TEST BANK
Evidence-Based Physical Examination Best Practices for
Health & Well-BeingAssessment by Kate Gawlic
1st Edition
TEST BANK
,Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND
WELL-BEING
Kate Gawlic: Evidence-Based Physical Examination Best Practices for Health & Well-
BeingAssessment 1st Edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse 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 Introspective.
.
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
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: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, 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 subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a Immediately notify the patients 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.
.
ANS: C
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
to listen.
,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
MSC: Client Needs: General
6. Expert nurses 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.
.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
MSC: Client Needs: General
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 fis fa fsystematic fapproach fto fpractice fthat femphasizes fthe fuse fof fbest fevidence fin
fcombination fwith fthe f clinicians fexperience, fas fwell fas fpatient fpreferences fand fvalues,
fwhen fmaking fdecisions fabout fcare f and ftreatment. fEBP fis fmore fthan fsimply fusing fthe
fbest fpractice ftechniques fto f treat fpatients, fand fquestioning ftradition f is f important fwhen f no
fcompelling fand fsupportive fresearch fevidence fexists.
DIF: fCognitive fLevel: fApplying f(Application) fREF: fz. f5
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
8. The fnurse fis fconducting fa fclass fon fpriority fsetting ffor fa fgroup fof fnew fgraduate
fnurses. fWhich f is f an fexample f of fa f first-level fpriority fproblem?
a Patient fwith fpostoperative fpain
.
b Newly fdiagnosed fpatient fwith fdiabetes fwho fneeds fdiabetic fteaching
.
c Individual fwith fa fsmall flaceration fon fthe fsole fof fthe ffoot
.
d Individual fwith fshortness fof fbreath fand frespiratory fdistress
.
ANS: fD
First-level fpriority fproblems fare fthose fthat fare femergent, flife fthreatening, fand fimmediate
f(e.g., festablishing fan fairway, fsupporting fbreathing, fmaintaining fcirculation, fmonitoring
fabnormal fvital fsigns) f(see fTable f1-1).
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f4
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
9. When fconsidering fpriority fsetting fof fproblems, fthe fnurse fkeeps fin fmind fthat
fsecond-level fpriority fproblems f include fwhich f of f these f aspects?
, a Low fself-esteem
.
b Lack fof fknowledge
.
c Abnormal flaboratory fvalues
.
d Severely fabnormal fvital fsigns
.
ANS: fC
Second-level fpriority fproblems fare fthose fthat frequire fprompt fintervention fto fforestall
ffurther fdeterioration f(e.g., fmental fstatus fchange, facute fpain, fabnormal flaboratory fvalues,
frisks fto fsafety f or fsecurity) f(see fTable f1-1).
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f4
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
10. Which fcritical fthinking fskill fhelps fthe fnurse fsee frelationships famong fthe f data?
a Validation
.
b Clustering frelated fcues
.
c Identifying fgaps fin fdata
.
d Distinguishing frelevant ffrom firrelevant
.
ANS: fB
Clustering frelated fcues fhelps fthe fnurse fsee frelationships famong fthe fdata.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f2
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
11. The fnurse fknows fthat fdeveloping fappropriate fnursing finterventions ffor fa fpatient frelies
fon fthe fappropriateness fof fthe diagnosis.
a Nursing
.
b Medical
.
, c Admission
.
d Collaborative
.
ANS: fA
An faccurate fnursing fdiagnosis fprovides fthe fbasis ffor fthe fselection fof fnursing
finterventions f to fachieve foutcomes f for fwhich fthe fnurse fis faccountable. fThe fother f items
fdo fnot fcontribute fto fthe fdevelopment f of fappropriate f nursing f interventions.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f6
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
12. The fnursing fprocess fis fa fsequential fmethod fof fproblem fsolving fthat fnurses fuse fand
fincludes fwhich fsteps?
a Assessment, ftreatment, fplanning, fevaluation, fdischarge, fand ffollow-up
.
b Admission, fassessment, fdiagnosis, ftreatment, fand fdischarge fplanning
.
c Admission, fdiagnosis, ftreatment, fevaluation, fand fdischarge fplanning
.
d Assessment, fdiagnosis, foutcome fidentification, fplanning, fimplementation, fand
. fevaluation
ANS: fD
The fnursing fprocess fis fa fmethod fof fproblem fsolving fthat fincludes fassessment, fdiagnosis,
foutcome f identification, fplanning, f implementation, fand fevaluation.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: f z. f 3
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
13. A fnewly fadmitted fpatient fis fin facute fpain, fhas fnot fbeen fsleeping fwell flately, fand
fis f having fdifficulty fbreathing. fHow fshould fthe f nurse fprioritize fthese f problems?
a Breathing, fpain, fand fsleep
.
b Breathing, fsleep, fand fpain
.
c Sleep, fbreathing, fand fpain
.
Evidence-Based Physical Examination Best Practices for
Health & Well-BeingAssessment by Kate Gawlic
1st Edition
TEST BANK
,Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND
WELL-BEING
Kate Gawlic: Evidence-Based Physical Examination Best Practices for Health & Well-
BeingAssessment 1st Edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse 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 Introspective.
.
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
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: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These 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.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, 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 subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a Immediately notify the patients 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.
.
ANS: C
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
to listen.
,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
MSC: Client Needs: General
6. Expert nurses 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.
.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
MSC: Client Needs: General
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 fis fa fsystematic fapproach fto fpractice fthat femphasizes fthe fuse fof fbest fevidence fin
fcombination fwith fthe f clinicians fexperience, fas fwell fas fpatient fpreferences fand fvalues,
fwhen fmaking fdecisions fabout fcare f and ftreatment. fEBP fis fmore fthan fsimply fusing fthe
fbest fpractice ftechniques fto f treat fpatients, fand fquestioning ftradition f is f important fwhen f no
fcompelling fand fsupportive fresearch fevidence fexists.
DIF: fCognitive fLevel: fApplying f(Application) fREF: fz. f5
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
8. The fnurse fis fconducting fa fclass fon fpriority fsetting ffor fa fgroup fof fnew fgraduate
fnurses. fWhich f is f an fexample f of fa f first-level fpriority fproblem?
a Patient fwith fpostoperative fpain
.
b Newly fdiagnosed fpatient fwith fdiabetes fwho fneeds fdiabetic fteaching
.
c Individual fwith fa fsmall flaceration fon fthe fsole fof fthe ffoot
.
d Individual fwith fshortness fof fbreath fand frespiratory fdistress
.
ANS: fD
First-level fpriority fproblems fare fthose fthat fare femergent, flife fthreatening, fand fimmediate
f(e.g., festablishing fan fairway, fsupporting fbreathing, fmaintaining fcirculation, fmonitoring
fabnormal fvital fsigns) f(see fTable f1-1).
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f4
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
9. When fconsidering fpriority fsetting fof fproblems, fthe fnurse fkeeps fin fmind fthat
fsecond-level fpriority fproblems f include fwhich f of f these f aspects?
, a Low fself-esteem
.
b Lack fof fknowledge
.
c Abnormal flaboratory fvalues
.
d Severely fabnormal fvital fsigns
.
ANS: fC
Second-level fpriority fproblems fare fthose fthat frequire fprompt fintervention fto fforestall
ffurther fdeterioration f(e.g., fmental fstatus fchange, facute fpain, fabnormal flaboratory fvalues,
frisks fto fsafety f or fsecurity) f(see fTable f1-1).
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f4
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
10. Which fcritical fthinking fskill fhelps fthe fnurse fsee frelationships famong fthe f data?
a Validation
.
b Clustering frelated fcues
.
c Identifying fgaps fin fdata
.
d Distinguishing frelevant ffrom firrelevant
.
ANS: fB
Clustering frelated fcues fhelps fthe fnurse fsee frelationships famong fthe fdata.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f2
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
11. The fnurse fknows fthat fdeveloping fappropriate fnursing finterventions ffor fa fpatient frelies
fon fthe fappropriateness fof fthe diagnosis.
a Nursing
.
b Medical
.
, c Admission
.
d Collaborative
.
ANS: fA
An faccurate fnursing fdiagnosis fprovides fthe fbasis ffor fthe fselection fof fnursing
finterventions f to fachieve foutcomes f for fwhich fthe fnurse fis faccountable. fThe fother f items
fdo fnot fcontribute fto fthe fdevelopment f of fappropriate f nursing f interventions.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: fz. f6
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
12. The fnursing fprocess fis fa fsequential fmethod fof fproblem fsolving fthat fnurses fuse fand
fincludes fwhich fsteps?
a Assessment, ftreatment, fplanning, fevaluation, fdischarge, fand ffollow-up
.
b Admission, fassessment, fdiagnosis, ftreatment, fand fdischarge fplanning
.
c Admission, fdiagnosis, ftreatment, fevaluation, fand fdischarge fplanning
.
d Assessment, fdiagnosis, foutcome fidentification, fplanning, fimplementation, fand
. fevaluation
ANS: fD
The fnursing fprocess fis fa fmethod fof fproblem fsolving fthat fincludes fassessment, fdiagnosis,
foutcome f identification, fplanning, f implementation, fand fevaluation.
DIF: fCognitive fLevel: fUnderstanding f(Comprehension) fREF: f z. f 3
MSC: fClient fNeeds: fSafe fand fEffective fCare fEnvironment: fManagement fof fCare
13. A fnewly fadmitted fpatient fis fin facute fpain, fhas fnot fbeen fsleeping fwell flately, fand
fis f having fdifficulty fbreathing. fHow fshould fthe f nurse fprioritize fthese f problems?
a Breathing, fpain, fand fsleep
.
b Breathing, fsleep, fand fpain
.
c Sleep, fbreathing, fand fpain
.
