TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 2
Chapter 01: Evidence-Based Assessment
p p p
MULTIPLEp CHOICE
1. Afterpcompletingpanpinitialpassessmentpofpappatient,pthepnursephasppch
artedpthatphisprespirationsparepeupneicpandhisppulsepisp58pbeatspperpminute.ppT
heseptypespofpdatapwouldpbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:p A
Objectivepdataparepwhatpthephealthpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpauscultatingpdu
ringpthepphysicalpexamination.pSubjectivepdatapispwhatptheppersonpsayspaboutphimporpherselfpduringphistorypta
king.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
2. Appatientp tellsp thep nursep thatphep isp veryp nervous,p isp nauseated,p andp feelsp hot.pThesep typesp ofp datap wouldp be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:p C
Subjectivepdataparepwhatptheppersonpsayspaboutphimporpherselfpduringphistoryptaking.pObjectivepdataparepwhatpthepheal
thpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpauscultatingpduringpthepphysicalpexaminatio
n.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
3. Thep patientsp record,plaboratoryp studies,p objectivep data,p andp subjectivep datap combinep top formp the:
a. Datapbase.
b. Admittingp data.
,TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 3
c. Financialp statement.
d. Dischargep summary.
ANS:p A
Togetherpwithptheppatientsprecordpandplaboratorypstudies,pthepobjectivepandpsubjectivepdatapformpthepdatapbase.pT
hepotherpitemsparepnotppartpofptheppatientsprecord,plaboratorypstudies,porpdata.
DIF:p Cognitivep Level:p Rememberingp (Knowledge)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
4. Whenplisteningptopappatientspbreathpsounds,pthepnursepispunsurepofp
apsoundpthatpispheard.pThepnursespnextactionpshouldpbepto:
a. Immediatelyp notifyp thep patientsp physician.
b. Documentp thep soundp exactlyp asp itp wasp heard.
c. Validatepthepdatap byp askingpapcoworkerptop listenptopthepbreathpsounds.
d. Assessp againpinp20p minutesptopnotepwhetherp thep soundpisp stillppresent.
ANS:p C
Whenpunsurepofpapsoundpheardpwhileplisteningptopappatientspbreathpsounds,pthepnursepvalidatespthepdataptopensurepaccu
racy.pIfpthepnursephasplesspexperiencepinpanparea,pthenpheporpshepaskspanpexpertptoplisten.
DIF:p Cognitivep Level:p Analyzingp (Analysis)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
5. Thepnursepispconductingpapclasspforpnewpgraduatepnurses.pDuringpthept
eachingpsession,pthepnursepshouldpkeeppinpmindpthatpnovicepnurses,pwithoutpap
backgroundpofpskillspandpexperiencepfrompwhichptopdraw,parepmoreplikelyptop
makeptheirpdecisionspusing:
a. Intuition.
b. Apsetpofprules.
c. Articlespinpjournals.
d. Advicep fromp supervisors.
ANS:p B
Novicepnursespoperatepfrompapsetpofpdefined,pstructuredprules.pThepexpertppractitionerpusespintuitiveplinks.pDIF
:pCognitivepLevel:pUnderstandingp(Comprehension)
,TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 4
MSC:p Clientp Needs:p General
6. Expertpnursesplearnptopattendptopappatternpofpassessmentpdatapandpactp
withoutpconsciouslyplabelingpit.pTheseresponsesparepreferredptopas:
a. Intuition.
b. Thep nursingp process.
c. Clinicalp knowledge.
d. Diagnosticp reasoning.
ANS:p A
Intuitionpispcharacterizedpbyppatternprecognitionexpertpnursesplearnptopattendptopappatternpofpassessmentpdatapandp
actpwithoutpconsciouslyplabelingpit.pThepotherpoptionsparepnotpcorrect.
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)p
MSC:pClientpNeeds:pGeneral
7. Thepnursepispreviewingpinformationpaboutpevidence-
basedppracticep(EBP).pWhichpstatementpbestpreflectsEBP?
a. EBPp reliesponp traditionpforp supportp ofp bestp practices.
b. EBPp isp simplyp thep usep ofpbestppracticeptechniquesp forptheptreatmentp ofp patients.
c. EBPpemphasizesp thepusepofpbestp evidencep withpthep cliniciansp experience.
d. Theppatientsp ownp preferencesp arep notp importantp withpEBP.
ANS:pC
EBPpispapsystematicpapproachptoppracticepthatpemphasizespthepusepofpbestpevidencepinpcombinationpwithpthepclinician
spexperience,paspwellpasppatientppreferencespandpvalues,pwhenpmakingpdecisionspaboutpcarepandptreatment.pEBPp
ispmorepthanpsimplypusingpthepbestppracticeptechniquesptoptreatppatients,pandpquestioningptraditionpispimportantp
whenpnopcompellingpandpsupportivepresearchpevidencepexists.
DIF:p Cognitivep Level:p Applyingp (Application)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
8. Thepnursepispconductingpapclassponpprioritypsettingpforpapgrouppofpnewpg
raduatepnurses.pWhichpispanpexampleofpapfirst-levelpprioritypproblem?
a. Patientp withp postoperativep pain
b. Newlyp diagnosedp patientp withp diabetesp whop needsp diabeticp teaching
, TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 5
c. Individualp withp ap smallp lacerationp onp thep solep ofp thep foot
d. Individualp withpshortnessp ofp breathp andp respiratoryp distress
ANS:pD
First-
levelpprioritypproblemsparepthosepthatparepemergent,plifepthreatening,pandpimmediatep(e.g.,pestablishingpanpairway,psu
pportingpbreathing,pmaintainingpcirculation,pmonitoringpabnormalpvitalpsigns).
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
9. Whenpconsideringpprioritypsettingpofpproblems,pthepnursepkeepspinpp
mindpthatpsecond-levelpprioritypproblemsincludepwhichpofpthesepaspects?
a. Lowp self-esteem
b. Lackpofpknowledge
c. Abnormalp laboratoryp values
d. Severelyp abnormalp vitalp signs
ANS:pC
Second-
levelpprioritypproblemsparepthosepthatprequireppromptpinterventionptopforestallpfurtherpdeteriorationp(e.g.,pmentalpstat
uspchange,pacuteppain,pabnormalplaboratorypvalues,prisksptopsafetyporpsecurity).
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
10. Whichpcriticalp thinkingp skillp helpsp thep nursep seep relationshipsp amongp thep data?
a. Validation
b. Clusteringp relatedp cues
c. Identifyingp gapsp inp data
d. Distinguishingp relevantp fromp irrelevant
ANS:pB
Clusteringprelatedpcuesphelpspthepnursepseeprelationshipspamongpthepdata.pDIF
:pCognitivepLevel:pUnderstandingp(Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
Chapter 01: Evidence-Based Assessment
p p p
MULTIPLEp CHOICE
1. Afterpcompletingpanpinitialpassessmentpofpappatient,pthepnursephasppch
artedpthatphisprespirationsparepeupneicpandhisppulsepisp58pbeatspperpminute.ppT
heseptypespofpdatapwouldpbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:p A
Objectivepdataparepwhatpthephealthpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpauscultatingpdu
ringpthepphysicalpexamination.pSubjectivepdatapispwhatptheppersonpsayspaboutphimporpherselfpduringphistorypta
king.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
2. Appatientp tellsp thep nursep thatphep isp veryp nervous,p isp nauseated,p andp feelsp hot.pThesep typesp ofp datap wouldp be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:p C
Subjectivepdataparepwhatptheppersonpsayspaboutphimporpherselfpduringphistoryptaking.pObjectivepdataparepwhatpthepheal
thpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpauscultatingpduringpthepphysicalpexaminatio
n.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
3. Thep patientsp record,plaboratoryp studies,p objectivep data,p andp subjectivep datap combinep top formp the:
a. Datapbase.
b. Admittingp data.
,TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 3
c. Financialp statement.
d. Dischargep summary.
ANS:p A
Togetherpwithptheppatientsprecordpandplaboratorypstudies,pthepobjectivepandpsubjectivepdatapformpthepdatapbase.pT
hepotherpitemsparepnotppartpofptheppatientsprecord,plaboratorypstudies,porpdata.
DIF:p Cognitivep Level:p Rememberingp (Knowledge)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
4. Whenplisteningptopappatientspbreathpsounds,pthepnursepispunsurepofp
apsoundpthatpispheard.pThepnursespnextactionpshouldpbepto:
a. Immediatelyp notifyp thep patientsp physician.
b. Documentp thep soundp exactlyp asp itp wasp heard.
c. Validatepthepdatap byp askingpapcoworkerptop listenptopthepbreathpsounds.
d. Assessp againpinp20p minutesptopnotepwhetherp thep soundpisp stillppresent.
ANS:p C
Whenpunsurepofpapsoundpheardpwhileplisteningptopappatientspbreathpsounds,pthepnursepvalidatespthepdataptopensurepaccu
racy.pIfpthepnursephasplesspexperiencepinpanparea,pthenpheporpshepaskspanpexpertptoplisten.
DIF:p Cognitivep Level:p Analyzingp (Analysis)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
5. Thepnursepispconductingpapclasspforpnewpgraduatepnurses.pDuringpthept
eachingpsession,pthepnursepshouldpkeeppinpmindpthatpnovicepnurses,pwithoutpap
backgroundpofpskillspandpexperiencepfrompwhichptopdraw,parepmoreplikelyptop
makeptheirpdecisionspusing:
a. Intuition.
b. Apsetpofprules.
c. Articlespinpjournals.
d. Advicep fromp supervisors.
ANS:p B
Novicepnursespoperatepfrompapsetpofpdefined,pstructuredprules.pThepexpertppractitionerpusespintuitiveplinks.pDIF
:pCognitivepLevel:pUnderstandingp(Comprehension)
,TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 4
MSC:p Clientp Needs:p General
6. Expertpnursesplearnptopattendptopappatternpofpassessmentpdatapandpactp
withoutpconsciouslyplabelingpit.pTheseresponsesparepreferredptopas:
a. Intuition.
b. Thep nursingp process.
c. Clinicalp knowledge.
d. Diagnosticp reasoning.
ANS:p A
Intuitionpispcharacterizedpbyppatternprecognitionexpertpnursesplearnptopattendptopappatternpofpassessmentpdatapandp
actpwithoutpconsciouslyplabelingpit.pThepotherpoptionsparepnotpcorrect.
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)p
MSC:pClientpNeeds:pGeneral
7. Thepnursepispreviewingpinformationpaboutpevidence-
basedppracticep(EBP).pWhichpstatementpbestpreflectsEBP?
a. EBPp reliesponp traditionpforp supportp ofp bestp practices.
b. EBPp isp simplyp thep usep ofpbestppracticeptechniquesp forptheptreatmentp ofp patients.
c. EBPpemphasizesp thepusepofpbestp evidencep withpthep cliniciansp experience.
d. Theppatientsp ownp preferencesp arep notp importantp withpEBP.
ANS:pC
EBPpispapsystematicpapproachptoppracticepthatpemphasizespthepusepofpbestpevidencepinpcombinationpwithpthepclinician
spexperience,paspwellpasppatientppreferencespandpvalues,pwhenpmakingpdecisionspaboutpcarepandptreatment.pEBPp
ispmorepthanpsimplypusingpthepbestppracticeptechniquesptoptreatppatients,pandpquestioningptraditionpispimportantp
whenpnopcompellingpandpsupportivepresearchpevidencepexists.
DIF:p Cognitivep Level:p Applyingp (Application)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
8. Thepnursepispconductingpapclassponpprioritypsettingpforpapgrouppofpnewpg
raduatepnurses.pWhichpispanpexampleofpapfirst-levelpprioritypproblem?
a. Patientp withp postoperativep pain
b. Newlyp diagnosedp patientp withp diabetesp whop needsp diabeticp teaching
, TestpBankp-pPhysicalpExaminationpandpHealthpAssessmentp8ep(bypJarvis)pCHAPTEERp1-3 5
c. Individualp withp ap smallp lacerationp onp thep solep ofp thep foot
d. Individualp withpshortnessp ofp breathp andp respiratoryp distress
ANS:pD
First-
levelpprioritypproblemsparepthosepthatparepemergent,plifepthreatening,pandpimmediatep(e.g.,pestablishingpanpairway,psu
pportingpbreathing,pmaintainingpcirculation,pmonitoringpabnormalpvitalpsigns).
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
9. Whenpconsideringpprioritypsettingpofpproblems,pthepnursepkeepspinpp
mindpthatpsecond-levelpprioritypproblemsincludepwhichpofpthesepaspects?
a. Lowp self-esteem
b. Lackpofpknowledge
c. Abnormalp laboratoryp values
d. Severelyp abnormalp vitalp signs
ANS:pC
Second-
levelpprioritypproblemsparepthosepthatprequireppromptpinterventionptopforestallpfurtherpdeteriorationp(e.g.,pmentalpstat
uspchange,pacuteppain,pabnormalplaboratorypvalues,prisksptopsafetyporpsecurity).
DIF:p Cognitivep Level:p Understandingp (Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
10. Whichpcriticalp thinkingp skillp helpsp thep nursep seep relationshipsp amongp thep data?
a. Validation
b. Clusteringp relatedp cues
c. Identifyingp gapsp inp data
d. Distinguishingp relevantp fromp irrelevant
ANS:pB
Clusteringprelatedpcuesphelpspthepnursepseeprelationshipspamongpthepdata.pDIF
:pCognitivepLevel:pUnderstandingp(Comprehension)
MSC:pClientp Needs:p Safep andp Effectivep Carep Environment:p Managementp ofp Care
