NURSING HEALTH ASSESSMENT A CLINICAL JUDGEMENT
APPROACH 4TH EDITION JENSEN TEST BANK/ALL CHAPTERS 1-
30
,CH 1.The Medical caretaker’s Role in Health Assessment
1. After completing an initial assessment of a hospital patient, the nursing attendant has
charted that his respirations are eupneic and his pulse is 58 beats per minute. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspectiv
e. CORRECT ANS:-A
Explanation:->>Objective data are what the health professional observes by inspecting, percussing,
palpatin and auscultating during the physical 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A hospital patient tells the nursing attendant that he is very nervous, is nauseated, and
feels hot. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspectiv
e. CORRECT ANS:-C
Explanation:->>Subjective data are what the person says about him or herself during history taking.
Objecti 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The hospital clients record, laboratory studies, objective data, and subjective data combine
to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge
summary. CORRECT ANS:-A
,Explanation:->>Together with the hospital clients record and laboratory studies, the
objective and subjective data form the data base. The other items are not part of the
hospital clients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a hospital clients breath sounds, the nursing attendant is unsure of a
sound that is heard. The medical caretakers next action should be to:
a. Immediately notify the hospital clients’ physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still
present. CORRECT ANS:-C
Explanation:->>When unsure of a sound heard while listening to a hospital clients breath sounds, the
nursin attendant validates the
data to ensure accuracy. If the nursing attendant has less experience in an area, then he or
she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nursing attendant is conducting a class for new graduate medical caretakers.
During the teaching session, the nursing attendant should keep in mind that novice
medical caretakers, 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. CORRECT ANS:-B
Explanation:->>Novice medical caretakers operate from a set of defined, structured rules. The expert
practitioner uses
intuitive links.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm.
3 MSC: Client Needs: General
6. Expert medical caretakers learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic
reasoning. CORRECT ANS:-A
Explanation:->>Intuition is characterized by pattern recognitionexpert medical caretakers learn to
attend to pattern of
assessment data and act without consciously labeling it. The other options are not
correct. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: General
7. The nursing attendant 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 hospital patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The hospital clients own preferences are not
important with EBP.
CORRECT ANS:-C
Explanation:->>EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination
with the clinicians experience, as well as hospital patient preferences and values, when
making decisions about care and treatment. EBP is more than simply using the best
practice techniques to treat hospital patients, and questioning tradition is important
when no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application) REF: dm. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nursing attendant is conducting a class on priority setting for a group of new graduate medical
caretak Which
is an example of a first-level priority problem?
a. Hospital patient with postoperative pain
b. Newly diagnosed hospital patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory
distress CORRECT ANS:-D
Explanation:->>First-level priority problems are those that are emergent, life threatening, and
immediate (e.
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When considering priority setting of problems, the nursing attendant keeps in mind that second-
level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital
signs CORRECT ANS:-C
Explanation:->>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) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the nursing attendant see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
APPROACH 4TH EDITION JENSEN TEST BANK/ALL CHAPTERS 1-
30
,CH 1.The Medical caretaker’s Role in Health Assessment
1. After completing an initial assessment of a hospital patient, the nursing attendant has
charted that his respirations are eupneic and his pulse is 58 beats per minute. These
types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspectiv
e. CORRECT ANS:-A
Explanation:->>Objective data are what the health professional observes by inspecting, percussing,
palpatin and auscultating during the physical 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A hospital patient tells the nursing attendant that he is very nervous, is nauseated, and
feels hot. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspectiv
e. CORRECT ANS:-C
Explanation:->>Subjective data are what the person says about him or herself during history taking.
Objecti 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The hospital clients record, laboratory studies, objective data, and subjective data combine
to form the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge
summary. CORRECT ANS:-A
,Explanation:->>Together with the hospital clients record and laboratory studies, the
objective and subjective data form the data base. The other items are not part of the
hospital clients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a hospital clients breath sounds, the nursing attendant is unsure of a
sound that is heard. The medical caretakers next action should be to:
a. Immediately notify the hospital clients’ physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still
present. CORRECT ANS:-C
Explanation:->>When unsure of a sound heard while listening to a hospital clients breath sounds, the
nursin attendant validates the
data to ensure accuracy. If the nursing attendant has less experience in an area, then he or
she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nursing attendant is conducting a class for new graduate medical caretakers.
During the teaching session, the nursing attendant should keep in mind that novice
medical caretakers, 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. CORRECT ANS:-B
Explanation:->>Novice medical caretakers operate from a set of defined, structured rules. The expert
practitioner uses
intuitive links.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm.
3 MSC: Client Needs: General
6. Expert medical caretakers learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic
reasoning. CORRECT ANS:-A
Explanation:->>Intuition is characterized by pattern recognitionexpert medical caretakers learn to
attend to pattern of
assessment data and act without consciously labeling it. The other options are not
correct. DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: General
7. The nursing attendant 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 hospital patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The hospital clients own preferences are not
important with EBP.
CORRECT ANS:-C
Explanation:->>EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination
with the clinicians experience, as well as hospital patient preferences and values, when
making decisions about care and treatment. EBP is more than simply using the best
practice techniques to treat hospital patients, and questioning tradition is important
when no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application) REF: dm. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nursing attendant is conducting a class on priority setting for a group of new graduate medical
caretak Which
is an example of a first-level priority problem?
a. Hospital patient with postoperative pain
b. Newly diagnosed hospital patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory
distress CORRECT ANS:-D
Explanation:->>First-level priority problems are those that are emergent, life threatening, and
immediate (e.
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal
vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When considering priority setting of problems, the nursing attendant keeps in mind that second-
level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital
signs CORRECT ANS:-C
Explanation:->>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) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the nursing attendant see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
