Chapter 01: Evidence-Based Assessment
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are 18 bre
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 ausc
examination. Subjective data are what the person says about himself or herself during history taking. T
introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
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 woul
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data are what the person says about himself or herself during history taking. Objective data
professional observes by inspecting, percussing, palpating, and auscultating during the physical examin
and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
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. Database
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 da
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
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s ne
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
nurse has less experience in an area, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
, 6. Expert nurses assess and make decisions through the use of:
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANS: A
Critical thinking is a multidimensional, dynamic, and interactive thinking process by which expert nurs
decisions in the clinical area.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
7. The nurse is reviewing information about evidence-informed practice (EIP). Which statement best refl
a. EIP relies on tradition for support of best practices.
b. EIP is simply the use of best practice techniques for the treatment of patients.
c. EIP emphasizes the use of best and most appropriate evidence with clinician
expertise and patient preference.
d. The patient’s own preferences are not important in EIP.
ANS: C
EIP is a problem-solving approach to decision making that emphasizes the use of best available eviden
clinician’s experience, patient preferences and values, and comprehensive assessment to determine the
treatment. EIP is more than simply using the best practice techniques to treat patients, and questioning
no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an exa
problem?
a. Patient with postoperative pain
b. Patient newly diagnosed with diabetes needing 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., establish
breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. 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 data from irrelevant data
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropria
diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are 18 bre
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 ausc
examination. Subjective data are what the person says about himself or herself during history taking. T
introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
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 woul
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data are what the person says about himself or herself during history taking. Objective data
professional observes by inspecting, percussing, palpating, and auscultating during the physical examin
and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
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. Database
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 da
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
4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s ne
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
nurse has less experience in an area, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
, 6. Expert nurses assess and make decisions through the use of:
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANS: A
Critical thinking is a multidimensional, dynamic, and interactive thinking process by which expert nurs
decisions in the clinical area.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
7. The nurse is reviewing information about evidence-informed practice (EIP). Which statement best refl
a. EIP relies on tradition for support of best practices.
b. EIP is simply the use of best practice techniques for the treatment of patients.
c. EIP emphasizes the use of best and most appropriate evidence with clinician
expertise and patient preference.
d. The patient’s own preferences are not important in EIP.
ANS: C
EIP is a problem-solving approach to decision making that emphasizes the use of best available eviden
clinician’s experience, patient preferences and values, and comprehensive assessment to determine the
treatment. EIP is more than simply using the best practice techniques to treat patients, and questioning
no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an exa
problem?
a. Patient with postoperative pain
b. Patient newly diagnosed with diabetes needing 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., establish
breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. 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 data from irrelevant data
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropria
diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
