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TEST BANK
Physical Examination and Health Assessment
4th Canadian Edition (Jarvis, 2024)
All Chapters 1 - 31
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TABLE OF CONTENTS
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Chapter 1;
Critical Thinking and Evidence-Informed Assessment
MULTIPLE CHOICE
1. Which type of data is collected by obtaining vital signs?
a. Objective
b. Reflecting
c. Subjective
d. Introspective
ANSWER: a
Objective data are what the health professional observesby
inspecting, percussing, palpating, and auscultating during the
physical examination. Subjective data are what the person says
about themselves during history taking. The terms reflective and
introspective are not used to describe data.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
2.During an assessment, a patient describes feeling warm,
nauseated, and nervous. Which type of data iscollected?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANSWER: c
Subjective data are what the person says about themselves during
history taking. Objective data are whatthe health professional
observes by inspecting, percussing, palpating, and auscultating
during the physical examination. The terms reflective and
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introspective are not used to describe data.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of
Care
3.Which part of a patient's health record is created when
combining laboratory studies, objective data, and subjective data?
a. Database
b. Admitting data
c. Triage form
d. Discharge summary
ANSWER: 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, laboratorystudies, or data.
PTS: 1
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
4.Which action will the nurse complete if while listeningto a
patient's breath sounds, they are unsure of a sound heard?
a. Immediately notify the patient's most responsible
practitioner.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker to listen to thebreath
sounds.
d. Assess again in 20 minutes to note whether the soundis still
present.
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ANSWER: c
When unsure of a sound heard while listening to a patient's breath
sounds, the nurse validates the data toensure accuracy. If the nurse
has less experience in an area, then they would ask an expert to
listen.
PTS: 1
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
5.Which approach do novice nurses utilize when making
decisions?
a. Intuition
b. Clear-cut rules
c. Articles in journals
d. Advice from supervisors
ANSWER: b
Novice nurses operate from a set of defined, structured rules.
Expert practitioners use critical thinking and their substantial
background of experience.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs:
General
6. Which method moves a nurse from novice to expert?
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANSWER: a
Critical thinking is a multidimensional, dynamic, andinteractive
thinking process by which expert nurses assess and make decisions
in the clinical area.
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PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs:
General
7. Which statement reflects the meaning of evidence-
informed practice (EIP)?
a. Best practice techniques to treat patients. Taking notesolely
from Registered Nurses Association of Ontario (RNAO)
b. Clinician experience and expertise to guide practice.
Sometimes reflecting on the patient perspective
c. Life-long problem-solving approach to clinical decisionmaking
using best available evidence
d. The patient's own preferences are not important in EIP
ANSWER: c
EIP is more than the use of best practice techniques to treat
patients; it can be defined as a paradigm and lifelong problem-
solving approach to clinical decision making that involves the
conscientious use of the best available evidence (including a
systematic search for andcritical appraisal of the most relevant
evidence to answera clinical question) with one's own clinical
expertise and patient values and preferences to improve outcomes
for individuals, groups, communities, and systems. 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.
PTS: 1
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
8. Which example illustrates a first-level priority problem?
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a. Postoperative pain
b. Newly diagnosed diabetes needing diabetic teaching
c. Small laceration on the sole of the foot
d. Shortness of breath and respiratory distress
ANSWER: 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 – Identifying Immediate Priorities).
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
9.Which critical thinking skill recognizes relationshipsamong
the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant data from irrelevant data
ANSWER: b
Clustering related cues helps the nurse see relationshipsamong the
data.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
10. Which diagnosis is critical to develop appropriatenursing
interventions for a patient?
a. Nursing
b. Medical
c. Admission
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d. Collaborative
ANSWER: a
An accurate nursing diagnosis provides the basis for the selection of
nursing interventions to achieve outcomes forwhich the nurse is
accountable. The other items do not contribute to the development
of appropriate nursing interventions.
PTS: 1
DIF: Cognitive Level: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
11. Which steps are included in the nursing process?
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
ANSWER: d
The nursing process is a method of problem solving thatincludes
assessment, diagnosis, outcome identification, planning,
implementation, and evaluation.
PTS: 1
DIF: Cognitive Level: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
12. A newly admitted patient is in acute pain, not sleeping well, and
is having difficulty breathing. In which sequencewill the nurse
prioritize the assessment?
a. Breathing, pain, and sleep
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b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
ANSWER: a
First-level priority problems are immediate priorities focused on
airway and breathing, followed by second-level problems, and then
third-level problems.
PTS: 1
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
13.Which step of the nursing process involves data collection
through health history, physical examination,and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
ANSWER: d
Data collection, including performing the health history, physical
examination, and interview, is the assessment step of the nursing
process (see Figure 1.2).
PTS: 1
DIF: Cognitive Level: Remembering (Knowledge)MSC: Client Needs:
General
14.Which concept is considered 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
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ANSWER: 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 indetermining normal and abnormal
findings.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management ofCare
15.Which statement outlines the purpose for a nurse
identifying priorities and assessing risk factors in patients?
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.
ANSWER: b
Identifying and working with patients to manage knownrisk
factors for their age group and social context supports disease
prevention and health promotion.
PTS: 1
DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs:
General
16. Which information is an example of objective data?
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
ANSWER: d
Objective data are the patient's record, laboratory
