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
,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.
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: Cognitive Level: Understanding (Comprehension) 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?
,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
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. hich critical thinking skill helps the nurse see relationships among the data?
W
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
1 0. 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
1 1. 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
1 2. 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 Effective Care Environment: Management of Care
1 3. 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
