Health & Well-Being Assessment 1st Edition Test Bank
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Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND WELL-
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BEING
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MULTIPLE CHOICE ty
1. After completing an initial assessment of a patient, the nurse has charted that his
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respirations are eupneic and his pulse is 58 beats per minute. These types of data would
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be:
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a Objective.
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b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: A ty
Objective data are what the health professional observes by inspecting, percussing, palpating,
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and auscultating during the physical examination. Subjective data is what the person says
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about him or herself during history taking. The terms reflective and introspective are not
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used to describe data.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
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of data would be:
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a Objective.
.
b Reflective.
.
c Subjective.
.
d Introspective.
.
ANS: C ty
Subjective data are what the person says about him or herself during history taking. Objective
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,data are what the health professional observes by inspecting, percussing, palpating, and
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auscultating during the physical examination. The terms reflective and introspective are not
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used to describe data.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to
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form the:
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a Data base. ty
.
b Admitting data. ty
.
c Financial statement. ty
.
d Discharge summary. ty
.
ANS: A ty
Together with the patients record and laboratory studies, the objective and subjective data
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form the data base. The other items are not part of the patients record, laboratory studies, or
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data.
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DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
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The nurses next action should be to:
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a Immediately notify the patients physician. ty ty ty ty
.
b Document the sound exactly as it was heard. ty ty ty ty ty ty ty
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c Validate the data by asking a coworker to listen to the breath sounds.
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d Assess again in 20 minutes to note whether the sound is still present.
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.
ANS: C ty
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates
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the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks
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an expert to listen.
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, DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session,
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the nurse should keep in mind that novice nurses, without a background of skills and
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experience from which to draw, are more likely to make their decisions using:
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a Intuition.
.
b A set of rules.
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.
c Articles in journals. ty ty
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d Advice from supervisors. ty ty
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ANS: B ty
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
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intuitive links.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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3 MSC: Client Needs: General
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6. Expert nurses learn to attend to a pattern of assessment data and act without
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consciously labeling it. These responses are referred to as:
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a Intuition.
.
b The nursing process.
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.
c Clinical knowledge. ty
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d Diagnostic reasoning. ty
.
ANS: A ty
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
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assessment data and act without consciously labeling it. The other options are not correct.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z.
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4 MSC: Client Needs: General
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7. The nurse is reviewing information about evidence-based practice (EBP). Which
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statement best reflects EBP?
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