NURSING HEALTH ASSESSMENT A MEDICAL CENTER AL
JUDGEMENT APPROACH 4TH EDITION JENSEN TEST
BANK/ALL CHAPTERS 1-30
,CH 1.The Medical caretaker’s Role in Health Assessment
1. After completing an initial assessment of a hospital patient, the professional 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.
ACCURATE ANS:-> A
Elaboration:->>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.
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. A hospital patient tells the professional 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.
ACCURATE ANS:-> C
Elaboration:->>Subjective data are what the person says about him or herself during history taking. Objectiv
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.
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The hospital 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.
ACCURATE ANS:-> A
,Elaboration:->>Together with the hospital patients record and laboratory studies, the objective
and subjective data form the data base. The other items are not part of the hospital patients
record, laboratory studies, or data.
DIFF: Cognitive Level: Remembering (Knowledge) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a hospital patients breath sounds, the professional nurse is unsure of a
sound that is heard. The Registered nurses next action should be to:
a. Immediately notify the hospital 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.
ACCURATE ANS:-> C
Elaboration:->>When unsure of a sound heard while listening to a hospital patients breath sounds, the
professional nurse validates the
data to ensure accuracy. If the professional nurse has less experience in an area, then he or she
asks an expert to listen.
DIFF: Cognitive Level: Analyzing (Analysis) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The professional nurse is conducting a class for new graduate medical caretakers. During
the teaching session, the professional nurse should keep in mind that novice medical
caretakers, 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.
ACCURATE ANS:-> B
Elaboration:->>Novice Registered nurses operate from a set of defined, structured rules. The expert
practitioner uses
intuitive links.
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm.
3 MSC: Client Needs: General
6. Expert Registered 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. Medical center al knowledge.
d. Diagnostic reasoning.
ACCURATE ANS:-> A
Elaboration:->>Intuition is characterized by pattern recognition expert Registered nurses learn to attend to a
pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: General
7. The professional 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 hospital patients.
c. EBP emphasizes the use of best evidence with the medical center ians experience.
d. The hospital patients own preferences are not important
with EBP.
ACCURATE ANS:-> C
Elaboration:->>EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination
with the medical center ians experience, as well as hospital patient preferences and values, when
making decisions about care and treatment. EBP is more than simply using the best practice
techniques to treat hospital patients, and questioning tradition is important when no compelling
and supportive research evidence exists.
DIFF: Cognitive Level: Applying (Application) REF: dm. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The professional nurse is conducting a class on priority setting for a group of new graduate medical
caretakers. Which
is an example of a first-level priority problem?
a. Hospital patient with postoperative pain
b. Newly diagnosed hospital 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
ACCURATE ANS:-> D
Elaboration:->>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).
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When considering priority setting of problems, the professional 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
ACCURATE ANS:-> C
Elaboration:->>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).
DIFF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the professional nurse see relationships among the data?
a. Validation
b. Clustering related cues
