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Chapter 1 evidence-based assessment Jarvis physical examination & health assessment

chapter 1 evidence-based assessment practices for health assessment

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Health Assessment Through The Lifespan (NURS 622)

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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 patient’s 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 patient’s record and laboratory studies, the objective and subjective data

form the data base. The other items are not part of the patient’s 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 patient’s breath sounds, the nurse is unsure of a sound that is heard. The

nurse’s next action should be to:

a. Immediately notify the patient’s 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 patient’s 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.

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. The expert practitioner uses

intuitive links.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: General

6. Expert 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. Clinical knowledge.

d. Diagnostic reasoning.

ANS: A

Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of

assessment data and act without consciously labeling it. The other options are not correct.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: General

7. 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. The patient’s own preferences are not important with EBP.

11. The nurse knows that developing appropriate nursing interventions for a patient relies on the

appropriateness of the __________ diagnosis.

a. Nursing

b. Medical

c. Admission

d. Collaborative

ANS: A

An accurate nursing diagnosis provides the basis for the selection of nursing interventions to

achieve outcomes for which the nurse is accountable. The other items do not contribute to the

development of appropriate nursing interventions.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. 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 identification, planning, implementation, and

evaluation

ANS: D

The nursing process is a method of problem solving that includes assessment, diagnosis,

outcome identification, planning, implementation, and evaluation.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

13. 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, and then third-level problems.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

14. Which of these would be formulated by a nurse using diagnostic reasoning?

a. Nursing diagnosis

b. Medical diagnosis

c. Diagnostic hypothesis

d. Diagnostic assessment

ANS: C

Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing

process calls for a nursing diagnosis.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: General

15. Barriers to incorporating EBP include:

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

As individuals, nurses lack research skills in evaluating the quality of research studies, are

isolated from other colleagues who are knowledgeable in research, and often lack the time to

visit the library to read research. The other responses are not considered barriers.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: General

16. What step of the nursing process includes data collection by health history, physical

examination, and interview?

a. Planning

b. Diagnosis

c. Evaluation

d. Assessment

ANS: D

Data collection, including performing the health history, physical examination, and interview,

is the assessment step of the nursing process (see Figure 1-2).

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: General

17. During a staff meeting, nurses discuss the problems with accessing research studies to

incorporate evidence-based clinical decision making into their practice. Which suggestion by

the nurse manager would best help these problems?

a. Form a committee to conduct research studies.

b. Post published research studies on the unit’s bulletin boards.

c. Encourage the nurses to visit the library to review studies.

d. Teach the nurses how to conduct electronic searches for research studies.

ANS: D

Facilitating support for EBP would include teaching the nurses how to conduct electronic

searches; time to visit the library may not be available for many nurses. Actually conducting

research studies may be helpful in the long-run but not an immediate solution to reviewing

existing research.

DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

c. A complete health data base because of the nurse’s primary responsibility for

monitoring the patient’s health

d. An emergency data base because of the need to collect information and make

accurate diagnoses rapidly

ANS: C

The complete data base is collected in a primary care setting, such as a pediatric or family

practice clinic, independent or group private practice, college health service, women’s health

care agency, visiting nurse agency, or community health agency. In these settings, the nurse is

the first health professional to see the patient and has the primary responsibility for

monitoring the person’s health care.

DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

22. Which situation is most appropriate during which the nurse performs a focused or

problem-centered history?

a. Patient is admitted to a long-term care facility.

b. Patient has a sudden and severe shortness of breath.

c. Patient is admitted to the hospital for surgery the following day.

d. Patient in an outpatient clinic has cold and influenza-like symptoms.

ANS: D

In a focused or problem-centered data base, the nurse collects a “mini” data base, which is

smaller in scope than the completed data base. This mini data base primarily concerns one

problem, one cue complex, or one body system.

DIF: Cognitive Level: Applying (Application) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic

weekly since she changed medications 2 months ago. The nurse should:

a. Collect a follow-up data base and then check her blood pressure.

b. Ask her to read her health record and indicate any changes since her last visit.

c. Check only her blood pressure because her complete health history was

documented 2 months ago.

d. Obtain a complete health history before checking her blood pressure because much

of her history information may have changed.

ANS: A

A follow-up data base is used in all settings to follow up short-term or chronic health

problems. The other responses are not appropriate for the situation.

DIF: Cognitive Level: Applying (Application) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

24. A patient is brought by ambulance to the emergency department with multiple traumas

received in an automobile accident. He is alert and cooperative, but his injuries are quite

severe. How would the nurse proceed with data collection?

a. Collect history information first, then perform the physical examination and

institute life-saving measures.

b. Simultaneously ask history questions while performing the examination and

initiating life-saving measures.

c. Collect all information on the history form, including social support patterns,

strengths, and coping patterns.

d. Perform life-saving measures and delay asking any history questions until the

patient is transferred to the intensive care unit.

ANS: B

The emergency data base calls for a rapid collection of the data base, often concurrently

compiled with life-saving measures. The other responses are not appropriate for the situation.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination.

The nurse knows that including cultural information in his health assessment is important to:

a. Identify the cause of his illness.

b. Make accurate disease diagnoses.

c. Provide cultural health rights for the individual.

d. Provide culturally sensitive and appropriate care.

ANS: D

The inclusion of cultural considerations in the health assessment is of paramount importance

to gathering data that are accurate and meaningful and to intervening with culturally sensitive

and appropriate care.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 8 MSC: Client Needs: Psychosocial Integrity

26. In the health promotion model, the focus of the health professional includes:

a. Changing the patient’s perceptions of disease.

b. Identifying biomedical model interventions.

c. Identifying negative health acts of the consumer.

d. Helping the consumer choose a healthier lifestyle.

ANS: D

In the health promotion model, the focus of the health professional is on helping the consumer

choose a healthier lifestyle.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 8 MSC: Client Needs: Health Promotion and Maintenance

27. The nurse has implemented several planned interventions to address the nursing diagnosis of

acute pain. Which would be the next appropriate action?

a. Establish priorities.

b. Identify expected outcomes.

c. Evaluate the individual’s condition, and compare actual outcomes with expected

outcomes.

d. Interpret data, and then identify clusters of cues and make inferences.

ANS: C

check his own blood glucose levels with a glucometer.

b. A teenager who was stung by a bee during a soccer match is having trouble

breathing.

c. An older adult with a urinary tract infection is also showing signs of confusion and

agitation.

1. a = First -level priority problem

2. b = Second -level priority problem

3. c = Third-level priority problem

ANS: B DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway, breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e., patient education) are important to a patient’s health but can be addressed after more urgent health problems are addressed (see Table 1 -1).
ANS: C DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway, breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e., patient education) are important to a patient’s health but can be addressed after more urgent health problems are addressed (see Table 1 -1).
ANS: A DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the “airway, breathing, circulation” priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e., patient education) are important to a patient’s health but can be addressed after more urgent health problems are addressed (see Table 1-1).

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