EVIDENCE-BASED PHYSICAL EXAMINATION f# f#
BEST PRACTICES FOR HEALTH & WELL-
f# f# f# f# f# f#
BEING,QASSESSMENT 1ST EDITION TEST BANK f# f# f# f#
Chapter f#1. f#APPROACH f#TO f#EVIDENCE-BASED f#ASSESSMENT f#OFHEALTH f#AND
f#WELL- f#BEING
MULTIPLE f#CHOICE
1. After f#completing f#an f#initial f#assessment f#of f#a f#patient, f#the f#nurse f#has f#charted f#that f#his
f#respirationsa re f#eupneic f#and f#his f#pulse f#is f#58 f#beats f#per f#minute. f#These f#types f#off#data
Q
,
f#would f # be:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: f#A
Objective f#data f#are f#what f#the f#health f#professional f# observes f#by f#inspecting, f#percussing,
f#palpating, f#and f#auscultating f#during f#the f#physical f#examination. f#Subjective f#data f#is f#what
f#the f#person f#says f#abouthim f#or f#herself f#during f#history f#taking. f#The f#terms f#reflective f#and
,Q
f#introspective f#are f#not f#used f#to f#describe f#data.
DIF:#fCognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
2. A f#patient f#tells f#the f#nurse f#that f#he f#is f#very f#nervous, f#is f#nauseated, f#and f#feels f#hot.
f#These f#types f#ofdata f# would f#be:
,Q
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:f#C
Subjective f#data are f#what f#the f#personsays f# about f#him f#or f#herselfduring f#history f#taking. f#Objective
Q,
,data f#are f#what f#the f#health f#professional f#observes f#by f#inspecting, f#percussing, f#palpating,
f#and f#auscultating during f#the f#physical f#examination. f#Thef#terms f#reflective f#and f#introspective f#are
Q,
f#not f#used to f#describe f#data.
Q,
DIF:f#Cognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
3. Thef#patients f#record, f#laboratorystudies, f#objective f#data, f#and f#subjectivef#data f#combine
f#to f#formthe:
Q
,
a Data f#base.
.
b Admitting f#data.
.
c Financialstatement.
.
d Dischargesummary.
.
ANS: f#A
Together f#withthe f#patients f#record f#and f#laboratorystudies, f#the f#objective f#and f#subjective
f#data f#formthe f#data f#base. f#The f#other f#items f#are f#not f#part f#ofthe f#patients f#record,
Q,
f#laboratorystudies, f#or f#data.
DIF:f#Cognitive f# Level: f#Remembering f# (Knowledge) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
4. Whenf#listening f#to af#patients f#breath sounds, f#the f#nurse f#is f#unsure f#ofa f#sound f#that f#is
Q, Q,
f#heard. f#Thenurses f# next f#action f#should f#be f # to:
Q
,
a Immediately f#notifyf#the f#patients f#physician.
.
b Documentf#thef#sound f#exactlyas f# itf#was f#heard.
.
c Validate f#the f#data f#byf#asking f#a f#coworker f#to f#listen tof#the f#breathf#sounds.
Q,
.
d Assess f#again f#inf#20 f#minutes f#to f#note f#whether f#thef#sound f#is f#stillf#present.
.
ANS:f#C
When f#unsure f#of f#a f#sound f#heard f#while f#listening f#to f#a f#patients f#breath f#sounds, f#the f#nurse
f#validates f#the f#data f#to f#ensure f#accuracy. f#If f#the f#nurse f#has f#less f # experience f # in f#an f#area,
f#then f#he f#or f#she f#asks f#an f#expertto f#listen.
,Q
,DIF:f#Cognitive f# Level: f#Analyzing f#(Analysis) f#REF:f#z. f#2
MSC:#fClient f#Needs:#fSafe f#and f#Effective f#Care f#Environment:f#Management f#off#Care
5. The f#nurse f#is f#conducting f#a f#class f#for f#new f#graduate f#nurses. f#During f#the f#teaching
f#session, f#the f#nurse f#should f#keep f#in f#mind f#that f#novice f#nurses, f#without f#a background
Q,
f# ofskills f#and f# experiencefrom f#which f#to f#draw, f#are f#more f#likely f#to f#make f#their f#decisions
Q
,
f # using:
a Intuition.
.
b Af#set f#ofrules.
.
c Articles f#inf#journals.
.
d Advice f#from f#supervisors.
.
ANS:f#B
Novice f#nurses f#operate f#fromf#af#set f#ofdefined, f#structured f#rules. f#Thef#expertf#practitioner
f#usesintuitive f# links.
Q
,
DIF:#fCognitive f#Level: f#Understanding f#(Comprehension) f#REF:
#fz. f#3 MSC: f#Client f#Needs: f#General
,Q
6. Expert f#nurses f#learntof#attend f#to f#a f#pattern f#of f#assessment f#data f#and f#act
f#without f#consciouslylabeling f#it. f#These f#responses f#are f#referred f#to f # as:
a Intuition.
.
b The f#nursing f#process.
.
c Clinical f#knowledge.
.
d Diagnosticreasoning.
.
ANS: f#A
Intuition f#is f#characterized f#by f#patternrecognitionexpert f#nurses f#learn f#toattend f#to f#a f#pattern
f#ofassessment f#data f#and f#act f#without f#consciously f#labeling f#it. f#The f#other f#options f#are f#notf#correct.
,Q
DIF:#fCognitive f#Level: f#Understanding f#(Comprehension) f#REF:
#fz. f#4 MSC: f#Client f#Needs: f#General
,Q
7. The f#nurse f#is f#reviewing f#information about f#evidence-based f#practice f#(EBP).
Q,
f#Which f#statementbest f# reflects f#EBP?
Q
,
, a EBP f#relies f# on f#tradition f#for f#support f#ofbest f#practices.
.
b EBP f#is f#simply f#the f#use f#ofbest f#practice f#techniques f# for f#the f#treatment f#of patients.
Q,
.
c EBP f#emphasizes f#the f#use f#off#best f#evidence f#with f#the f#clinicians f# experience.
.
d Thef#patients f#ownpreferences f#are f#not f#important f#with f#EBP.
.
ANS:f#C
EBP f#is f#a f#systematic f#approachto f#practice f#that f#emphasizes f#the f#use f#ofbest f#evidence f#in
f#combinationw ith f#the f#clinicians f#experience, f#as f#well f#as f#patient f#preferences f#and f#values, f#when
Q
,
f#making f#decisions f#about f#care f#and f#treatment. f#EBP f#is f#more f#than f#simply f#using f#the f#best
f#practice f#techniques f#to f#treat f#patients, f#and f#questioning f#tradition f#is f#important f#when f#no
f#compelling f#and f#supportive f#research f#evidence f#exists.
DIF:f#Cognitive f# Level: f#Applying f#(Application) f#REF: f#z. f#5
MSC:#fClient f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f#of f#Care
8. The f#nurse f#is f#conducting f#a f#class f#onprioritysetting f#for f#af#group f#of f#new f#graduate f#nurses.
f#Whichi s f# an f#example f#of f#a f#first-level f#priority f # problem?
Q,
a Patient f#with postoperative f#pain
Q,
.
b Newlydiagnosed f#patient f#withf#diabetes f#who f#needs f#diabetic f#teaching
.
c Individualwitha f#small f# laceration f#on f#the f#sole f# of f#the f# foot
.
d Individualwith f#shortness f#off#breath f#and f#respiratory f#distress
.
ANS:f#D
First-level f#priority f#problems f#are f#those f#that f#are f#emergent, f#life f#threatening, f#and f#immediate
f#(e.g., f#establishing f#anairway, f#supporting f#breathing, f#maintaining f#circulation, f#monitoring
f#abnormal f#vitals igns) f# (see f#Table f#1-1).
Q
,
DIF:#fCognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#4
MSC:#fClient f#Needs:#fSafe f#and f#Effective f#Care f#Environment:f#Management f#off#Care
9. When f#considering f#priorityf#setting f#ofproblems, f#the f#nurse f#keeps f#inmind f#that
f#second- f#levelpriority f#problems f#include f#which f#of f#these f # aspects?
,Q
BEST PRACTICES FOR HEALTH & WELL-
f# f# f# f# f# f#
BEING,QASSESSMENT 1ST EDITION TEST BANK f# f# f# f#
Chapter f#1. f#APPROACH f#TO f#EVIDENCE-BASED f#ASSESSMENT f#OFHEALTH f#AND
f#WELL- f#BEING
MULTIPLE f#CHOICE
1. After f#completing f#an f#initial f#assessment f#of f#a f#patient, f#the f#nurse f#has f#charted f#that f#his
f#respirationsa re f#eupneic f#and f#his f#pulse f#is f#58 f#beats f#per f#minute. f#These f#types f#off#data
Q
,
f#would f # be:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: f#A
Objective f#data f#are f#what f#the f#health f#professional f# observes f#by f#inspecting, f#percussing,
f#palpating, f#and f#auscultating f#during f#the f#physical f#examination. f#Subjective f#data f#is f#what
f#the f#person f#says f#abouthim f#or f#herself f#during f#history f#taking. f#The f#terms f#reflective f#and
,Q
f#introspective f#are f#not f#used f#to f#describe f#data.
DIF:#fCognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
2. A f#patient f#tells f#the f#nurse f#that f#he f#is f#very f#nervous, f#is f#nauseated, f#and f#feels f#hot.
f#These f#types f#ofdata f# would f#be:
,Q
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:f#C
Subjective f#data are f#what f#the f#personsays f# about f#him f#or f#herselfduring f#history f#taking. f#Objective
Q,
,data f#are f#what f#the f#health f#professional f#observes f#by f#inspecting, f#percussing, f#palpating,
f#and f#auscultating during f#the f#physical f#examination. f#Thef#terms f#reflective f#and f#introspective f#are
Q,
f#not f#used to f#describe f#data.
Q,
DIF:f#Cognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
3. Thef#patients f#record, f#laboratorystudies, f#objective f#data, f#and f#subjectivef#data f#combine
f#to f#formthe:
Q
,
a Data f#base.
.
b Admitting f#data.
.
c Financialstatement.
.
d Dischargesummary.
.
ANS: f#A
Together f#withthe f#patients f#record f#and f#laboratorystudies, f#the f#objective f#and f#subjective
f#data f#formthe f#data f#base. f#The f#other f#items f#are f#not f#part f#ofthe f#patients f#record,
Q,
f#laboratorystudies, f#or f#data.
DIF:f#Cognitive f# Level: f#Remembering f# (Knowledge) f#REF:f#z. f#2
MSC:f#Client f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f# of f#Care
4. Whenf#listening f#to af#patients f#breath sounds, f#the f#nurse f#is f#unsure f#ofa f#sound f#that f#is
Q, Q,
f#heard. f#Thenurses f# next f#action f#should f#be f # to:
Q
,
a Immediately f#notifyf#the f#patients f#physician.
.
b Documentf#thef#sound f#exactlyas f# itf#was f#heard.
.
c Validate f#the f#data f#byf#asking f#a f#coworker f#to f#listen tof#the f#breathf#sounds.
Q,
.
d Assess f#again f#inf#20 f#minutes f#to f#note f#whether f#thef#sound f#is f#stillf#present.
.
ANS:f#C
When f#unsure f#of f#a f#sound f#heard f#while f#listening f#to f#a f#patients f#breath f#sounds, f#the f#nurse
f#validates f#the f#data f#to f#ensure f#accuracy. f#If f#the f#nurse f#has f#less f # experience f # in f#an f#area,
f#then f#he f#or f#she f#asks f#an f#expertto f#listen.
,Q
,DIF:f#Cognitive f# Level: f#Analyzing f#(Analysis) f#REF:f#z. f#2
MSC:#fClient f#Needs:#fSafe f#and f#Effective f#Care f#Environment:f#Management f#off#Care
5. The f#nurse f#is f#conducting f#a f#class f#for f#new f#graduate f#nurses. f#During f#the f#teaching
f#session, f#the f#nurse f#should f#keep f#in f#mind f#that f#novice f#nurses, f#without f#a background
Q,
f# ofskills f#and f# experiencefrom f#which f#to f#draw, f#are f#more f#likely f#to f#make f#their f#decisions
Q
,
f # using:
a Intuition.
.
b Af#set f#ofrules.
.
c Articles f#inf#journals.
.
d Advice f#from f#supervisors.
.
ANS:f#B
Novice f#nurses f#operate f#fromf#af#set f#ofdefined, f#structured f#rules. f#Thef#expertf#practitioner
f#usesintuitive f# links.
Q
,
DIF:#fCognitive f#Level: f#Understanding f#(Comprehension) f#REF:
#fz. f#3 MSC: f#Client f#Needs: f#General
,Q
6. Expert f#nurses f#learntof#attend f#to f#a f#pattern f#of f#assessment f#data f#and f#act
f#without f#consciouslylabeling f#it. f#These f#responses f#are f#referred f#to f # as:
a Intuition.
.
b The f#nursing f#process.
.
c Clinical f#knowledge.
.
d Diagnosticreasoning.
.
ANS: f#A
Intuition f#is f#characterized f#by f#patternrecognitionexpert f#nurses f#learn f#toattend f#to f#a f#pattern
f#ofassessment f#data f#and f#act f#without f#consciously f#labeling f#it. f#The f#other f#options f#are f#notf#correct.
,Q
DIF:#fCognitive f#Level: f#Understanding f#(Comprehension) f#REF:
#fz. f#4 MSC: f#Client f#Needs: f#General
,Q
7. The f#nurse f#is f#reviewing f#information about f#evidence-based f#practice f#(EBP).
Q,
f#Which f#statementbest f# reflects f#EBP?
Q
,
, a EBP f#relies f# on f#tradition f#for f#support f#ofbest f#practices.
.
b EBP f#is f#simply f#the f#use f#ofbest f#practice f#techniques f# for f#the f#treatment f#of patients.
Q,
.
c EBP f#emphasizes f#the f#use f#off#best f#evidence f#with f#the f#clinicians f# experience.
.
d Thef#patients f#ownpreferences f#are f#not f#important f#with f#EBP.
.
ANS:f#C
EBP f#is f#a f#systematic f#approachto f#practice f#that f#emphasizes f#the f#use f#ofbest f#evidence f#in
f#combinationw ith f#the f#clinicians f#experience, f#as f#well f#as f#patient f#preferences f#and f#values, f#when
Q
,
f#making f#decisions f#about f#care f#and f#treatment. f#EBP f#is f#more f#than f#simply f#using f#the f#best
f#practice f#techniques f#to f#treat f#patients, f#and f#questioning f#tradition f#is f#important f#when f#no
f#compelling f#and f#supportive f#research f#evidence f#exists.
DIF:f#Cognitive f# Level: f#Applying f#(Application) f#REF: f#z. f#5
MSC:#fClient f#Needs:f#Safe f#and f#Effective f#Care f#Environment:f#Management f#of f#Care
8. The f#nurse f#is f#conducting f#a f#class f#onprioritysetting f#for f#af#group f#of f#new f#graduate f#nurses.
f#Whichi s f# an f#example f#of f#a f#first-level f#priority f # problem?
Q,
a Patient f#with postoperative f#pain
Q,
.
b Newlydiagnosed f#patient f#withf#diabetes f#who f#needs f#diabetic f#teaching
.
c Individualwitha f#small f# laceration f#on f#the f#sole f# of f#the f# foot
.
d Individualwith f#shortness f#off#breath f#and f#respiratory f#distress
.
ANS:f#D
First-level f#priority f#problems f#are f#those f#that f#are f#emergent, f#life f#threatening, f#and f#immediate
f#(e.g., f#establishing f#anairway, f#supporting f#breathing, f#maintaining f#circulation, f#monitoring
f#abnormal f#vitals igns) f# (see f#Table f#1-1).
Q
,
DIF:#fCognitive f # Level: f#Understanding f#(Comprehension) f#REF:f#z. f#4
MSC:#fClient f#Needs:#fSafe f#and f#Effective f#Care f#Environment:f#Management f#off#Care
9. When f#considering f#priorityf#setting f#ofproblems, f#the f#nurse f#keeps f#inmind f#that
f#second- f#levelpriority f#problems f#include f#which f#of f#these f # aspects?
,Q
