Exam (elaborations)

Test Bank - Bates Guide To Physical Examination and History Taking, 13th Edition (Bickley, 2021), Chapter 1-20 | All Chapters with Questions and Answers

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msc client needs health promotion and maintenanc
after completing an initial assessment of a patien
a patient tells the nurse that he is very nervous
the patients record laboratory studies objective
w

Institution Bates, 13e
Course Bates, 13e

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Test Bank - Bates Guide To Physical Examination and History
Taking, 13th Edition (Bickley, 2021), Chapter 1-20 | All Chapters
with Questions and Answers
REF: p. 741

MSC: Client Needs: Health Promotion and Maintenance

13. A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts
and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she
started 3 months earlier. The nurse should tell her:

a HRT is at such a low dose that side effects are very unusual.

b HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding.

c Vaginal bleeding - Correct AnswerANS: B

Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other responses are
not correct.

CHAPTER 1 Foundations for Clinical Proficiency

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. - Correct AnswerANS: 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.

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. - Correct AnswerANS: 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 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. - Correct AnswerANS: 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.

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. - Correct AnswerANS: 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.

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. - Correct AnswerANS: 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:

a Intuition.

b The nursing process.

c Clinical knowledge.

d Diagnostic reasoning. - Correct AnswerANS: 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?

a EBP relies on tradition for support of best practices.

b EBP is simply the use of best practice techniques for the treatment of patients.

c EBP emphasizes the use of best evidence with the clinicians experience.

d The patients own preferences are not important with EBP. - Correct AnswerANS: 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.

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 - Correct AnswerANS: 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

b Lack of knowledge

c Abnormal laboratory values

d Severely abnormal vital signs - Correct AnswerANS: 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?

a Validation

b Clustering related cues

c Identifying gaps in data

d Distinguishing relevant from irrelevant - Correct AnswerANS: 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.

a Nursing

b Medical

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