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, Evidence-Based Physical Examination Best Practices for Health & ju ju ju ju ju ju ju
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Chapter 1. APPROACH TO EVIDENCE-BASED ASSESSMENT OF HEALTH AND
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1. After completing an initial assessment of a patient, the nurse has charted that his
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ju respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
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a
. Objective.
b
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. Reflective.
c
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. Subjective.
d
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. Introspective.
ANS: A ju
Objective data are what the health professional observes by inspecting, percussing, palpating,
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ju and auscultating during the physical examination. Subjective data is what the person says about
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ju him or herself during history taking. The terms reflective and introspective are not used to
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ju describe data. ju
DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types
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ju of data would be:
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a
. Objective.
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,b
. Reflective.
c
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. Subjective.
d
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. Introspective.
ANS: C ju
Subjective data are what the person says about him or herself during history taking. Objective
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data are what the health professional observes by inspecting, percussing, palpating, and
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ju auscultating during the physical examination. The terms reflective and introspective are not used
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ju to describe data.
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DIF: Cognitive Level: Understanding (Comprehension) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to
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ju form the: ju
a
. Data base. ju
ju b
. Admitting data. ju
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. Financial statement. ju
ju d
. Discharge summary. ju
ANS: A ju
Together with the patients record and laboratory studies, the objective and subjective data form
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ju the data base. The other items are not part of the patients record, laboratory studies, or data.
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, DIF: Cognitive Level: Remembering (Knowledge) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard.
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ju The nurses next action should be to:
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a
. Immediately notify the patients physician. ju ju ju ju
ju b
. Document the sound exactly as it was heard. ju ju ju ju ju ju ju
ju c
. Validate the data by asking a coworker to listen to the breath sounds.
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ju d
. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C ju
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
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ju data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert
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ju to listen.
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DIF: Cognitive Level: Analyzing (Analysis) REF: z. 2
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
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ju nurse should keep in mind that novice nurses, without a background of skills and experience
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ju from which to draw, are more likely to make their decisions using:
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a
. Intuition.
b
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. A set of rules.
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ju c
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