Chapter 01: Evidence-Based Assessment
Jarvis: Physical Examination and Health Assessment, 8th Edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupne
per minute. What type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: A
Objective data is what the health professional observes by inspecting, percussing, palpating, and auscu
examination. Subjective data is what the person says about him or herself during history taking. The te
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, nauseous, and “feels hot.” What type of assessment da
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data is what the person says about him or herself during history taking. Objective data is wh
observes by inspecting, percussing, palpating, and auscultating during the physical examination. The te
introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. What do the patient’s record, laboratory studies, objective data, and subjective data combine to form?
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. Which action s
a. Notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse 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
repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse ha
breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listen
sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying
validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to ass
, 6. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflect
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. EBP does not consider the patient’s own preferences as important.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of research evidence in combination w
and clinical knowledge (physical assessment), as well as patient values and preferences, when making
treatment. EBP 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
7. 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. Newly diagnosed patient with diabetes who needs 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). Postoperative pain, diabetic teach
diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. When considering priority setting of problems, the nurse keeps in mind that second-level priority probl
aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS: C
Abnormal laboratory values are a second-level priority problem. Second-level priority problems are tho
intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laborator
security). Low self-esteem and lack of knowledge are considered third-level priority as although they a
health, they can be addressed after more urgent health problems are addressed. Severely abnormal vita
first-level priority problem.
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 from irrelevant
ANS: B
Clustering related cues involves clustering, or grouping together, assessment data that appear to be asso
the nurse see relationships among the data. Identifying gaps is looking for missing information and val
accuracy, and distinguishing relevant and irrelevant data involves identifying data the fit, or support th
help the nurse to see relationships.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
Jarvis: Physical Examination and Health Assessment, 8th Edition
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupne
per minute. What type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: A
Objective data is what the health professional observes by inspecting, percussing, palpating, and auscu
examination. Subjective data is what the person says about him or herself during history taking. The te
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, nauseous, and “feels hot.” What type of assessment da
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data is what the person says about him or herself during history taking. Objective data is wh
observes by inspecting, percussing, palpating, and auscultating during the physical examination. The te
introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. What do the patient’s record, laboratory studies, objective data, and subjective data combine to form?
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. Which action s
a. Notify the patient’s physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse 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
repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse ha
breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listen
sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying
validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to ass
, 6. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflect
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. EBP does not consider the patient’s own preferences as important.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of research evidence in combination w
and clinical knowledge (physical assessment), as well as patient values and preferences, when making
treatment. EBP 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
7. 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. Newly diagnosed patient with diabetes who needs 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). Postoperative pain, diabetic teach
diagnosed with diabetes, and a small laceration on sole of the foot are not considered first-level priority
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. When considering priority setting of problems, the nurse keeps in mind that second-level priority probl
aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS: C
Abnormal laboratory values are a second-level priority problem. Second-level priority problems are tho
intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laborator
security). Low self-esteem and lack of knowledge are considered third-level priority as although they a
health, they can be addressed after more urgent health problems are addressed. Severely abnormal vita
first-level priority problem.
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 from irrelevant
ANS: B
Clustering related cues involves clustering, or grouping together, assessment data that appear to be asso
the nurse see relationships among the data. Identifying gaps is looking for missing information and val
accuracy, and distinguishing relevant and irrelevant data involves identifying data the fit, or support th
help the nurse to see relationships.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
