n ExaminationandHistoryTaking13th n n n n
Edition Bickley n n n
CHAPTER1 n
Foundationsfor Clinical Proficiency MULTIPLE
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nCHOICE
1. After completing an initial assessment of a patient,the nurse has charted that his
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respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
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a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A n
Objective data are what the health professional observes by inspecting, percussing, palpating, and
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auscultatingduringthe physicalexamination.Subjective data is what theperson says about him or
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herself during history taking. The terms reflective and introspective are not used to describe data.
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DIF:Cognitive Level: Understanding(Comprehension)REF: p. 2
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MSC:ClientNeeds: Safe andEffective CareEnvironment:ManagementofCare
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2. Apatienttellsthenursethat he isverynervous, is nauseated, andfeels hot.These types of data
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nwould be: n
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
,ANS: C n
Subjective data are what the person says about him or herself during history taking. Objective
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data are what the health professional observes byinspecting, percussing, palpating, and
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, auscultatingduringthe physicalexamination.Theterms reflective andintrospective arenot used
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todescribe data.
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DIF:Cognitive Level: Understanding(Comprehension)REF: p. 2
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MSC:ClientNeeds: Safe andEffective CareEnvironment:ManagementofCare
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3. The patientsrecord,laboratorystudies, objective data, and subjective datacombineto
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nform the: n
a Data base. n
.
b Admitting data. n
.
c Financialstatement. n
.
d Discharge summary. n
.
ANS: A n
Togetherwith the patientsrecordand laboratorystudies, the objective and subjective data form the
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data base. The other items are not part of the patients record, laboratory studies, or data.
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DIF:Cognitive Level:Remembering(Knowledge)REF: p. 2
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MSC:ClientNeeds: Safe andEffective CareEnvironment:ManagementofCare
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4. When listeningto a patients breath sounds, the nurse is unsure ofa sound that is heard. The
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nnurses next action should be to:
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a Immediatelynotifythe patients physician. n n n n
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b Documentthe sound exactlyas it was heard. n n n n n n n
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c Validatethe data byaskinga coworker to listen to the breath sounds.
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d Assessagain in 20 minutes to note whether the sound is still present.
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.
ANS: C n
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to
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ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
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DIF:Cognitive Level: Analyzing(Analysis) REF: p. 2
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