physical examination and health assessment canadian 2nd edition jarvis test bank
physical examination and health assessment canadian 2nd edition
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Physical Examination and Health Assessment CANADIAN 2nd Edition Jarvis Test Bank
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Physical Examination and Health Assessment CANADIAN 2nd Edition Jarvis Test Bank
Physical Examination and Health Assessment CANADIAN 2nd Edition
Jarvis
Test Bank
Chapter 01: Critical Thinking and Evidence-Informed Assessment
Test Bank
MULTIPLE CHOICE
1. After completing an initial assessment on a patient, the nurse has charted that his respirations
are eupneic and his pulse is 58. This type of data would be:
a. objective.
b. reflective.
c. subjective.
d. introspective.
ANS: A
Objective data are what the health care provider observes by inspecting, percussing, palpating,
and auscultating during the physical examination.
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.”
This type of data would be:
a. objective.
b. reflective.
c. subjective.
d. introspective.
ANS: C
Subjective data are what the patient says about himself or herself during history taking.
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patient’s record, laboratory studies, objective data, and subjective data together form the:
a. database.
b. admitting data.
c. financial statement.
d. discharge summary.
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data
form the database.
DIF: Cognitive Level: Remembering (Knowledge) REF: Page: 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard.
The nurse should:
a. notify the patient’s physician immediately.
b. document the sound exactly as it was heard.
c. validate the data by asking a colleague to listen to the breath sounds.
d. assess again in 20 minutes to note whether the sound is still present.
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,Physical Examination and Health Assessment CANADIAN 2nd Edition Jarvis Test Bank
ANS: C
Validate any data when you need to ensure their accuracy. If you have less experience in an
area, ask an expert to listen to the sound.
DIF: Cognitive Level: Analyzing (Analysis) REF: Page: 3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. Novice nurses, without a background of skills and experience to draw from, 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 rules (such as the nursing process).
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labelling it. This is referred to as:
a. intuition.
b. the nursing process.
c. clinical knowledge.
d. diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognition; expert nurses learn to attend to a pattern of
assessment data and act without consciously labelling it.
7. Critical thinking in the expert nurse is greatly enhanced by opportunities to:
a. apply theory in real situations.
b. work with physicians to provide patient care.
c. follow physician orders in providing patient care.
d. develop nursing diagnoses for commonly occurring illnesses.
ANS: A
Critical thinking is the means by which nurses learn to assess and modify, if indicated, before
acting, and this happens in the clinical setting. The depth and breadth of expert knowledge,
largely gained from opportunities to apply theory in real situations, greatly enhances a nurse’s
critical thinking ability.
8. Which of the following is an example of a first-level priority problem?
a. A patient with postoperative pain
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, Physical Examination and Health Assessment CANADIAN 2nd Edition Jarvis Test Bank
b. A patient newly diagnosed with diabetes who needs teaching about diabetes
c. An individual with a small laceration on the sole of the foot
d. An individual with shortness of breath and respiratory distress
ANS: D
First-level priority problems are those that are emergent, are life-threatening, and require
immediate action (e.g., establishing airway, supporting breathing, maintaining circulation, and
monitoring vital signs).
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. Which of the following are considered second-level priority problems?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS: C
Second-level priority problems are those that require prompt intervention to prevent further
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, and risks to
safety or security).
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the nurse recognize relationships among data?
a. Validation
b. Clustering-related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
ANS: B
Clustering-related cues help the nurse recognize relationships among data.
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 5
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:
a. nursing diagnosis.
b. medical diagnosis.
c. admission diagnosis.
d. collaborative diagnosis.
ANS: A
An accurate nursing diagnosis provides the basis for selecting nursing interventions to achieve
outcomes for which the nurse is accountable.
DIF: Cognitive Level: Understanding (Comprehension) REF: Page: 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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, Physical Examination and Health Assessment CANADIAN 2nd Edition Jarvis Test Bank
12. Which six phases are included in the nursing process?
a. Assessment, treatment, client outcome, evaluation, discharge, follow-up
b. Admission, assessment, outcome identification, diagnosis, treatment, discharge
planning
c. Admission, diagnosis, expected outcome, treatment, evaluation, discharge
planning
d. Assessment, diagnosis, outcome identification, planning, implementation,
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) REF: Page: 3
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, sleep
b. Breathing, sleep, pain
c. Sleep, breathing, pain
d. Sleep, pain, breathing
ANS: A
First-level priority problems are immediate priorities (remember the ABCs), followed by
second-level problems, and then third-level problems.
DIF: Cognitive Level: AnalyzN ing R
U (ASnI
alysG
Nis)T REF: Page: 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. Which of the following 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.
15. A nursing diagnosis made by a critical thinker using a dynamic nursing process would
identify the actual problem and would also:
a. continue to reassess.
b. predict potential problems.
c. check the appropriateness of goals.
d. modify the diagnosis if necessary.
ANS: B
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