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JARVIS-PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8ED TESTBANK

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For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. ANS: A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. TO GET MORE MATERIALS FOR NURSING SCHOOL HESI,ATI,KAPLAN DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen. ANS: C The thickness of the persons body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-yearold child. The nurse should: a. Palpate over the area for increased pain and tenderness. TO GET MORE MATERIALS FOR NURSING SCHOOL HESI,ATI,KAPLAN b. Ask the child to take shallow breaths, and percuss over the area again. c. Immediately refer the child because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination. ANS: D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a childs lung. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patients respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray study, and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations. ANS: B TO GET MORE MATERIALS FOR NURSING SCHOOL HESI,ATI,KAPLAN Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patients physical status. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?

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JARVIS-PHYSICAL EXAMINATION
AND HEALTH ASSESSMENT 8ED
TESTBANK




TO

,Chapter 01: Evidence-Based Assessment

MULTIPLE CHOICE



1. 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.



ANS: A



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.



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
would be:



a. Objective.



b. Reflective.

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,c. Subjective.



d. Introspective.



ANS: C



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.



DIF: Cognitive Level: Understanding (Comprehension)



MSC: Client Needs: Safe and Effective Care Environment: Management of Care



3. 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.



ANS: A




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, 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.



DIF: Cognitive Level: Remembering (Knowledge)



MSC: Client Needs: Safe and Effective Care Environment: Management of Care



4. 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.



ANS: C



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.



DIF: Cognitive Level: Analyzing (Analysis)



MSC: Client Needs: Safe and Effective Care Environment: Management of Care



5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse
should keep in mind that novice nurses, without a background of skills and experience from which to
draw, are more likely to make their decisions using:

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