TestkBankkPhysicalkExaminationkandkHealthkAssessment
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
Chapter 01: Evidence-Based Assessment
k k k
Jarvis: Physical Examination and Health Assessment, 8th Edition
k k k k k k k
MULTIPLEkCHOICE
1. Afterkcompletingkankinitialkassessmentkofkakpatient,ktheknursekhaskchartedkthatkhisrespirationska
rekeupneickandkhiskpulsekisk58kbeatskperkminute.kWhatktypekofkassessmentkdatakiskthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS:kA
Objectivekdatakiskwhatkthekhealthkprofessionalkobserveskbykinspecting,kpercussing,kpalpating,kan
dkauscultatingkduringkthekphysicalkexamination.kSubjectivekdatakiskwhatkthekpersonksayskaboutkh
imkorkherselfkduringkhistoryktaking.kThektermskreflectivekandkintrospectivekareknotkusedktokdescrib
ekdata.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
2. Akpatientktellsktheknursekthatkhekiskveryknervous,knauseous,kandk“feelskhot.”kWhatktypeofka
ssessmentkdatakiskthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS:kC
Subjectivekdatakiskwhatkthekpersonksayskaboutkhimkorkherselfkduringkhistoryktaking.kObjectivekdat
akiskwhatkthekhealthkprofessionalkobserveskbykinspecting,kpercussing,kpalpating,kandkauscultatin
gkduringkthekphysicalkexamination.kThektermskreflectivekandkintrospectivekareknotkusedktokdescri
bekdata.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
3. Whatkdokthekpatient’skrecord,klaboratorykstudies,kobjectivekdata,kandksubjectivekdatacombinekt
okform?
a. Database
b. Admittingkdata
c. Financialkstatement
d. Dischargeksummary
ANS:kA
Togetherkwithkthekpatient’skrecordkandklaboratorykstudies,kthekobjectivekandksubjectivekdatakf
ormkthekdatabase.kThekotherkitemskareknotkpartkofkthekpatient’skrecord,klaboratorykstudies,korkda
ta.
DIF:k k CognitivekLevel:kRememberingk(Knowledge)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
Chapterk1k-kEvidence-BasedkAssessment 3
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
4. Whenklisteningktokakpatient’skbreathksounds,ktheknursekiskunsurekofkaksoundkthatkiskheard.k
Whichkactionkshouldktheknursektakeknext?
a. Notifykthekpatient’skphysician.
b. Documentktheksoundkexactlykaskitkwaskheard.
c. Validatekithekidatakibykiaskingkianotherkinursekitokilistenitokithekibreathisounds.
d. Assesskagainkink20kminutesktoknotekwhetherktheksoundkiskstillkpresent.
ANS:kC
Whenkunsurekofkaksoundkheardkwhileklisteningktokakpatient’skbreathksounds,ktheknursekvalidateskt
hekdataktokensurekaccuracykbykeitherkrepeatingkthekassessmentkthemselveskorkaskingkanotherknur
sektokassesskthekbreathksounds.kIfktheknursekhasklesskexperiencekanalyzingkbreathksounds,kthenkhe
korkshekshouldkaskkankexpertktoklisten.kWhenkunsurekofkaksoundkheardkwhileklisteningktokakpatient’s
kbreathksounds,ktheknursekshouldkvalidatekthekdatakbeforekdocumentingktokensurekaccuracykandkb
eforeknotifyingkthekpatient’skphysician.kTokvalidatekthatkdata,ktheknursekeitherkrepeatskthekassess
mentkhimselfkorkherselfkorkaskskanotherknursektokassesskthekbreathksounds.
DIF: CognitivekLevel:kAnalyzingk(Analysis)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
5. Theknursekiskconductingkakclasskforknewkgraduateknurses.kWhilekteachingkthekclass,kwhatksho
uldktheknursekkeepkinkmindkregardingkwhatknoviceknurses,kwithoutkakbackgroundkofkskillskandk
experiencekfromkwhichktokdrawkupon,karekmoreklikelyktokbasektheirkdecisionskon?
a. Intuition
b. Aisetkiofkirules
c. Articleskinkjournals
d. Advicekfromksupervisors
ANS:kB
Noviceknurseskoperatekfromkaksetkofkdefined,kstructuredkrulesktokmakekdecisions.kItktakesktime,kpe
rhapskakfewkyears,kinksimilarkclinicalksituationsktokachievekcompetencykandkitkiskfunctioningkatkth
eklevelkofkankexpertkpractitionerkwhenkintuitionkiskincludedkinkmakingkclinicalkdecisions.kIntuiti
onkiskincludedkinkdecisionkmakingkwhenkfunctioningkatktheklevelkofkankexpertkpractitioner.kWhil
ekinformationkinkjournalkarticleskandkadvicekfromksupervisorskmaykassistkinkmakingkdecisions,kn
oviceknurseskdoknotktypicallykbasektheirkdecisionskonkthem.kItkwouldkalsokbekimportantkthatkifkinf
ormationkfromkjournalkarticleskandkadvicekfromksupervisorskwerekused,kthatktheykwerekevidencek
based.
DIF: Cognitivek Level:kUnderstandingk(Comprehension) MSC:kClientkNeeds:kGeneral
6. Theknursekiskreviewingkinformationkaboutkevidence-
basedkpracticek(EBP).kWhichstatementkbestkreflectskEBP?
a. EBPkrelieskonktraditionkforksupportkofkbestkpractices.
b. EBPkisksimplykthekusekofkbestkpracticektechniqueskforkthektreatmentkofkpatients.
c. EBPiemphasizesithekiusekiofkibestkievidencekiwithithekiclinician’skiexperience.
d. EBPkdoesknotkconsiderkthekpatient’skownkpreferenceskaskimportant.
ANS:kC
Chapterk1k-kEvidence-BasedkAssessment 4
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
EBPkiskaksystematickapproachktokpracticekthatkemphasizeskthekusekofkresearchkevidencekinkcomb
inationkwithkthekclinician’skexpertisekandkclinicalkknowledgek(physicalkassessment),kaskwellkask
patientkvalueskandkpreferences,kwhenkmakingkdecisionskaboutkcarekandktreatment.kEBPkiskmorekt
hanksimplykusingkthekbestkpracticektechniquesktoktreatkpatients,kandkquestioningktraditionkiskimp
ortantkwhenknokcompellingkandksupportivekresearchkevidencekexists.
DIF: CognitivekLevel:kApplyingk(Application)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
7. Theknursekiskconductingkakclasskonkpriorityksettingkforkakgroupkofknewkgraduateknurses.Whichki
skankexamplekofkakfirst-levelkprioritykproblem?
a. Patientkwithkpostoperativek pain
b. Newlykdiagnosedkpatientkwithkdiabeteskwhokneedskdiabetickteaching
c. Individualkwithkaksmallklacerationkonktheksolekofkthekfoot
d. Individualkiwithishortnesskiofkibreathiandkirespiratorykidistress
ANS:kD
First-levelkprioritykproblemskarekthosekthatkarekemergent,klife-
threatening,kandkimmediatek(e.g.,kestablishingkankairway,ksupportingkbreathing,kmaintainingkcir
culation,kmonitoringkabnormalkvitalksigns).kPostoperativekpain,kdiabetickteachingkforkakpatientkn
ewlykdiagnosedkwithkdiabetes,kandkaksmallklacerationkonksolekofkthekfootkareknotkconsideredkfirst-
levelkprioritykproblems.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
8. Whenkconsideringkpriorityksettingkofkproblems,ktheknursekkeepskinkmindkthatsecond-
levelkprioritykproblemskincludekwhichkofkthesekaspects?
a. Lowkself-esteem
b. Lackkofkknowledge
c. Abnormalkilaboratorykivalues
d. Severelykabnormalkvitalksigns
ANS:kC
Abnormalklaboratorykvalueskarekaksecond-levelkprioritykproblem.kSecond-
levelkprioritykproblemskarekthosekthatkrequirekpromptkinterventionktokforestallkfurtherkdeteriorat
ionk(e.g.,kmentalkstatuskchange,kacutekpain,kabnormalklaboratorykvalues,krisksktoksafetykorksecurit
y).kLowkself-esteemkandklackkofkknowledgekarekconsideredkthird-
levelkprioritykaskalthoughktheykarekimportantktokakpatient’skhealth,ktheykcankbekaddressedkafterk
morekurgentkhealthkproblemskarekaddressed.kSeverelykabnormalkvitalksignskwouldkbekconsidere
dkakfirst-levelkprioritykproblem.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
9. Whichkcritical-thinkingkskillk helpskthek nursekseekrelationshipskamongkthekdata?
a. Validation
b. Clusteringkirelatedkicues
c. Identifyingk gapskinkdata
d. Distinguishingk relevantkfromkirrelevant
ANS:kB
Chapterk1k-kEvidence-BasedkAssessment 5
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
Chapter 01: Evidence-Based Assessment
k k k
Jarvis: Physical Examination and Health Assessment, 8th Edition
k k k k k k k
MULTIPLEkCHOICE
1. Afterkcompletingkankinitialkassessmentkofkakpatient,ktheknursekhaskchartedkthatkhisrespirationska
rekeupneickandkhiskpulsekisk58kbeatskperkminute.kWhatktypekofkassessmentkdatakiskthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS:kA
Objectivekdatakiskwhatkthekhealthkprofessionalkobserveskbykinspecting,kpercussing,kpalpating,kan
dkauscultatingkduringkthekphysicalkexamination.kSubjectivekdatakiskwhatkthekpersonksayskaboutkh
imkorkherselfkduringkhistoryktaking.kThektermskreflectivekandkintrospectivekareknotkusedktokdescrib
ekdata.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
2. Akpatientktellsktheknursekthatkhekiskveryknervous,knauseous,kandk“feelskhot.”kWhatktypeofka
ssessmentkdatakiskthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS:kC
Subjectivekdatakiskwhatkthekpersonksayskaboutkhimkorkherselfkduringkhistoryktaking.kObjectivekdat
akiskwhatkthekhealthkprofessionalkobserveskbykinspecting,kpercussing,kpalpating,kandkauscultatin
gkduringkthekphysicalkexamination.kThektermskreflectivekandkintrospectivekareknotkusedktokdescri
bekdata.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
3. Whatkdokthekpatient’skrecord,klaboratorykstudies,kobjectivekdata,kandksubjectivekdatacombinekt
okform?
a. Database
b. Admittingkdata
c. Financialkstatement
d. Dischargeksummary
ANS:kA
Togetherkwithkthekpatient’skrecordkandklaboratorykstudies,kthekobjectivekandksubjectivekdatakf
ormkthekdatabase.kThekotherkitemskareknotkpartkofkthekpatient’skrecord,klaboratorykstudies,korkda
ta.
DIF:k k CognitivekLevel:kRememberingk(Knowledge)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
Chapterk1k-kEvidence-BasedkAssessment 3
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
4. Whenklisteningktokakpatient’skbreathksounds,ktheknursekiskunsurekofkaksoundkthatkiskheard.k
Whichkactionkshouldktheknursektakeknext?
a. Notifykthekpatient’skphysician.
b. Documentktheksoundkexactlykaskitkwaskheard.
c. Validatekithekidatakibykiaskingkianotherkinursekitokilistenitokithekibreathisounds.
d. Assesskagainkink20kminutesktoknotekwhetherktheksoundkiskstillkpresent.
ANS:kC
Whenkunsurekofkaksoundkheardkwhileklisteningktokakpatient’skbreathksounds,ktheknursekvalidateskt
hekdataktokensurekaccuracykbykeitherkrepeatingkthekassessmentkthemselveskorkaskingkanotherknur
sektokassesskthekbreathksounds.kIfktheknursekhasklesskexperiencekanalyzingkbreathksounds,kthenkhe
korkshekshouldkaskkankexpertktoklisten.kWhenkunsurekofkaksoundkheardkwhileklisteningktokakpatient’s
kbreathksounds,ktheknursekshouldkvalidatekthekdatakbeforekdocumentingktokensurekaccuracykandkb
eforeknotifyingkthekpatient’skphysician.kTokvalidatekthatkdata,ktheknursekeitherkrepeatskthekassess
mentkhimselfkorkherselfkorkaskskanotherknursektokassesskthekbreathksounds.
DIF: CognitivekLevel:kAnalyzingk(Analysis)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
5. Theknursekiskconductingkakclasskforknewkgraduateknurses.kWhilekteachingkthekclass,kwhatksho
uldktheknursekkeepkinkmindkregardingkwhatknoviceknurses,kwithoutkakbackgroundkofkskillskandk
experiencekfromkwhichktokdrawkupon,karekmoreklikelyktokbasektheirkdecisionskon?
a. Intuition
b. Aisetkiofkirules
c. Articleskinkjournals
d. Advicekfromksupervisors
ANS:kB
Noviceknurseskoperatekfromkaksetkofkdefined,kstructuredkrulesktokmakekdecisions.kItktakesktime,kpe
rhapskakfewkyears,kinksimilarkclinicalksituationsktokachievekcompetencykandkitkiskfunctioningkatkth
eklevelkofkankexpertkpractitionerkwhenkintuitionkiskincludedkinkmakingkclinicalkdecisions.kIntuiti
onkiskincludedkinkdecisionkmakingkwhenkfunctioningkatktheklevelkofkankexpertkpractitioner.kWhil
ekinformationkinkjournalkarticleskandkadvicekfromksupervisorskmaykassistkinkmakingkdecisions,kn
oviceknurseskdoknotktypicallykbasektheirkdecisionskonkthem.kItkwouldkalsokbekimportantkthatkifkinf
ormationkfromkjournalkarticleskandkadvicekfromksupervisorskwerekused,kthatktheykwerekevidencek
based.
DIF: Cognitivek Level:kUnderstandingk(Comprehension) MSC:kClientkNeeds:kGeneral
6. Theknursekiskreviewingkinformationkaboutkevidence-
basedkpracticek(EBP).kWhichstatementkbestkreflectskEBP?
a. EBPkrelieskonktraditionkforksupportkofkbestkpractices.
b. EBPkisksimplykthekusekofkbestkpracticektechniqueskforkthektreatmentkofkpatients.
c. EBPiemphasizesithekiusekiofkibestkievidencekiwithithekiclinician’skiexperience.
d. EBPkdoesknotkconsiderkthekpatient’skownkpreferenceskaskimportant.
ANS:kC
Chapterk1k-kEvidence-BasedkAssessment 4
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
, TestkBankkPhysicalkExaminationkandkHealthkAssessment
EBPkiskaksystematickapproachktokpracticekthatkemphasizeskthekusekofkresearchkevidencekinkcomb
inationkwithkthekclinician’skexpertisekandkclinicalkknowledgek(physicalkassessment),kaskwellkask
patientkvalueskandkpreferences,kwhenkmakingkdecisionskaboutkcarekandktreatment.kEBPkiskmorekt
hanksimplykusingkthekbestkpracticektechniquesktoktreatkpatients,kandkquestioningktraditionkiskimp
ortantkwhenknokcompellingkandksupportivekresearchkevidencekexists.
DIF: CognitivekLevel:kApplyingk(Application)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
7. Theknursekiskconductingkakclasskonkpriorityksettingkforkakgroupkofknewkgraduateknurses.Whichki
skankexamplekofkakfirst-levelkprioritykproblem?
a. Patientkwithkpostoperativek pain
b. Newlykdiagnosedkpatientkwithkdiabeteskwhokneedskdiabetickteaching
c. Individualkwithkaksmallklacerationkonktheksolekofkthekfoot
d. Individualkiwithishortnesskiofkibreathiandkirespiratorykidistress
ANS:kD
First-levelkprioritykproblemskarekthosekthatkarekemergent,klife-
threatening,kandkimmediatek(e.g.,kestablishingkankairway,ksupportingkbreathing,kmaintainingkcir
culation,kmonitoringkabnormalkvitalksigns).kPostoperativekpain,kdiabetickteachingkforkakpatientkn
ewlykdiagnosedkwithkdiabetes,kandkaksmallklacerationkonksolekofkthekfootkareknotkconsideredkfirst-
levelkprioritykproblems.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
8. Whenkconsideringkpriorityksettingkofkproblems,ktheknursekkeepskinkmindkthatsecond-
levelkprioritykproblemskincludekwhichkofkthesekaspects?
a. Lowkself-esteem
b. Lackkofkknowledge
c. Abnormalkilaboratorykivalues
d. Severelykabnormalkvitalksigns
ANS:kC
Abnormalklaboratorykvalueskarekaksecond-levelkprioritykproblem.kSecond-
levelkprioritykproblemskarekthosekthatkrequirekpromptkinterventionktokforestallkfurtherkdeteriorat
ionk(e.g.,kmentalkstatuskchange,kacutekpain,kabnormalklaboratorykvalues,krisksktoksafetykorksecurit
y).kLowkself-esteemkandklackkofkknowledgekarekconsideredkthird-
levelkprioritykaskalthoughktheykarekimportantktokakpatient’skhealth,ktheykcankbekaddressedkafterk
morekurgentkhealthkproblemskarekaddressed.kSeverelykabnormalkvitalksignskwouldkbekconsidere
dkakfirst-levelkprioritykproblem.
DIF: Cognitivek Level:k Understandingk(Comprehension)
MSC:kClientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare
9. Whichkcritical-thinkingkskillk helpskthek nursekseekrelationshipskamongkthekdata?
a. Validation
b. Clusteringkirelatedkicues
c. Identifyingk gapskinkdata
d. Distinguishingk relevantkfromkirrelevant
ANS:kB
Chapterk1k-kEvidence-BasedkAssessment 5
ealthkAssessment TestkBankkPhysicalkExaminationkandkHealthkAssessment
