TEST BANK FOR Jarvis: Physical Examination & Health Assessment, 7th Edition

,HAxExamx1-27,x29

Chapterx01:xEvidence-BasedxAssessment
Jarvis:xPhysicalxExaminationx&xHealthxAssessment,x7thxEdition
xMULTIPLExCHOICE

1. Afterxcompletingxanxinitialxassessmentxofxaxpatient,xthexnursexhasxchartedxthatxhisxrespirationsxarexeupneicxandxhisxpulsexisx58xbeatsx
perxminute.xThesextypesxofxdataxwouldxbe:
a. Objective.

b. Reflective.

c. Subjective.

d. Introspective.
xANS:xA
Objectivexdataxarexwhatxthexhealthxprofessionalxobservesxbyxinspecting,xpercussing,xpalpating,xandxauscultatingxduringxthexphysicalxexaminat
ion.xSubjectivexdataxisxwhatxthexpersonxsaysxaboutxhimxorxherselfxduringxhistoryxtaking.xThe
termsxreflectivexandxintrospectivexarexnotxusedxtoxdescribexdata.xD
IF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x2
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
2. Axpatientxtellsxthexnursexthatxhexisxveryxnervous,xisxnauseated,xandx“feelsxhot.”xThesextypesxofxdataxwouldxbe:
a. Objective.

b. Reflective.

c. Subjective.

d. Introspective.
xANS:xC
Subjectivexdataxarexwhatxthexpersonxsaysxaboutxhimxorxherselfxduringxhistoryxtaking.xObjectivexdataxarexwhatxthexhealthxprofessionalxobs
ervesxbyxinspecting,xpercussing,xpalpating,xandxauscultatingxduringxthexphysicalxexamination.xThe
termsxreflectivexandxintrospectivexarexnotxusedxtoxdescribexdata.xD
IF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x2
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
3. Thexpatient’sxrecord,xlaboratoryxstudies,xobjectivexdata,xandxsubjectivexdataxcombinextoxformxthe:
a. Dataxbase.

b. Admittingxdata.

c. Financialxstatement.

d. Dischargexsummary.
ANS:xA
x

Togetherxwithxthexpatient’sxrecordxandxlaboratoryxstudies,xthexobjectivexandxsubjectivexdataxformxthexdataxbase.xThexotherxitemsxarexnotx
partxofxthexpatient’sxrecord,xlaboratoryxstudies,xorxdata.
DIF:xCognitivexLevel:xRememberingx(Knowledge)xREF:xp.x2
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
4. Whenxlisteningxtoxaxpatient’sxbreathxsounds,xthexnursexisxunsurexofxaxsoundxthatxisxheard.xThexnurse’sxnextxactionxshouldxbexto:
a. Immediatelyxnotifyxthexpatient’sxphysician.

b. Documentxthexsoundxexactlyxasxitxwasxheard.

c. Validatexthexdataxbyxaskingxaxcoworkerxtoxlistenxtoxthexbreathxsounds.

d. Assessxagainxinx20xminutesxtoxnotexwhetherxthexsoundxisxstillxpresent.
xANS:xC
Whenxunsurexofxaxsoundxheardxwhilexlisteningxtoxaxpatient’sxbreathxsounds,xthexnursexvalidatesxthexdataxtoxensurexaccuracy.xIfxthexnursex
hasxlessxexperiencexinxanxarea,xthenxhexorxshexasksxanxexpertxtoxlisten.
DIF:xCognitivexLevel:xAnalyzingx(Analysis)xREF:xp.x2
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare

,5. Thexnursexisxconductingxaxclassxforxnewxgraduatexnurses.xDuringxthexteachingxsession,xthexnursexshouldxkeepxinxmindxthatxnovicex
nurses,xwithoutxaxbackgroundxofxskillsxandxexperiencexfromxwhichxtoxdraw,xarexmorexlikelyxtoxmakextheirxdecisionsxusing:
a. Intuition.

b. Axsetxofxrules.

c. Articlesxinxjournals.

d. Advicexfromxsupervisors.
xANS:xB
Novicexnursesxoperatexfromxaxsetxofxdefined,xstructuredxrules.xThexexpertxpractitionerxusesxintuitivexlinks.xDI
F:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x3
MSC:xClientxNeeds:xGeneral
6. Expertxnursesxlearnxtoxattendxtoxaxpatternxofxassessmentxdataxandxactxwithoutxconsciouslyxlabelingxit.xThesexresponsesxarexreferredxto
xas:


a. Intuition.

b. Thexnursingxprocess.

c. Clinicalxknowledge.

d. Diagnosticxreasoning.
ANS:xA
Intuitionxisxcharacterizedxbyxpatternxrecognition—
expertxnursesxlearnxtoxattendxtoxaxpatternxofxassessmentxdataxandxactxwithoutxconsciouslyxlabelingxit.xThexotherxoptionsxarexnotxcorrect.
DIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x4x
MSC:xClientxNeeds:xGeneral
7. Thexnursexisxreviewingxinformationxaboutxevidence-basedxpracticex(EBP).xWhichxstatementxbestxreflectsxEBP?
a. EBPxreliesxonxtraditionxforxsupportxofxbestxpractices.

b. EBPxisxsimplyxthexusexofxbestxpracticextechniquesxforxthextreatmentxofxpatients.

c. EBPxemphasizesxthexusexofxbestxevidencexwithxthexclinician’sxexperience.

d. Thexpatient’sxownxpreferencesxarexnotximportantxwithxEBP.
xANS:xC
EBPxisxaxsystematicxapproachxtoxpracticexthatxemphasizesxthexusexofxbestxevidencexinxcombinationxwithxthexclinician’sxexperience,xasxwe
llxasxpatientxpreferencesxandxvalues,xwhenxmakingxdecisionsxaboutxcarexandxtreatment.xEBPxisxmorexthanxsimplyxusingxthexbestxpracticex
techniquesxtoxtreatxpatients,xandxquestioningxtraditionxisximportantxwhenxnoxcompellingxandxsupportivexresearchxevidencexexists.
DIF:xCognitivexLevel:xApplyingx(Application)xREF:xp.x5
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
8. Thexnursexisxconductingxaxclassxonxpriorityxsettingxforxaxgroupxofxnewxgraduatexnurses.xWhichxisxanxexamplexofxaxfirst-
levelxpriorityxproblem?
a. Patientxwithxpostoperativexpain

b. Newlyxdiagnosedxpatientxwithxdiabetesxwhoxneedsxdiabeticxteaching

c. Individualxwithxaxsmallxlacerationxonxthexsolexofxthexfoot

d. Individualxwithxshortnessxofxbreathxandxrespiratoryxdistress
xANS:xD
First-
levelxpriorityxproblemsxarexthosexthatxarexemergent,xlifexthreatening,xandximmediatex(e.g.,xestablishingxanxairway,xsupportingxbreathing,x
maintainingxcirculation,xmonitoringxabnormalxvitalxsigns)x(seexTablex1-1).
DIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x4
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
9. Whenxconsideringxpriorityxsettingxofxproblems,xthexnursexkeepsxinxmindxthatxsecond-
levelxpriorityxproblemsxincludexwhichxofxthesexaspects?
a. Lowxself-esteem

, b. Lackxofxknowledge

c. Abnormalxlaboratoryxvalues

d. Severelyxabnormalxvitalxsigns
xANS:xC
Second-
levelxpriorityxproblemsxarexthosexthatxrequirexpromptxinterventionxtoxforestallxfurtherxdeteriorationx(e.g.,xmentalxstatusxchange,xacutexpai
n,xabnormalxlaboratoryxvalues,xrisksxtoxsafetyxorxsecurity)x(seexTablex1-1).
DIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x4
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
10. Whichxcriticalxthinkingxskillxhelpsxthexnursexseexrelationshipsxamongxthexdata?
a. Validation

b. Clusteringxrelatedxcues

c. Identifyingxgapsxinxdata

d. Distinguishingxrelevantxfromxirrelevant
xANS:xB
Clusteringxrelatedxcuesxhelpsxthexnursexseexrelationshipsxamongxthexdata.
xDIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x2

MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
11. Thexnursexknowsxthatxdevelopingxappropriatexnursingxinterventionsxforxaxpatientxreliesxonxthexappropriatenessxofxthex
diagnosis.
a. Nursing

b. Medical

c. Admission

d. Collaborative
ANS:xA
x

Anxaccuratexnursingxdiagnosisxprovidesxthexbasisxforxthexselectionxofxnursingxinterventionsxtoxachievexoutcomesxforxwhichxthexnursexisxaccou
ntable.xThexotherxitemsxdoxnotxcontributextoxthexdevelopmentxofxappropriatexnursingxinterventions.
DIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x6
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
12. Thexnursingxprocessxisxaxsequentialxmethodxofxproblemxsolvingxthatxnursesxusexandxincludesxwhichxsteps?
a. Assessment,xtreatment,xplanning,xevaluation,xdischarge,xandxfollow-up

b. Admission,xassessment,xdiagnosis,xtreatment,xandxdischargexplanning

c. Admission,xdiagnosis,xtreatment,xevaluation,xandxdischargexplanning

d. Assessment,xdiagnosis,xoutcomexidentification,xplanning,ximplementation,xandxevaluation
xANS:xD
Thexnursingxprocessxisxaxmethodxofxproblemxsolvingxthatxincludesxassessment,xdiagnosis,xoutcomexidentification,xplanning,ximplementat
ion,xandxevaluation.
DIF:xCognitivexLevel:xUnderstandingx(Comprehension)xREF:xp.x3
MSC:xClientxNeeds:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
13. Axnewlyxadmittedxpatientxisxinxacutexpain,xhasxnotxbeenxsleepingxwellxlately,xandxisxhavingxdifficultyxbreathing.xHowxshouldxthex
nursexprioritizexthesexproblems?
a. Breathing,xpain,xandxsleep

b. Breathing,xsleep,xandxpain

c. Sleep,xbreathing,xandxpain

d. Sleep,xpain,xandxbreathing
ANS:xA
x