Chapter k 01: k Evidence-Based k Assessment
MULTIPLE k CHOICE
1. After kcompleting kan kinitial kassessment kof ka kpatient, kthe knurse khas kcharted kthat khis krespirations kare
keupneic kand khis kpulse kis k58 kbeats kper kminute. kThese ktypes kof kdata kwould kbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: k A
Objective kdata kare kwhat kthe khealth kprofessional kobserves kby kinspecting, kpercussing, kpalpating, kand
kauscultating kduring kthe kphysical kexamination. kSubjective kdata kis kwhat kthe kperson ksays kabout khim
kor kherself kduring khistory ktaking. kThe kterms kreflective kand kintrospective kare knot kused kto kdescribe
kdata.
DIF: k Cognitive k Level: k Understanding k (Comprehension)
MSC: kClient k Needs: k Safe k and k Effective k Care k Environment: k Management k of k Care
2. A kpatient ktells kthe knurse kthat khe kis kvery kn e r v No uUsR, kSisIN
naGuTsB
ea.C
teOdM
, kand kfeels khot. kThese ktypes kof kdata
kwould kbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: k C
Subjective kdata kare kwhat kthe kperson ksays kabout khim kor kherself kduring khistory ktaking. kObjective kdata kare
kwhat kthe khealth kprofessional kobserves kby kinspecting, kpercussing, kpalpating, kand kauscultating kduring
kthe kphysical kexamination. kThe kterms kreflective kand kintrospective kare knot kused kto kdescribe kdata.
DIF: k Cognitive k Level: k Understanding k (Comprehension)
MSC: kClient k Needs: k Safe k and k Effective k Care k Environment: k Management k of k Care
3. The kpatients k record, k laboratory k studies, k objective k data, k and k subjective k data k combine k to k form k the:
DIF: k Cognitive k Level: k Remembering k (Knowledge)
MSC: kClient k Needs: k Safe k and k Effective k Care k Environment: k Management k of k Care
4. When klistening kto ka kpatients kbreath ksounds, kthe knurse kis kunsure kof ka ksound kthat kis kheard. kThe
knurses knext kaction kshould kbe kto:
a. Immediately k notify k the k patients k physician.
b. Document k the k sound k exactly k as k it k was k heard.
c. Validate kthe kdata k by kasking k a k coworker kto klisten kto kthe k breath ksounds.
d. Assess k again kin k20 k minutes kto knote kwhether k the k sound kis k still kpresent.
NURSINGTB.COM
ANS: k C
When kunsure kof ka ksound kheard kwhile klistening kto ka kpatients kbreath ksounds, kthe knurse kvalidates kthe
kdata kto kensure kaccuracy. kIf kthe knurse khas kless kexperience kin kan karea, kthen khe kor kshe kasks kan
kexpert kto klisten.
DIF: k Cognitive k Level: k Analyzing k (Analysis)
MSC: kClient k Needs: k Safe k and k Effective k Care k Environment: k Management k of k Care
5. The knurse kis kconducting ka kclass kfor knew kgraduate knurses. kDuring kthe kteaching ksession, kthe knurse
kshould kkeep kin k mind kthat knovice knurses, k without k a kbackground k of kskills k and kexperience k from
kwhich kto kdraw, k are k more klikely kto kmake ktheir kdecisions kusing:
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