndare ndwhat ndthe ndhealth ndprofessional ndobserves ndby ndinspecting, ndpercussing,
nd palpating, ndand ndauscultating ndduring ndthe ndphysical ndexamination. ndSubjective nddata ndis ndwhat ndthe
nd person ndsays ndabout ndhim ndor ndherself ndduring ndhistory ndtaking. ndThe ndterms ndreflective ndand
nd introspective ndare ndnot ndused ndto nddescribe nddata.
DIF: ndCognitive ndLevel: ndUnderstanding nd(Comprehension) ndREF: ndz. nd2
MSC: ndClient ndNeeds: ndSafe ndand ndEffective ndCare ndEnvironment: ndManagement ndof ndCare
2. A ndpatient ndtells ndthe ndnurse ndthat ndhe ndis ndvery ndnervous, ndis ndnauseated, ndand ndfeels ndhot.
nd These ndtypes ndof nddata ndwould ndbe:
a
. Objective.
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b
. Reflective.
nd c
. Subjective.
nd d
. Introspective.
ANS: ndC
Subjective nddata ndare ndwhat ndthe ndperson ndsays ndabout ndhim ndor ndherself ndduring ndhistory ndtaking.
ndObjective
data ndare ndwhat ndthe ndhealth ndprofessional ndobserves ndby ndinspecting, ndpercussing, ndpalpating, ndand
nd auscultating ndduring ndthe ndphysical ndexamination. ndThe ndterms ndreflective ndand ndintrospective ndare
nd not ndused ndto nddescribe nddata.
DIF: ndCognitive ndLevel: ndUnderstanding nd(Comprehension) ndREF: ndz. nd2
MSC: ndClient ndNeeds: ndSafe ndand ndEffective ndCare ndEnvironment: ndManagement ndof ndCare
3. The ndpatients ndrecord, ndlaboratory ndstudies, ndobjective nddata, ndand ndsubjective nddata
nd combine ndto ndform ndthe:
a
. Data
nd base. ndb
. Admitting
nd data. ndc
. Financial
nd statement. ndd
. Discharge ndsummary.
ANS: ndA
Together ndwith ndthe ndpatients ndrecord ndand ndlaboratory ndstudies, ndthe ndobjective ndand ndsubjective nddata
nd form ndthe nddata ndbase. ndThe ndother nditems ndare ndnot ndpart ndof ndthe ndpatients ndrecord, ndlaboratory
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ndstudies, ndor nddata.
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DIF: ndCognitive ndLevel: ndRemembering nd(Knowledge) ndREF: ndz. nd2
MSC: ndClient ndNeeds: ndSafe ndand ndEffective ndCare ndEnvironment: ndManagement ndof ndCare
4. When ndlistening ndto nda ndpatients ndbreath ndsounds, ndthe ndnurse ndis ndunsure ndof nda ndsound ndthat
nd is ndheard. ndThe ndnurses ndnext ndaction ndshould ndbe ndto:
a
. Immediately ndnotifyndthe ndpatients
nd physician. ndb
. Document ndthe ndsound ndexactly ndas ndit ndwas
nd heard. ndc
. Validate ndthe nddata ndby ndasking nda ndcoworker ndto ndlisten ndto ndthe ndbreath
nd sounds. ndd
. Assess ndagain ndin nd20 ndminutes ndto ndnote ndwhether ndthe ndsound ndis ndstill ndpresent.
ANS: ndC
When ndunsure ndof nda ndsound ndheard ndwhile ndlistening ndto nda ndpatients ndbreath ndsounds, ndthe ndnurse
nd validates ndthe nddata ndto ndensure ndaccuracy. ndIf ndthe ndnurse ndhas ndless ndexperience ndin ndan ndarea, ndthen
nd he ndor ndshe ndasks ndan ndexpert ndto ndlisten.
DIF: ndCognitive ndLevel: ndAnalyzing nd(Analysis) ndREF: ndz. nd2
MSC: ndClient ndNeeds: ndSafe ndand ndEffective ndCare ndEnvironment: ndManagement ndof ndCare
5. The ndnurse ndis ndconducting nda ndclass ndfor ndnew ndgraduate ndnurses. ndDuring ndthe ndteaching
nd session, ndthe ndnurse ndshould ndkeep ndin ndmind ndthat ndnovice ndnurses, ndwithout nda ndbackground ndof
nd skills ndand ndexperience ndfrom ndwhich ndto nddraw, ndare ndmore ndlikely ndto ndmake ndtheir nddecisions
nd using:
a
. Intuition.
nd b
. A ndset ndof
rules. ndc
nd
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