Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis, Ann Eckhardt Test Bank
Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis,
Ann Eckhardt Full Test Bank
Chapter 01: Evidence-Based Assessment
Jarvis: Physical Examination and Health Assessment, 9th Edition
MULTIPLE CHOICE
- 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. What
type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: A
Objective data is 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - A patient tells the nurse that he is very nervous, nauseous, and “feels hot.” What type of assessment
data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data is what the person says about him or herself during history taking. Objective data is
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 - What do the patient’s record, laboratory studies, objective data, and subjective data combine to form?
a. Database
b. Admitting data
c. Financial statement
d. Discharge summary
ANS: A
The objective and subjective data together with the patient’s record and laboratory studies, 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
- When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. Which action
would the nurse take next?
a. Notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse 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 by either repeating the assessment themselves or asking another nurse to assess the
breath sounds. If the nurse has less experience analyzing breath sounds, then he or she should ask an
expert to listen. When unsure of a sound heard while listening to a patient’s breath sounds, the nurse
should validate the data before documenting to ensure accuracy and before notifying the patient’s
physician. To validate that data, the nurse either repeats the assessment himself or herself or asks
another nurse to assess the breath sounds.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - The nurse is conducting a class for new graduate nurses. While teaching the class, what would the
nurse keep in mind regarding what novice nurses, without a background of skills and experience from
which to draw upon, are more likely to base their decisions on?
a. Intuition
b. A set of rules
c. Articles in journals
d. Advice from supervisors
ANS: B
Novice nurses operate from a set of defined, structured rules to make decisions. It takes time, perhaps a
few years, in similar clinical situations to achieve competency and it is functioning at the level of an
expert practitioner when intuition is included in making clinical decisions. While information in
journal articles and advice from supervisors may assist in making decisions, novice nurses do not
typically base their decisions on them. It would also be important that if information from journal
articles and advice from supervisors were used, that they were evidence based.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General - The 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 patients.
c. EBP emphasizes the use of best evidence with the clinician’s experience.
d. EBP does not consider the patient’s own preferences as important.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of research evidence in combination
with the clinician’s expertise and clinical knowledge (physical assessment), as well as patient values
and preferences, when making decisions about care and treatment. EBP 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: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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. Newly diagnosed 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
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). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes, and a small
laceration on sole of the foot are not considered first-level priority problems.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - When considering priority setting of problems, the 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
ANS: C
Abnormal laboratory values are a second-level priority problem. 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). Low self-esteem and lack of
knowledge are considered third-level priority as although they are important to a patient’s health, they
can be addressed after more urgent health problems are addressed. Severely abnormal vital signs
would be considered a first-level priority problem.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - Which critical-thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
ANS: B
Clustering related cues involves clustering, or grouping together, assessment data that appear to be
associated, or related, and helps the nurse see relationships among the data. Identifying gaps is looking
for missing information and validation involves ensuring accuracy, and distinguishing relevant and
irrelevant data involves identifying data the fit, or support the problem, but none of those help the
nurse to see relationships.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 planning, implementation, and evaluation
ANS: D
The nursing process is a method of problem solving that includes assessment, diagnosis, planning,
implementation, and evaluation.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - 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, remembering the ABCs (airway, breathing, and
circulation), followed by second-level problems (e.g., mental status change, acute pain, acute urinary
elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or
risk to safety or security), and then third-level problems (those that are important to the patient’s health
but can be attended to after more urgent health problems are addressed).
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care - Which is a barrier to incorporating EBP?
a. Nurses’ lack of research skills in evaluating the quality of research studies
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills
ANS: A
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