Evidence-Based Physical Examination Best Practices for Health & Well-Being
B B B B B B B B
Assessment 1st Edition Test Bank B B B B B
Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
B B B B B B B B B
BEING
B
MULTIPLE CHOICE B
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
B B B B B B B B B B B B B B B
eupneic and his pulse is 58 beats per minute. These types of data would be:
B B B B B B B B B B B B B B B
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A B
Objective data are what the health professional observes by inspecting, percussing, palpating, and
B B B B B B B B B B B B
auscultating during the physical examination. Subjective data is what the person says about him or
B B B B B B B B B B B B B B B
herself during history taking. The terms reflective and introspective are not used to describe data.
B B B B B B B B B B B B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data
B B B B B B B B B B B B B B B B B B
would be:
B B
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C B
Subjective data are what the person says about him or herself during history taking. Objective
B B B B B B B B B B B B B B
,data are what the health professional observes by inspecting, percussing, palpating, and
B B B B B B B B B B B
auscultating during the physical examination. The terms reflective and introspective are not used to
B B B B B B B B B B B B B B
describe data.
B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
B B B B B B B B B B B B B
a Data base. B
.
b Admitting data. B
.
c Financial statement. B
.
d Discharge summary. B
.
ANS: A B
Together with the patients record and laboratory studies, the objective and subjective data form the
B B B B B B B B B B B B B B
data base. The other items are not part of the patients record, laboratory studies, or data.
B B B B B B B B B B B B B B B B
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
B B B B B B B B B B B B B B B B B
nurses next action should be to:
B B B B B B
a Immediately notify the patients physician. B B B B
.
b Document the sound exactly as it was heard. B B B B B B B
.
c Validate the data by asking a coworker to listen to the breath sounds.
B B B B B B B B B B B B
.
d Assess again in 20 minutes to note whether the sound is still present.
B B B B B B B B B B B B
.
ANS: C B
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data
B B B B B B B B B B B B B B B B B
to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
B B B B B B B B B B B B B B B B B B B B B
,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
B B B B B B B B B B B B B B
nurse should keep in mind that novice nurses, without a background of skills and experience
B B B B B B B B B B B B B B B
from which to draw, are more likely to make their decisions using:
B B B B B B B B B B B B
a Intuition.
.
b A set of rules.
B B B
.
c Articles in journals. B B
.
d Advice from supervisors. B B
.
ANS: B B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
B B B B B B B B B B B B B B
links.
B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
B B B B B B B
MSC: Client Needs: General
B B B B
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
B B B B B B B B B B B B B B
labeling it. These responses are referred to as:
B B B B B B B B
a Intuition.
.
b The nursing process. B B
.
c Clinical knowledge. B
.
d Diagnostic reasoning. B
.
ANS: A B
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
B B B B B B B B B B B B B B
data and act without consciously labeling it. The other options are not correct.
B B B B B B B B B B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
B B B B B B B
MSC: Client Needs: General
B B B B
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
B B B B B B B B B B
best reflects EBP?
B B B
, a EBP relies on tradition for support of best practices.
B B B B B B B B
.
b EBP is simply the use of best practice techniques for the treatment of patients.
B B B B B B B B B B B B B
.
c EBP emphasizes the use of best evidence with the clinicians experience.
B B B B B B B B B B
.
d The patients own preferences are not important with EBP.
B B B B B B B B
.
ANS: C B
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with
B B B B B B B B B B B B B B B B
the clinicians experience, as well as patient preferences and values, when making decisions about
B B B B B B B B B B B B B B
care and treatment. EBP is more than simply using the best practice techniques to treat patients, and
B B B B B B B B B B B B B B B B B
questioning tradition is important when no compelling and supportive research evidence exists.
B B B B B B B B B B B B
DIF: Cognitive Level: Applying (Application) REF: z. 5
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an
B B B B B B B B B B B B B B B B B B
example of a first-level priority problem?
B B B B B B
a Patient with postoperative pain B B B
.
b Newly diagnosed patient with diabetes who needs diabetic teaching
B B B B B B B B
.
c Individual with a small laceration on the sole of the foot B B B B B B B B B B
.
d Individual with shortness of breath and respiratory distressB B B B B B B
.
ANS: D B
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
B B B B B B B B B B B B
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
B B B B B B B B B B
signs) (see Table 1-1).
B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
9. When considering priority setting of problems, the nurse keeps in mind that second-level
B B B B B B B B B B B B
priority problems include which of these aspects?
B B B B B B B
B B B B B B B B
Assessment 1st Edition Test Bank B B B B B
Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
B B B B B B B B B
BEING
B
MULTIPLE CHOICE B
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
B B B B B B B B B B B B B B B
eupneic and his pulse is 58 beats per minute. These types of data would be:
B B B B B B B B B B B B B B B
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A B
Objective data are what the health professional observes by inspecting, percussing, palpating, and
B B B B B B B B B B B B
auscultating during the physical examination. Subjective data is what the person says about him or
B B B B B B B B B B B B B B B
herself during history taking. The terms reflective and introspective are not used to describe data.
B B B B B B B B B B B B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data
B B B B B B B B B B B B B B B B B B
would be:
B B
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C B
Subjective data are what the person says about him or herself during history taking. Objective
B B B B B B B B B B B B B B
,data are what the health professional observes by inspecting, percussing, palpating, and
B B B B B B B B B B B
auscultating during the physical examination. The terms reflective and introspective are not used to
B B B B B B B B B B B B B B
describe data.
B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
B B B B B B B B B B B B B
a Data base. B
.
b Admitting data. B
.
c Financial statement. B
.
d Discharge summary. B
.
ANS: A B
Together with the patients record and laboratory studies, the objective and subjective data form the
B B B B B B B B B B B B B B
data base. The other items are not part of the patients record, laboratory studies, or data.
B B B B B B B B B B B B B B B B
DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
B B B B B B B B B B B B B B B B B
nurses next action should be to:
B B B B B B
a Immediately notify the patients physician. B B B B
.
b Document the sound exactly as it was heard. B B B B B B B
.
c Validate the data by asking a coworker to listen to the breath sounds.
B B B B B B B B B B B B
.
d Assess again in 20 minutes to note whether the sound is still present.
B B B B B B B B B B B B
.
ANS: C B
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data
B B B B B B B B B B B B B B B B B
to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
B B B B B B B B B B B B B B B B B B B B B
,DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
B B B B B B B B B B B B B B
nurse should keep in mind that novice nurses, without a background of skills and experience
B B B B B B B B B B B B B B B
from which to draw, are more likely to make their decisions using:
B B B B B B B B B B B B
a Intuition.
.
b A set of rules.
B B B
.
c Articles in journals. B B
.
d Advice from supervisors. B B
.
ANS: B B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
B B B B B B B B B B B B B B
links.
B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 3
B B B B B B B
MSC: Client Needs: General
B B B B
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
B B B B B B B B B B B B B B
labeling it. These responses are referred to as:
B B B B B B B B
a Intuition.
.
b The nursing process. B B
.
c Clinical knowledge. B
.
d Diagnostic reasoning. B
.
ANS: A B
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
B B B B B B B B B B B B B B
data and act without consciously labeling it. The other options are not correct.
B B B B B B B B B B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
B B B B B B B
MSC: Client Needs: General
B B B B
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
B B B B B B B B B B
best reflects EBP?
B B B
, a EBP relies on tradition for support of best practices.
B B B B B B B B
.
b EBP is simply the use of best practice techniques for the treatment of patients.
B B B B B B B B B B B B B
.
c EBP emphasizes the use of best evidence with the clinicians experience.
B B B B B B B B B B
.
d The patients own preferences are not important with EBP.
B B B B B B B B
.
ANS: C B
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with
B B B B B B B B B B B B B B B B
the clinicians experience, as well as patient preferences and values, when making decisions about
B B B B B B B B B B B B B B
care and treatment. EBP is more than simply using the best practice techniques to treat patients, and
B B B B B B B B B B B B B B B B B
questioning tradition is important when no compelling and supportive research evidence exists.
B B B B B B B B B B B B
DIF: Cognitive Level: Applying (Application) REF: z. 5
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an
B B B B B B B B B B B B B B B B B B
example of a first-level priority problem?
B B B B B B
a Patient with postoperative pain B B B
.
b Newly diagnosed patient with diabetes who needs diabetic teaching
B B B B B B B B
.
c Individual with a small laceration on the sole of the foot B B B B B B B B B B
.
d Individual with shortness of breath and respiratory distressB B B B B B B
.
ANS: D B
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
B B B B B B B B B B B B
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
B B B B B B B B B B
signs) (see Table 1-1).
B B B B
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 4
B B B B B B B
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
B B B B B B B B B B
9. When considering priority setting of problems, the nurse keeps in mind that second-level
B B B B B B B B B B B B
priority problems include which of these aspects?
B B B B B B B
