Canadian Physical Examination and Health Assessment 4th Edition Test Bank by Jarvis | All Chapters 1-31 | ULTIMATE GUIDE A+.

Canadian Physical Examination and Health Assessment 4th Edition Test Bank by Jarvis | All Chapters 1-31 | ULTIMATE GUIDE A+. Chapter 01: Critical Thinking and Evidence-Informed Assessment Jarvis: Physical Examination and Health Assessment, 4th Edition MULTIPLE CHOICE 1. Which type of data is collected by obtaining vital signs? a. Objective b. Reflecting c. Subjective d. Introspective ANSWER: A Objective data are what the nurse observes by inspecting, percussing, palpating,and auscultating during the physical examination. Subjective data are what the person says about themselves during history taking. The terms reflective and introspective are not used to describe data. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. During an assessment, a patient describes feeling warm, nauseated, and nervous. Which type of data is collected? a. Objective b. Reflective c. Subjective d. Introspective ANSWER: C Subjective data are what the person says about themselves during history taking. Objective data are what the nurse observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are notused to describe data. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. Which part of a patient’s health record is created when combining laboratory studies, objective data, and subjective data? a. Database b. Admitting data c. Triage form d. Discharge summary ANSWER: A Together with the patient’s record and laboratory studies, the objective and subjective data form the database. The other items are not part of the patient’s record, laboratory studies, or data. DIFFICULTY: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. Which action will the nurse complete if while listening to a patient’s breath sounds, they are not sure of a sound heard? a. Immediately notify the patient’s most responsible practitioner. 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 When not sure 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 they would ask an expert to listen. DIFFICULTY: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. Which approach do novice caregivers utilize when making decisions? a. Intuition b. Clear-cut rules c. Articles in journals d. Advice from supervisors ANSWER: B Novice caregivers operate from a set of defined, structured rules. Expert practitioners use criticalthinking and their substantial background of experience. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 6. Which method moves a nurse from novice to expert? a. Critical thinking b. The nursing process c. Clinical knowledge d. Diagnostic reasoning ANSWER: A Critical thinking is a multidimensional, dynamic, and interactive thinking process by which expert caregivers assess and make decisions in the clinical area. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 7. Which statement reflects the meaning of evidence-informed practice (EIP)? a. Best practice techniques to treat patients. Taking note solely from Registered Caregivers Association of Ontario (RNAO) b. Clinician experience and expertise to guide practice. Sometimes reflecting on the patient perspective c. Life-long problem-solving approach to clinical decision making using best available evidence d. The patient’s own preferences are not important in EIP ANSWER: C EIP is more than the use of best practice techniques to treat patients; it can be defined as a paradigm and lifelong problem-solving approach to clinical decision making that involves the conscientious use of the best available evidence (including a systematic search for and critical appraisal of the most relevant evidence to answer a clinical question) with one’s own clinical expertise and patient values and preferences to improve outcomes for individuals, groups, communities, and systems. EIP 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. DIFFICULTY: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. Which critical thinking skill recognizes relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant data from irrelevant data ANSWER: B Clustering related cues helps the nurse see relationships among the data. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. Which diagnosis is critical to develop appropriate nursing interventions for a patient? a. Nursing b. Medical c. Admission d. Collaborative ANSWER: 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. DIFFICULTY: Cognitive Level: Remembering MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. Which steps are included in the nursing process? 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 The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIFFICULTY: Cognitive Level: Remembering MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. A newly admitted patient is in acute pain, not sleeping well, and is having difficulty breathing. In which sequence will the nurse prioritize the assessment? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing ANSWER: A First-level priority problems are immediate priorities focused on airway and breathing, followed by second-level problems, and then third-level problems. DIFFICULTY: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. Which example illustrates a first-level priority problem? a. Postoperative pain b. Newly diagnosed diabetes needing diabetic teaching c. Small laceration on the sole of the foot d. Shortness of breath and respiratory distress ANSWER: 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) (see Table 1.1 – Identifying Immediate Priorities). DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. Which step of the nursing process involves data collection through health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment ANSWER: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1.2). DIFFICULTY: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 14. Which concept is considered when undertaking a life-cycle approach to health assessment? a. Consideration of the patient’s cultural view of health b. Being responsive to the patient’s gestures to build a relationship c. Acknowledgement of the effect of poverty on health d. Awareness of age-specific developmental factors ANSWER: D A life-cycle approach requires familiarity with the usual and expected developmental tasks for various age groups. Being aware of age-specific data can be helpful in determining normal and abnormal findings. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 15. Which statement outlines the purpose for a nurse identifying priorities and assessing risk factors in patients? a. Identify patterns to discover missing information. b. Determine areas for health promotion and disease prevention. c. Distinguish normal from abnormal findings. d. Determine treatment for a medical diagnosis. ANSWER: B Identifying and working with patients to manage known risk factors for their age group and social context supports disease prevention and health promotion. DIFFICULTY: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 16. Which information is an example of objective data? a. Patient’s history of allergies b. Patient’s use of medications at home c. Last menstrual period 1 month ago d. 2.5 cm scar on the right lower forearm ANSWER: D Objective data are the patient’s record, laboratory studies, and condition that the nurse observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data. DIFFICULTY: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 17. A patient is at the clinic to have their blood pressure checked. They have been coming to the clinic weekly since changing medications two months ago. Which action will the nurse perform? a. Collect a follow-up database and then check blood pressure. b. Ask patient to read health record and indicate any changes since last visit. c. Check only blood pressure because the complete health history was documented two months ago. d. Obtain a complete health history before checking blood pressure because much of the history information may have changed. ANSWER: A A follow-up database is used in all settings to monitor short-term or chronic health problems. The other responses are not appropriate for the situation. DIFFICULTY: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 20. Which method will the nurse take to collect data for a patient brought to the emergency department by ambulance with multiple injuries after an automobile accident? The patient is alert, cooperative, with severe injuries. a. Collect history information first and 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. ANSWER: B The emergency database calls for a rapid collection of the database, and often data are compiled concurrently with administration of life-saving measures. The other responses are not appropriate for the situation. DIFFICULTY: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 21. Which example illustrates the new national and provincial guidelines developed for particular populations? a. Pain assessments b. Human papillomavirus (HPV) vaccine guidelines c. Antipsychotic medications d. Acute urinary elimination treatments ANSWER: B