PHYSICAL EXAMINATION AND HISTORY
13thEDITION QUESTION WITH DETAILED A+
,CHAPTER 1 Foundations for Clinical
Proficiency
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) REF: p. 2
,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.
.
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
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
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 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.
.