CHAPTER 1 Approach to the Clinical Encounter
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) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• 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.
.
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) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• 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
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) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• 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) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• 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:
a
Intuition.
.
b
A set of rules.
.
c
Articles in journals.
.
d
Advice from supervisors.
.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner
uses intuitive links.
DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 3 MSC: Client Needs: General
• Expert nurses learn to attend to a pattern of assessment data and act without
consciously labeling it. These responses are referred to as:
a
Intuition.
.
b
The nursing process.
.
c
Clinical knowledge.
.
d
Diagnostic reasoning.
.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 4 MSC: Client Needs: General
• The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
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 clinicians experience.
d The patients own preferences are not
. important with EBP.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinicians experience, as well as patient preferences and values,
when making decisions about care and treatment. EBP 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.
DIF: Cognitive Level: Applying (Application) REF: p. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• The nurse is conducting a class on priority setting for a group of new graduate
nurses. Which is an example of a first-level priority 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.,
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
• When considering priority setting of problems, the nurse keeps in mind that
second-level priority problems include which of these aspects?
a
Low self-esteem
.
b
Lack of knowledge
.
c
Abnormal laboratory values
.