Test Bank for Nursing Health Assessment: A
Clinical Judgment Approach 4th Edition Jensen |
All Chapters (1–30)| 100% Pass
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 - ANSWER-a. Objective
Rationale: 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.
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 - ANSWER-c. Subjective
,Rationale: 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.
When listening to a patients breath sounds, the nurse is unsure of a
sound that is heard. The nurses next action should be to:
a. Immediately notify the 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 -
ANSWER-c. Validate the data by asking a coworker to listen to the
breath sounds
Rationale: When unsure of a sound heard while listening to a patients
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.
The 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 - ANSWER-a. Data base
Rationale: Together with the patients record and laboratory studies, the
objective and subjective data form the data base. The other items are not
part of the patients record, laboratory studies, or data.
,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 - ANSWER-d. Assessment, diagnosis,
outcome identification, planning, implementation, and evaluation
Rationale: The nursing process is a method of problem solving that
includes assessment, diagnosis, outcome identification, planning,
implementation, and evaluation.
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 - ANSWER-a. Nurses lack of
research skills in evaluating the quality of research studies
Rationale: 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.
, The nurse is reviewing data collected after an assessment. Of the data
listed below, which would be considered related cues that would be
clustered together during data analysis? Select all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - ANSWER-a. Inspiratory
wheezes noted in left lower lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
Rationale: Clustering related cues help the nurse recognize relationships
among the data. The cues related to the patients respiratory status (e.g.,
wheezes, cough, report of dyspnea, respiration rate and rhythm) are all
related. Cues related to bowels and peripheral edema are not related to
the respiratory cues.
The nurse is conducting an interview. Which of these statements is true
regarding open-ended questions? Select all that apply.
a. Open-ended questions elicit cold facts
b. They allow for self-expression
c. Open-ended questions build and enhance rapport
Clinical Judgment Approach 4th Edition Jensen |
All Chapters (1–30)| 100% Pass
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 - ANSWER-a. Objective
Rationale: 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.
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 - ANSWER-c. Subjective
,Rationale: 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.
When listening to a patients breath sounds, the nurse is unsure of a
sound that is heard. The nurses next action should be to:
a. Immediately notify the 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 -
ANSWER-c. Validate the data by asking a coworker to listen to the
breath sounds
Rationale: When unsure of a sound heard while listening to a patients
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.
The 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 - ANSWER-a. Data base
Rationale: Together with the patients record and laboratory studies, the
objective and subjective data form the data base. The other items are not
part of the patients record, laboratory studies, or data.
,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 - ANSWER-d. Assessment, diagnosis,
outcome identification, planning, implementation, and evaluation
Rationale: The nursing process is a method of problem solving that
includes assessment, diagnosis, outcome identification, planning,
implementation, and evaluation.
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 - ANSWER-a. Nurses lack of
research skills in evaluating the quality of research studies
Rationale: 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.
, The nurse is reviewing data collected after an assessment. Of the data
listed below, which would be considered related cues that would be
clustered together during data analysis? Select all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - ANSWER-a. Inspiratory
wheezes noted in left lower lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
Rationale: Clustering related cues help the nurse recognize relationships
among the data. The cues related to the patients respiratory status (e.g.,
wheezes, cough, report of dyspnea, respiration rate and rhythm) are all
related. Cues related to bowels and peripheral edema are not related to
the respiratory cues.
The nurse is conducting an interview. Which of these statements is true
regarding open-ended questions? Select all that apply.
a. Open-ended questions elicit cold facts
b. They allow for self-expression
c. Open-ended questions build and enhance rapport
