Test Bank for Physical Examination and Health Assessment, 8th Edition by Carolyn Jarvis
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly a...
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
eupneic andhis pulse is 58 beats per minute. These types of data wouldbe:
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 is what the person says about him or
herself during historytaking. The terms reflective and introspective are not used to describe data.
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 him or herself during history taking. Objective data are
what thehealth professional observes by inspecting, percussing, palpating, and auscultating during the
physical examination. The terms reflective and introspective are not used to describe data.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
2
,c. Financial statement.
d. Discharge summary.
ANS: A
Together with the patients record and laboratory studies, the objective and subjective data form the
data base.The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses nextaction should be to:
a. Immediately notify the patients 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 patients breath sounds, the nurse validates the data to
ensureaccuracy. 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, without a background of skills and experience from which to
draw, are more likelyto make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
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