Evidence-BasedPhysicalExaminationBestPractices forHealth&Well-Being n
Assessment 1st Edition Test Bank ss ss ss ss
Chapter1.APPROACHTOEVIDENCE-BASEDASSESSMENTOFHEALTHANDWELL-
s s BEING
MULTIPLE ssCHOICE
1. Aftercompletingan initialassessment ssofa patient, ssthenurse sshascharted thathisrespirations
n n n
ssare ss eupneic ssand sshis sspulse ssis ss58 ssbeats ssper ssminute. ssThese sstypes ssof ssdata sswould ssbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:sA
Objective ssdata ssare sswhat ssthe sshealth ssprofessional ssobserves ssby ssinspecting, sspercussing, sspalpating,
ssand ssauscultatingduringthephysical examination. ssSubjective ssdatais whattheperson sssaysabout
n n
sshim ssor ssherself ssduring sshistory sstaking. ssThe ssterms ssreflective ssand ssintrospective ssare ssnot ssused ssto
ssdescribe ssdata.
DIF:ssCognitivesLevel: ssUnderstanding ss(Comprehension) ssREF:ssz. ss2
MSC:ClientNeeds:Safeand EffectiveCareEnvironment: ssManagement ssofCare
n
2. Apatienttells the ssnursethatheis verynervous, ssisnauseated, ssandfeels sshot.Thesetypes ssof
n n
ssdata sswould ssbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:Cs
Subjectivedata arewhatthepersonsaysssaboutsshimorherselfduring shistorytaking.sObjective
n
,data ssare sswhat ssthe sshealth ssprofessional ssobserves ssby ssinspecting, sspercussing, sspalpating, ssand
ssauscultatingduring thephysical examination.Theterms ssreflectiveandssintrospective ssarenotused ssto
n n
ssdescribe ssdata.
DIF:Cognitive Level:Understanding (Comprehension) s s REF:z.2
n n
MSC:Client Needs:Safeand EffectiveCareEnvironment:sManagement ssofCare
n n
3. Thepatientsrecord,laboratorystudies,objectivedata,and subjectivedatacombinetoform
n
s s the:
a Data base. n
.
b Admitting ssdata.
.
c Financial ssstatement.
.
d Discharge sssummary.
.
ANS:sA
Togetherwith thepatientsrecordand laboratorystudies, sstheobjectiveandsubjective ssdataform ssthe
n n
ssdata ssbase. ssThe ssother ssitems ssare ssnot sspart ssof ssthe sspatients ssrecord, sslaboratory ssstudies, ssor
ssdata.
DIF:Cognitive Level:Rememberingss(Knowledge)REF:z.2
n
MSC:Client Needs:Safeand EffectiveCareEnvironment:sManagement ssofCare
n n
4. Whenlisteningtoapatientsbreath sounds, ssthe ssnurse ssisunsureofasound ssthat ssisheard.
n
ssThe ssnurses ssnext ssaction ssshould ssbe ss to:
a Immediately ssnotifyssthe sspatients ssphysician.
.
b Document the sssoundexactlyas ssitwas ssheard.
n
.
c Validate the ssdata ss byasking ssacoworkertolistentothe ssbreathsounds.
n
.
d Assessagaininss20 ssminutes ssto ssnotewhetherthe sssound isstill sspresent.
n
.
ANS:C s
When ssunsure ssof ssa sssound ssheard sswhile sslistening ssto ssa sspatients ssbreath sssounds, ssthe ssnurse
ssvalidates ssthe ssdata ssto ssensure ssaccuracy. ssIf ssthe ssnurse s s has ssless ssexperience s s in ssan ssarea, ssthen
sshe ssor ssshe ssasks ssan ssexpert ssto sslisten.
,DIF:CognitiveLevel:sAnalyzingss(Analysis)sREF:sz.2
MSC:ClientNeeds:Safeand EffectivessCareEnvironment:sManagement ssofCare
n
5. The ssnurse ssis ssconducting ssa ssclass ssfor ssnew ssgraduate ssnurses. ssDuring ssthe ssteaching
sssession, ss the ssnurse ssshould sskeep ssin ssmind ssthat ssnovice ssnurses, sswithout ssa ssbackground ssof
ssskills ssand ssexperience ssfrom sswhich ssto ssdraw, ssare ssmore sslikely ssto ssmake sstheir ssdecisions
s s using:
a Intuition.
.
b Aset ssof ssrules.
.
c Articles ssinjournals.
.
d Advicefrom supervisors.
n
.
ANS:B s
Novicenursesoperatefroma setofdefined,ssstructuredrules.Theexpertpractitioneruses ssintuitive
n
sslinks.
DIF:ssCognitivesLevel:sUnderstanding ss(Comprehension) ssREF:ssz.ss3
ssMSC: ssClient ssNeeds: ss General
6. Expert nurseslearnto attendto apatternofassessmentdata andact withoutssconsciously
n n n n n
sslabeling ssit. ss These ssresponses ssare ssreferred ssto ssas:
a Intuition.
.
b Thessnursingprocess.
.
c Clinicalknowledge.
.
d Diagnostic ssreasoning.
.
ANS:sA
Intuition ischaracterizedsbypattern recognitionexpertssnurses learn toattendtoapatternssof ssassessment
n n n n
ssdataandactwithoutconsciouslylabelingit. ssTheotheroptionsare ssnot sscorrect.
DIF:ssCognitivesLevel:sUnderstanding ss(Comprehension) ssREF:ssz.ss4
ssMSC: ssClient ssNeeds: ss General
7. Thenurseisreviewing information aboutevidence-based practice(EBP).Which statement
n n n n
ssbest ssreflects ssEBP?
, a EBPrelies ssonsstradition ssforsupport ssofbest sspractices.
.
b EBPissimplytheuseofbestpractice ss techniques s s for ssthetreatment s s ofpatients.
.
c EBPemphasizesthe ssuse ssofbestevidence sswiththeclinicians ss ss experience.
.
d Thepatientsownpreferences arenotimportantn s s with EBP.
n
.
ANS:C s
EBPis a systematic ssapproachtopracticethat ssemphasizes sstheuseofbest evidence ssinscombination
n n n
sswith ssthe ssclinicians ssexperience, ssas sswell ssas sspatient sspreferences ssand ssvalues, sswhen ssmaking
ssdecisions ssabout sscare ssand sstreatment. ssEBP ssis ssmore ssthan sssimply ssusing ssthe ssbest sspractice
sstechniques ssto sstreat sspatients, ssand ssquestioning sstradition ss is ssimportant sswhen ssno sscompelling
ssand sssupportive ssresearch ss evidence ssexists.
DIF:Cognitive Level:ssApplying(Application)ssREF:z.ss5
n
MSC:ClientNeeds:Safeand EffectiveCareEnvironment:ssManagement ssofCare
n
8. Thenurseisconductinga classon prioritysetting ssforagroup ssofnewgraduate ssnurses. ssWhich
n n
ssis ssan ssexample ssof ssa ssfirst-level sspriority ssproblem?
a Patient sswith sspostoperative sspain
.
b Newlydiagnosed patient withdiabeteswhoneedsdiabetic ssteaching
n n
.
c Individual sswitha sssmall sslacerationon thesole ssofthe ssfoot
n
.
d Individualwithshortnessofbreathandrespiratorydistress
.
ANS:D s
First-level sspriority ssproblems ssare ssthose ssthat ssare ssemergent, sslife ssthreatening, ssand ssimmediate
ss(e.g.,
ssestablishinganairway, supporting breathing, maintaining circulation,monitoringabnormalvital
n n n n
sssigns) ss(see ssTable ss1-1).
DIF:ssCognitivesLevel: ssUnderstanding ss(Comprehension) ssREF: ssz. ss4
MSC:ClientsNeeds:SafeandEffective ssCareEnvironment: ssManagement ssofCare
9. Whenconsideringprioritysetting ofproblems,sthenursekeepsinmind thatsecond-level
n n
sspriority ssproblems ss include sswhich ssof ss these ss aspects?
Assessment 1st Edition Test Bank ss ss ss ss
Chapter1.APPROACHTOEVIDENCE-BASEDASSESSMENTOFHEALTHANDWELL-
s s BEING
MULTIPLE ssCHOICE
1. Aftercompletingan initialassessment ssofa patient, ssthenurse sshascharted thathisrespirations
n n n
ssare ss eupneic ssand sshis sspulse ssis ss58 ssbeats ssper ssminute. ssThese sstypes ssof ssdata sswould ssbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:sA
Objective ssdata ssare sswhat ssthe sshealth ssprofessional ssobserves ssby ssinspecting, sspercussing, sspalpating,
ssand ssauscultatingduringthephysical examination. ssSubjective ssdatais whattheperson sssaysabout
n n
sshim ssor ssherself ssduring sshistory sstaking. ssThe ssterms ssreflective ssand ssintrospective ssare ssnot ssused ssto
ssdescribe ssdata.
DIF:ssCognitivesLevel: ssUnderstanding ss(Comprehension) ssREF:ssz. ss2
MSC:ClientNeeds:Safeand EffectiveCareEnvironment: ssManagement ssofCare
n
2. Apatienttells the ssnursethatheis verynervous, ssisnauseated, ssandfeels sshot.Thesetypes ssof
n n
ssdata sswould ssbe:
a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS:Cs
Subjectivedata arewhatthepersonsaysssaboutsshimorherselfduring shistorytaking.sObjective
n
,data ssare sswhat ssthe sshealth ssprofessional ssobserves ssby ssinspecting, sspercussing, sspalpating, ssand
ssauscultatingduring thephysical examination.Theterms ssreflectiveandssintrospective ssarenotused ssto
n n
ssdescribe ssdata.
DIF:Cognitive Level:Understanding (Comprehension) s s REF:z.2
n n
MSC:Client Needs:Safeand EffectiveCareEnvironment:sManagement ssofCare
n n
3. Thepatientsrecord,laboratorystudies,objectivedata,and subjectivedatacombinetoform
n
s s the:
a Data base. n
.
b Admitting ssdata.
.
c Financial ssstatement.
.
d Discharge sssummary.
.
ANS:sA
Togetherwith thepatientsrecordand laboratorystudies, sstheobjectiveandsubjective ssdataform ssthe
n n
ssdata ssbase. ssThe ssother ssitems ssare ssnot sspart ssof ssthe sspatients ssrecord, sslaboratory ssstudies, ssor
ssdata.
DIF:Cognitive Level:Rememberingss(Knowledge)REF:z.2
n
MSC:Client Needs:Safeand EffectiveCareEnvironment:sManagement ssofCare
n n
4. Whenlisteningtoapatientsbreath sounds, ssthe ssnurse ssisunsureofasound ssthat ssisheard.
n
ssThe ssnurses ssnext ssaction ssshould ssbe ss to:
a Immediately ssnotifyssthe sspatients ssphysician.
.
b Document the sssoundexactlyas ssitwas ssheard.
n
.
c Validate the ssdata ss byasking ssacoworkertolistentothe ssbreathsounds.
n
.
d Assessagaininss20 ssminutes ssto ssnotewhetherthe sssound isstill sspresent.
n
.
ANS:C s
When ssunsure ssof ssa sssound ssheard sswhile sslistening ssto ssa sspatients ssbreath sssounds, ssthe ssnurse
ssvalidates ssthe ssdata ssto ssensure ssaccuracy. ssIf ssthe ssnurse s s has ssless ssexperience s s in ssan ssarea, ssthen
sshe ssor ssshe ssasks ssan ssexpert ssto sslisten.
,DIF:CognitiveLevel:sAnalyzingss(Analysis)sREF:sz.2
MSC:ClientNeeds:Safeand EffectivessCareEnvironment:sManagement ssofCare
n
5. The ssnurse ssis ssconducting ssa ssclass ssfor ssnew ssgraduate ssnurses. ssDuring ssthe ssteaching
sssession, ss the ssnurse ssshould sskeep ssin ssmind ssthat ssnovice ssnurses, sswithout ssa ssbackground ssof
ssskills ssand ssexperience ssfrom sswhich ssto ssdraw, ssare ssmore sslikely ssto ssmake sstheir ssdecisions
s s using:
a Intuition.
.
b Aset ssof ssrules.
.
c Articles ssinjournals.
.
d Advicefrom supervisors.
n
.
ANS:B s
Novicenursesoperatefroma setofdefined,ssstructuredrules.Theexpertpractitioneruses ssintuitive
n
sslinks.
DIF:ssCognitivesLevel:sUnderstanding ss(Comprehension) ssREF:ssz.ss3
ssMSC: ssClient ssNeeds: ss General
6. Expert nurseslearnto attendto apatternofassessmentdata andact withoutssconsciously
n n n n n
sslabeling ssit. ss These ssresponses ssare ssreferred ssto ssas:
a Intuition.
.
b Thessnursingprocess.
.
c Clinicalknowledge.
.
d Diagnostic ssreasoning.
.
ANS:sA
Intuition ischaracterizedsbypattern recognitionexpertssnurses learn toattendtoapatternssof ssassessment
n n n n
ssdataandactwithoutconsciouslylabelingit. ssTheotheroptionsare ssnot sscorrect.
DIF:ssCognitivesLevel:sUnderstanding ss(Comprehension) ssREF:ssz.ss4
ssMSC: ssClient ssNeeds: ss General
7. Thenurseisreviewing information aboutevidence-based practice(EBP).Which statement
n n n n
ssbest ssreflects ssEBP?
, a EBPrelies ssonsstradition ssforsupport ssofbest sspractices.
.
b EBPissimplytheuseofbestpractice ss techniques s s for ssthetreatment s s ofpatients.
.
c EBPemphasizesthe ssuse ssofbestevidence sswiththeclinicians ss ss experience.
.
d Thepatientsownpreferences arenotimportantn s s with EBP.
n
.
ANS:C s
EBPis a systematic ssapproachtopracticethat ssemphasizes sstheuseofbest evidence ssinscombination
n n n
sswith ssthe ssclinicians ssexperience, ssas sswell ssas sspatient sspreferences ssand ssvalues, sswhen ssmaking
ssdecisions ssabout sscare ssand sstreatment. ssEBP ssis ssmore ssthan sssimply ssusing ssthe ssbest sspractice
sstechniques ssto sstreat sspatients, ssand ssquestioning sstradition ss is ssimportant sswhen ssno sscompelling
ssand sssupportive ssresearch ss evidence ssexists.
DIF:Cognitive Level:ssApplying(Application)ssREF:z.ss5
n
MSC:ClientNeeds:Safeand EffectiveCareEnvironment:ssManagement ssofCare
n
8. Thenurseisconductinga classon prioritysetting ssforagroup ssofnewgraduate ssnurses. ssWhich
n n
ssis ssan ssexample ssof ssa ssfirst-level sspriority ssproblem?
a Patient sswith sspostoperative sspain
.
b Newlydiagnosed patient withdiabeteswhoneedsdiabetic ssteaching
n n
.
c Individual sswitha sssmall sslacerationon thesole ssofthe ssfoot
n
.
d Individualwithshortnessofbreathandrespiratorydistress
.
ANS:D s
First-level sspriority ssproblems ssare ssthose ssthat ssare ssemergent, sslife ssthreatening, ssand ssimmediate
ss(e.g.,
ssestablishinganairway, supporting breathing, maintaining circulation,monitoringabnormalvital
n n n n
sssigns) ss(see ssTable ss1-1).
DIF:ssCognitivesLevel: ssUnderstanding ss(Comprehension) ssREF: ssz. ss4
MSC:ClientsNeeds:SafeandEffective ssCareEnvironment: ssManagement ssofCare
9. Whenconsideringprioritysetting ofproblems,sthenursekeepsinmind thatsecond-level
n n
sspriority ssproblems ss include sswhich ssof ss these ss aspects?
