,Test Bank for Physical Examination and Health Assessment, 8th Edition
by Carolyn Jarvis
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:
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 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 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.
DIF: Cognitive Level: Understanding (Comprehension)
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.
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 next action
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 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, without a background of skills and experience from which to draw, are more likely to
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 links.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These
responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act
without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
a.
b. EBP relies on tradition for supportNoUf R
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c. EBP is simply the use of best practice techniques for the treatment of patients.
d. EBP emphasizes the use of best evidence with the clinicians experience.
The patients own preferences are not important with EBP.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the
clinicians 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.
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. Newly diagnosed patient with diabetes who needs 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).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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
Lack of knowledge
b. Abnormal laboratory values
c. Severely abnormal vital signs
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).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. 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 from irrelevant
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
11. 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
12. 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
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?
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, remembering the ABCs (airway, breathing, and circulation),
followed by second-level problems, and then third-level problems.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis
b. Medical diagnosis
c. Diagnostic hypothesis
d. Diagnostic assessment
ANS: C
Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing
diagnosis.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
15. Barriers to incorporating EBP include:
a.
b. Lack of significant research studies.
c. Insufficient clinical skills of nurses.
d. Inadequate physical assessment skills.
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)
,MSC: Client Needs: General
16. What step of the nursing process includes data collection by 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 assessmen
step of the nursing process.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: General
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?
a. Form a committee to conduct research studies.
b.
c. Post published research studies onNthUeRuSnIN
itsGbTuBll.eCtO
inMboards.
d.
Encourage the nurses to visit the library to review studies.
ANS: D
Teach the nurses how to conduct electronic searches for research studies.
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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which
of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patients health state.
,d. Holistic health views the mind, body, and spirit as interdependent.
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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. The nurse recognizes that the concept of prevention in describing health is essential because:
a. Disease can be prevented by treating the external environment.
b. The majority of deaths among Americans under age 65 years are not preventable.
c. Prevention places the emphasis on the link between health and personal behavior.
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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
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:
a. Patients history of allergies.
b. Patients 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 patients 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.
, DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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?
a. A follow-up data base to evaluate changes at appropriate intervals
b. An episodic data base because of the continuing, complex medical problems of this patient
c. A complete health data base because of the nurses primary responsibility for monitoring the patients
health
d. An emergency data base because of the need to collect information and make accurate diagnoses
rapidly
ANS: C
The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic,
independent or group private practice, college health service, womens health care agency, visiting nurse
agency, or community health agency. In these settings, the nurse is the first health professional to see the
patient and has the primary responsibility for monitoring the persons health care.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
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 following day.
d. Patient in an outpatient clinic has cold and influenza-like symptoms.
ANS: D
In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the
completed data base. This mini data base 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
23. 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 data base and then check her blood pressure.
