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Test Bank for Physical Examination and Health Assessment, 8th Edition, Carolyn Jarvis| With Rationale | LATEST
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Test Bank For Canadian Physical Examination and Health Assessment, 4th Edition, by Jarvis, All Chapters 1-31 ||Complete A+ Guide
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Physical Examination and Health Assessment CANADIAN 3rd EditionJarvis Test Bank
Chapter 01: Evidence-Based Assessment
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations
are 18 breaths per minute and his pulse is 58 beats per minute. These types of data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. Subjective data are what the person says
about himself or herself during history taking. The terms reflective and introspective are not
used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of
data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data are what the person says about himself 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form
the:
a. Database
b. Admitting data
c. Financial statement
d. Discharge summary
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data
form the database. The other items are not part of the patient’s record, laboratory studies, or
data.
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, DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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:
a. Immediately notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to the breath sounds.
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.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, with less experience, are more likely to base
their decisions on:
a. Intuition
b. Clear-cut rules
c. Articles in journals
d. Advice from supervisors
ANS: B
Novice nurses operate from a set of defined, structured rules. Expert practitioners use critical
thinking and their substantial background of experiences.
DIF:
U S N T
Cognitive Level: Understanding (Comprehension)
O MSC: Client Needs: General
6. Expert nurses assess and make decisions through the use of:
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANS: A
Critical thinking is a multidimensional, dynamic, and interactive thinking process by which
expert nurses assess and make decisions in the clinical area.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
7. The nurse is reviewing information about evidence-informed practice (EIP). Which statement
best reflects EIP?
a. EIP relies on tradition for support of best practices.
b. EIP is simply the use of best practice techniques for the treatment of patients.
c. EIP emphasizes the use of best and most appropriate evidence with clinician
expertise and patient preference.
d. The patient’s own preferences are not important in EIP.
ANS: C
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, EIP is a problem-solving approach to decision making that emphasizes the use of best
available evidence in combination with the clinician’s experience, patient preferences and
values, and comprehensive assessment to determine the best outcomes in care and treatment.
EIP 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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?
a. Patient with postoperative pain
b. Patient newly diagnosed with diabetes needing diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress
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).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant data from irrelevant data
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The nurse knows that developing appropriate nursing interventions for a patient relies on the
appropriateness of the diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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,11. The nursing process is a sequential method of problem solving that nurses use and includes
which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. 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?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
ANS: A
First-level priority problems are immediate priorities focused on airway and breathing,
followed by second-level problems, and then third-level problems.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and ENffecR
tiveICarG
e EnBv.
iroCnmM
ent: Management of Care
U S N T O
13. What step of the nursing process includes data collection through health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
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).
DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General
14. What is an important concept when undertaking a life-cycle approach to health assessment?
a. Consideration of the patient’s cultural view of health
b. Being responsive to the patient’s gestures to build a relationship
c. Acknowledgement of the effect of poverty on health
d. Awareness of age-specific developmental factors
ANS: D
A life-cycle approach requires familiarity with the usual and expected developmental tasks for
various age groups. Being aware of age-specific data can be helpful in determining normal
and abnormal findings.
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, DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
15. The nurse identifies priorities and assesses risk factors with a generally healthy individual to:
a. Identify patterns to discover missing information.
b. Determine areas for health promotion and disease prevention.
c. Distinguish normal from abnormal findings.
d. Determine treatment for a medical diagnosis.
ANS: B
Identifying and working with patients to manage known risk factors for their age group and
social context supports disease prevention and health promotion.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
16. The nurse is performing a physical assessment on a newly admitted patient. An example of
objective information obtained during the physical assessment includes the:
a. Patient’s history of allergies.
b. Patient’s use of medications at home.
c. Last menstrual period 1 month ago.
d. 2 5 cm scar on the right lower forearm.
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.
N R I G B.C M
U S N T
DIF: Cognitive Level: Applying (Application) O
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. A visiting nurse is making an initial home visit for a patient who has many chronic medical
problems. Which type of database is most appropriate to collect in this setting?
a. A follow-up database to evaluate changes at appropriate intervals
b. An episodic database because of the continuing, complex medical problems of this
patient
c. A complete health database because of the nurse’s primary responsibility for
monitoring the patient’s health
d. An emergency database because of the need to collect information and make
accurate diagnoses rapidly
ANS: C
The complete database is collected in a primary care setting, such as a pediatric or family
practice clinic, independent or group private practice, college health service, women’s health
care agency, visiting nurse agency, or community health agency. In these settings, the nurse is
the first health care professional to see the patient and has the primary responsibility for
monitoring the person’s health care.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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, 18. Which situation is most appropriate during which the nurse collects episodic or
problem-centred data?
a. Patient is admitted to a long-term care facility.
b. Patient has a sudden and severe shortness of breath.
c. Patient is admitted to the hospital for surgery the next day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
ANS: D
In compiling the episodic or problem-centered database, the nurse collects a “mini-database,”
which is smaller in scope compared with the complete database. This mini database primarily
concerns one problem, one cue complex, or one body system.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic
weekly since she changed medications 2 months ago. The nurse should:
a. Collect a follow-up database and then check her blood pressure.
b. Ask her to read her health record and indicate any changes since her last visit.
c. Check only her blood pressure because her complete health history was
documented 2 months ago.
d. Obtain a complete health history before checking her blood pressure because much
of her history information may have changed.
ANS: A
A follow-up database is used in all settings to monitor short-term or chronic health problems.
The other responses are not appropriate for the situation.
NURSINGTB.COM
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. A patient is brought by ambulance to the emergency department with multiple injuries
received in an automobile accident. The patient is alert and cooperative, but his injuries are
quite severe. How would the nurse proceed with data collection?
a. Collect history information first and then perform the physical examination and
institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and
initiating life-saving measures.
c. Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the
patient is transferred to the intensive care unit.
ANS: B
The emergency database calls for a rapid collection of the database, and often data are
compiled concurrently with administration of life-saving measures. The other responses are
not appropriate for the situation.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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