Evidence-Based Physical Examination: Test Bank for Health & Well-Being Assessment (1st Edition)

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Evidence-Based Physical Examination Best Practices for Health & x x x x x x x




x Well-Being Assessment 1st Edition Test Bank A+ x x x x x x




Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND
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x WELL- BEING x




MULTIPLE CHOICE x




1. After completing an initial assessment of a patient, the nurse has charted that his
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x respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
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a
. Objective.
b
x




. Reflective.
c
x




. Subjective.
d
x




. Introspective.


ANS: A x




Objective data are what the health professional observes by inspecting, percussing, palpating,
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x and auscultating during the physical examination. Subjective data is what the person says about
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x him or herself during history taking. The terms reflective and introspective are not used to
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x describe data. x




DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
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x of data would be:
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a
. Objective.


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b
. Reflective.
c
x




. Subjective.
d
x




. Introspective.


ANS: C x




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 by inspecting, percussing, palpating, and
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x auscultating during the physical examination. The terms reflective and introspective are not used
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x to describe data.
x x




DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to
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x form the: x




a
. Data base. x




x b
. Admitting data. x




x c
. Financial statement. x




x d
. Discharge summary. x




ANS: A x




Together with the patients record and laboratory studies, the objective and subjective data form
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x the 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: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
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x The nurses next action should be to:
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a
. Immediately notify the patients physician. x x x x




x b
. Document the sound exactly as it was heard. x x x x x x x




x c
. Validate the data by asking a coworker to listen to the breath sounds.
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x d
. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C x




When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
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x data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
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x to listen.
x




DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
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x nurse should keep in mind that novice nurses, without a background of skills and experience
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x from which to draw, are more likely to make their decisions using:
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a
. Intuition.
b
x




. A set of rules.
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x c


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. Articles in journals. x x




x d
. Advice from supervisors. x x




ANS: B x




Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
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x intuitive links. x




DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3 MSC: Client Needs: General
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6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
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x labeling it. These responses are referred to as:
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a
. Intuition.
b
x




. The nursing process.
x x




x c
. Clinical knowledge. x




x d
. Diagnostic reasoning. x




ANS: A x




Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
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x assessment data and act without consciously labeling it. The other options are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4 MSC: Client Needs: General
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7. The nurse is reviewing information about evidence-based practice (EBP). Which
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x statement best reflects EBP?
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a


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x