,Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
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BEING
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MULTIPLE CHOICE z
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
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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 z
Objective data are what the health professional observes by inspecting, percussing, palpating, and a
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uscultating during the physical e z z z z
amination. Subjective data is what the person says about him or herself during history taking. The te
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rms reflective and introspective are not used to describe data.
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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 of data
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would be:
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a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C z
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 auscultatin
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g during the physical e
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amination. The terms reflective and introspective are not used to describe data.
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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 form the
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:
a Data base. z
.
b Admitting data. z
.
c Financial statement. z
.
d Discharge summary. z
.
ANS: A z
Together with the patients record and laboratory studies, the objective and subjective data form the d
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ata 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. The nur
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ses ne t action should be to:
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a Immediately notify the patients physician. z z z z
.
b Document the sound e actly as it was heard. z z z z z z z
.
c Validate the data by asking a coworker to listen to the breath sounds.
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.
d Assess again in 20 minutes to note whether the sound is still present.
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.
ANS: C z
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data t
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o ensure accuracy. If the nurse has less e perience in an area, then he or she asks an e pert to listen.
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, 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 nur
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se should keep in mind that novice nurses, without a background of skills and e
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perience from which to draw, are more likely to make their decisions using:
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a Intuition.
.
b A set of rules.
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.
c Articles in journals. z z
.
d Advice from supervisors. z z
.
ANS: B z
Novice nurses operate from a set of defined, structured rules. The e
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pert practitioner uses intuitive links.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
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MSC: Client Needs: General
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6. E
pert nurses learn to attend to a pattern of assessment data and act without consciously labeling
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it. These responses are referred to as:
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a Intuition.
.
b The nursing process.z z
.
c Clinical knowledge. z
.
d Diagnostic reasoning. z
.
ANS: A z
Intuition is characterized by pattern recognitione
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pert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. Th
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e other options are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
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MSC: Client Needs: General
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7. The nurse is reviewing information about evidence-
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based practice (EBP). Which statement best reflects EBP?
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BEING
z
MULTIPLE CHOICE z
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
z z z z z z z z z z z z z z z
eupneic and his pulse is 58 beats per minute. These types of data would be:
z z z z z z z z z z z z z z z
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A z
Objective data are what the health professional observes by inspecting, percussing, palpating, and a
z z z z z z z z z z z z z
uscultating during the physical e z z z z
amination. Subjective data is what the person says about him or herself during history taking. The te
z z z z z z z z z z z z z z z z
rms reflective and introspective are not used to describe data.
z z z z z z z z z
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
z z z z z z z
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
z z z z z z z z z z
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data
z z z z z z z z z z z z z z z z z z
would be:
z z
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C z
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 auscultatin
z z z z z z z z z z z z
g during the physical e
z z z z
amination. The terms reflective and introspective are not used to describe data.
z z z z z z z z z z z
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
z z z z z z z
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
z z z z z z z z z z
3. The patients record, laboratory studies, objective data, and subjective data combine to form the
z z z z z z z z z z z z z
:
a Data base. z
.
b Admitting data. z
.
c Financial statement. z
.
d Discharge summary. z
.
ANS: A z
Together with the patients record and laboratory studies, the objective and subjective data form the d
z z z z z z z z z z z z z z z
ata base. The other items are not part of the patients record, laboratory studies, or data.
z z z z z z z z z z z z z z z
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
z z z z z z z
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
z z z z z z z z z z
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nur
z z z z z z z z z z z z z z z z z z
ses ne t action should be to:
z z z z z
a Immediately notify the patients physician. z z z z
.
b Document the sound e actly as it was heard. z z z z z z z
.
c Validate the data by asking a coworker to listen to the breath sounds.
z z z z z z z z z z z z
.
d Assess again in 20 minutes to note whether the sound is still present.
z z z z z z z z z z z z
.
ANS: C z
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data t
z z z z z z z z z z z z z z z z z z
o ensure accuracy. If the nurse has less e perience in an area, then he or she asks an e pert to listen.
z z z z z z z z z z z z z z z z z z z z
, DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
z z z z z z z
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
z z z z z z z z z z
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nur
z z z z z z z z z z z z z z z
se should keep in mind that novice nurses, without a background of skills and e
z z z z z z z z z z z z z z
perience from which to draw, are more likely to make their decisions using:
z z z z z z z z z z z z
a Intuition.
.
b A set of rules.
z z z
.
c Articles in journals. z z
.
d Advice from supervisors. z z
.
ANS: B z
Novice nurses operate from a set of defined, structured rules. The e
z z z z z z z z z z z
pert practitioner uses intuitive links.
z z z z
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
z z z z z z z z
MSC: Client Needs: General
z z z
6. E
pert nurses learn to attend to a pattern of assessment data and act without consciously labeling
z z z z z z z z z z z z z z z z
it. These responses are referred to as:
z z z z z z
a Intuition.
.
b The nursing process.z z
.
c Clinical knowledge. z
.
d Diagnostic reasoning. z
.
ANS: A z
Intuition is characterized by pattern recognitione
z z z z z
pert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. Th
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e other options are not correct.
z z z z z
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
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MSC: Client Needs: General
z z z
7. The nurse is reviewing information about evidence-
z z z z z z
based practice (EBP). Which statement best reflects EBP?
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