HAP FINAL TEST BANK QUESTIONS: Jarvis 7th Edition

HAP FINAL TEST BANK QUESTIONS: Jarvis 7th Edition Chapter 01: Evidence-Based Assessment MULTIPLE CHOICE 1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person saysabout him or herself during history taking. The terms reflective and introspective are not used to describe data. 2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be: ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data. 3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: ANS: A Together with the patient’s record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patient’s record, laboratory studies, or data. 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to: d. Assess again in 20 minutes to note whether the sound is still present. ANS: C When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen. 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: ANS: A Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. 7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. 8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1). 9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Low self-esteem ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1). 10. Which critical thinking skill helps the nurse see relationships among the data? ANS: B Clustering related cues helps the nurse see relationships among the data. 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. 13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. 14. Which of these would be formulated by a nurse using diagnostic reasoning? ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. 15. Barriers to incorporating EBP include: ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: General 16. What step of the nursing process includes data collection by health history, physical examination, and interview? ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2). 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? d. Teach the nurses how to conduct electronic searches for research studies. ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. 18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. 19. The nurse recognizes that the concept of prevention in describing health is essential because: d. The means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: ANS: D Objective data are the patient’s record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. 21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?