12 chapter 01 evidence based assessment jarvis physical examination amp health assessment
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NURSING
CH 1 , 2, 3, 4, 5, 8, 9, 10, 11, 12
Chapter 01: Evidence-Based Assessment
Jarvis: Physical Examination & Health Assessment, 7th Edition
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) REF: p. 2
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) REF: p. 2
,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) REF: p. 2
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) REF: p. 2
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.
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