TEST BANK
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 9TH EDITION BY
CAROLYN JARVIS AND ANN L. ECKHARDT
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