11/11/23,b6:40bPM TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b Chap
ter b 01:b Evidence-Basedb Assessment
MULTIPLEb CHOICE
1. After bcompleting banbinitialbassessment b of b abpatient, bthebnursebhas bcharted bthat bhis brespirations b are
b eupneic b andb his bpulsebis b58 bbeats bper b minute. bThesebtypes b of bdatab wouldb be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
b ANS: bA
Objectivebdatabarebwhatbthebhealth bprofessionalbobserves bbybinspecting, bpercussing, b palpating, b andba
uscultating b duringbtheb physicalbexamination. bSubjectiveb databis b what bthebpersonbsays b aboutbhimb or
bherself bduringbhistory
taking. bThebterms breflectiveb andbintrospective b arebnotbused btobdescribebdata. bDIF:bCognitivebLevel: bUnderstanding b(C
omprehension) b MSC:b ClientbNeeds: b Safeb andb EffectivebCareb Environment: b Management b of bCare
2. Abpatientbtells b thebnursebthatb hebis b veryb nervous, bis b nauseated, b andbfeels bhot.b Thesebtypes b of bdatab wouldbbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
b ANS: bC
Subjectiveb datab areb whatbthebperson bsays b aboutbhimb or bherself bduringbhistorybtaking. bObjectivebdata
bareb whatbtheb health bprofessionalbobserves b bybinspecting, bpercussing,bpalpating,b and bauscultating bd
uringbthebphysical
examination. bThebterms breflective b and bintrospective barebnot busedbtobdescribebdata. bDIF:bCognitivebLevel: bUnderstanding b(Com
prehension) b MSC:bClient bNeeds: bSafeb and bEffectiveb CarebEnvironment: b Management b of bCare
3. Thebpatients brecord,blaboratory bstudies, bobjectivebdata,b and bsubjectiveb databcombinebtobformbthe:
a. Databbase.
b. Admittingbdata.
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b2
c. Financialb statement.
d. Dischargebsummary
.b ANS:bA
Together b withbthebpatients brecord band blaboratorybstudies, bthebobjectivebandbsubjectivebdatabform bthebdatab base.bThe bother bitems b ar
ebnotb partb of btheb patients brecord, blaboratorybstudies, b or bdata. bDIF:bCognitiveb Level: bRememberingb(Knowledge)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
4. When blisteningbtob abpatients bbreathbsounds, bthebnursebis b unsurebof babsoundbthatbis bheard.bT
hebnurses bnextb action bshouldb bebto:
a. Immediatelybnotifyb thebpatients b physician.
b. Document bthebsoundb exactlyb as bitb was bheard.
c. Validatebthebdatab byb askingb abcoworker btoblisten btobthebbreath bsounds.
d. Assess bagain binb20b minutes btobnoteb whether bthebsoundbis bstil
lbpresent. b ANS: bC
When bunsurebof b absoundbheard bwhileblistening btobab patients bbreathbsounds, b thebnurseb validates bthebdatabtob ensure
accuracy. bIf bthebnursebhas bless b experiencebinbanbarea, bthen bhebor bshebasks b an bexpertbtoblisten. bDIF:b CognitivebLevel: b Anal
yzingb(Analysis) b MSC:bClientbNeeds: bSafeb andbEffectivebCarebEnvironment: b Management b of bCare
5. Theb nursebis bconductingbabclass bfor bnew b graduateb nurses.bDuringbthebteaching bsession, bthebnurs
ebshouldbkeepb inbmindbthatbnoviceb nurses,b without b abbackground bof bskills b andbexperiencebfrom b wh
ichbtobdraw, b arebmoreblikely
tobmakebtheir bdecisions b using:
a. Intuition.
b. Absetb of b rules.
c. Articles b inbjournals.
d. Advicebfrom bsupervisor
s.b ANS: bB
Noviceb nurses b operatebfromb abset b of bdefined, bstructuredbrules.bThebexpertb practitioner buses bintuitiveblinks. bDIF:bCognitivebLevel: b Und
erstandingb (Comprehension)
TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b3b MSC
:bClientbNeeds:bGeneral
6. Expertb nurses blearnbtob attend btobabpattern bof b assessment b datab andb actb without bconsciouslyblabe
lingbit.bTheseb responses b arebreferred btob as:
a. Intuition.
b. Theb nursingb process.
c. Clinicalbknowledge.
d. Diagnosticbreasoning.
b ANS: bA
Intuitionbis bcharacterized bbyb pattern brecognitionexpert bnurses blearn btob attendbtobabpatternbof b assessment bdatab and
actb without bconsciouslyblabeling bit.bThebother boptions b arebnotbcorrect. bDIF:bCognitivebLevel: bUnderstanding b(Compr
ehension) b MSC:bClientb Needs:bGeneral
7. Thebnursebis breviewingbinformation baboutbevidence-based bpracticeb(EBP).bW hichbstatement b bestbreflects
EBP?
a. EBP brelies b onbtradition bfor bsupport b ofbbestbpractices.
b. EBPbis bsimplybtheb useb of b best b practicebtechniques bfor bthe btreatment b of bpatients.
c. EBPb emphasizes bthebuseb of bbestbevidenceb withbthebclinicians b experience.
d. Thebpatients bown bpreferences barebnotbimportant bwith
bEBP.b ANS:bC
EBPbis b absystematic b approachbtob practicebthatb emphasizes bthebusebof bbest b evidencebinbcombinatio
nbwithbtheb clinicians b experience, b as b wellb as bpatientb preferences b andb values, b when bmakingbdecision
s baboutbcarebandb treatment. bEBP bis b morebthanbsimplybusingbthebbestbpracticebtechniques btobtreat
bpatients,band bquestioning
traditionbis bimportant b whenbnobcompelling bandbsupportivebresearchb evidencebexists. bDIF:bCognitivebLevel: bApplyingb
(Application) b MSC:b ClientbNeeds: b Safeb and bEffectivebCare bEnvironment: b Management b of bCare
8. Theb nursebis bconductingbabclass b on bprioritybsetting bfor bab groupb of bnew bgraduatebnurses. bW hich
bis banb exampleb of b abfirst-level bpriorityb problem?
about:blank 1/167
,11/11/23,b6:40bPM TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
a. Patientbwithbpostoperative bpain
b. Newlybdiagnosed bpatientb with bdiabetes b whob needs bdiabetic bteac
hingb TestbBankb-
bPhysicalbExamination bandbHealth bAssessment b8eb(bybJarvis)b4
c. Individualbwith babsmallblaceration bonbthebsolebof b thebfoot
d. Individual bwith bshortness bof bbreath bandbrespiratorybdi
stress b ANS: bD
First-level bprioritybproblems barebthose bthat barebemergent, blifebthreatening, b and bimmediateb(e.g.,b establishing ban
airway, bsupporting bbreathing, bmaintaining bcirculation, bmonitoring babnormal bvital bsigns). bDIF:bCognitivebLevel: bUnderstanding b(Compre
hension) b MSC:bClientbNeeds:b Safeb andb EffectivebCarebEnvironment: b Management b of bCare
9. When bconsidering bprioritybsetting bof bproblems, bthebnursebkeeps binbmind bthat bsecond-
level bprioritybproblems b includeb whichb of btheseb aspects?
a. Lowbself-esteem
b. Lack b of b knowledge
c. Abnormalb laboratoryb values
d. Severelybabnormal bvital bsi
gns b ANS: bC
Second-
level bprioritybproblems b arebthose bthatbrequirebpromptbintervention btobforestall bfurther bdeterioration b(e.g.,b mentalbstatus bchange, b acutebp
ain,b abnormal blaboratoryb values, brisks btobsafetyb or bsecurity). bDIF:bCognitive bLevel: bUnderstanding b(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
10. Whichbcriticalbthinking bskillbhelps b thebnursebseebrelationships bamong bthebdata?
a. Validation
b. Clusteringb relatedb cues
c. Identifyingbgaps b in bdata
d. Distinguishingbrelevantbfrombirreleva
ntb ANS: bB
Clusteringbrelated bcues bhelps bthebnursebseebrelationships bamongbthebdata.b DIF: bCognitivebLevel: bUnderstanding b(Comp
rehension) b MSC:b ClientbNeeds:b Safeb andb EffectivebCareb Environment: b Management b of bCare
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b5
11. Thebnursebknows bthatbdeveloping bappropriatebnursing binterventions bfor babpatientbrel
ies bon btheb appropriateness b of btheb diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
b ANS: bA
An baccuratebnursing bdiagnosis bprovides bthebbasis bfor bthebselectionbof bnursing binterventions btobachie
veboutcomes b for bwhichbthebnursebis b accountable. bThebother bitems b dobnotbcontributebtobthebdevelo
pmentb of b appropriatebnursingb interventions. bDIF:bCognitiveb Level: bUnderstanding b(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
12. Thebnursingbprocess bis b absequential bmethod bof bproblem bsolving bthat bnurses buseband bincludes bwhich bsteps?
a. Assessment, btreatment, bplanning, bevaluation, bdischarge, band bfollow-up
b. Admission, bassessment, bdiagnosis, btreatment, b and bdischarge bplanning
c. Admission,b diagnosis,b treatment,b evaluation, b andb dischargeb planning
d. Assessment, bdiagnosis, boutcome bidentification, bplanning, bimplementation, band beval
uationb ANS: bD
Theb nursingbprocess bis b ab method b of bproblem bsolving bthatb includes b assessment, bdiagnosis, b outcom
eb identification, bplanning, bimplementation, band bevaluation. bDIF:bCognitivebLevel: bUnderstanding b(Com
prehension) b MSC:bClient bNeeds: bSafeb and bEffectiveb CarebEnvironment: b Management b of bCare
13. Abnewlyb admitted bpatientbis binbacutebpain,b has b notb been bsleepingb well blately,b andbis bh
aving bdifficultyb breathing. bHow bshould bthebnurseb prioritizeb thesebproblems?
a. Breathing, b pain,b andb sleep
b. Breathing, b sleep,b andb pain
c. Sleep,b breathing,b andb pain
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b6
d. Sleep,bpain,b andbbreathi
ngb ANS: bA
First-levelb priorityb problems b areb immediateb priorities,b rememberingb theb ABCsb (airway, b breathing,b and
circulation), bfollowed bbybsecond-level bproblems, b andbthenbthird-
level bproblems. bDIF:bCognitivebLevel: bAnalyzing b(Analysis) b MSC:bClientbNeeds: bSafeb andbEffectiveb CarebEnv
ironment: b Management b of bCare
14. Whichbof bthesebwouldb bebformulated bbyb ab nursebusingbdiagnostic breasoning?
a. Nursingb diagnosis
b. Medicalbdiagnosis
c. Diagnostic bhypothesis
d. Diagnostic bassessmen
tb ANS:bC
Diagnostic breasoning bcalls bfor bthebnursebtobformulateb abdiagnostic bhypothesis; bthebnursingbprocess bc
alls bfor b ab nursingbdiagnosis. bDIF: bCognitiveb Level: bUnderstanding b(Comprehension)
MSC:b ClientbNeeds:b General
15. Barriersb tobincorporatingb EBP b include:
a. Nurses blackb of bresearchbskills binb evaluatingbthebqualityb of bresearchbstudies.
b. Lackbof bsignificant bresearch bstudies.
c. Insufficient b clinicalbskills b of b nurses.
d. Inadequatebphysicalbassessment bskil
ls.b ANS: bA
As bindividuals, bnurses black bresearch bskills binbevaluatingbthebqualityb of bresearchbstudies, b arebisolated
bfromb otherb colleagues b whob arebknowledgeablebin bresearch,b andboftenblackbthebtimebtobvisitbthebli
brarybtobreadbresearch. bTheb other bresponses b arebnotbconsideredbbarriers. bDIF:bCognitivebLevel: b Un
derstandingb(Comprehension)
MSC:b ClientbNeeds:b General
16. Whatbstep bof bthebnursingbprocess bincludes bdatabcollectionbbybhealth bhistory, bphysical bexami
nation, bandb interview?
about:blank 2/167
,11/11/23,b6:40bPM TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b7
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
b ANS: bD
Databcollection, bincluding bperforming bthebhealth bhistory, bphysicalbexamination, band binterview, bis bthebassessment
step bof bthebnursing bprocess. b DIF: bCognitivebLevel: bRemembering b(Kno
wledge) b MSC:b Clientb Needs:bGeneral
17. Duringb abstaff bmeeting, bnurses b discuss btheb problems b withb accessingbresearch bstudies btobin
corporateb evidence-
based bclinical bdecisionbmakingbinto btheir bpractice. bW hichbsuggestion bbybthebnursebmanager bwou
ldb bestb helpbtheseb problems?
a. Formb abcommitteebtobconduct bresearchbstudies.
b. Postbpublished bresearch bstudies bonbthebunits bbulletin bboards.
c. Encouragebthebnurses btobvisit btheblibraryb tobreview bstudies.
d. Teach bthebnurses bhow btobconduct b electronic bsearches bfor bresearch
bstudies.b ANS: bD
Facilitating bsupportbfor bEBP b would bincludebteaching bthebnurses bhow btobconduct b electronic bsearche
s;btimebtob visitbtheblibraryb maybnot bbebavailablebfor bmany bnurses. bActuallybconductingbresearchb
studies b mayb bebhelpfulbin
theblong-
runbbut bnot b anbimmediatebsolution btobreviewing bexisting bresearch. bDIF:bCognitive bLevel: bApplyingb(Application)
b MSC:bClientbNeeds:bSafeb andbEffectiveb CarebEnvironment:bManagementb of bCare
18. When breviewing bthebconcepts b of bhealth, bthebnursebrecalls bthatbthebcomponents bof bholistic bh
ealth bincludeb whichb of bthese?
a. Diseaseboriginates bfrombthebexternal benvironment.
b. Thebindividualbhumanbis babclosed bsystem.
c. Nurses b arebresponsiblebfor babpatients b healthbstate.
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b8
d. Holistic bhealth bviews bthebmind, bbody,b andbspirit bas binterdep
endent. b ANS:bD
Consideration bof bthebwholebperson bis bthebessencebof b holistic bhealth, b whichbviews bthebmind,b body,b and bspiritb as
interdependent. bThebbasis b of bdisease boriginates bfromb both bthebexternalbenvironment b andbfromb withinbthebperson. bBoth bthebindividual
bhuman band btheb externalbenvironment barebopen bsystems,bcontinuallybchanging band badapting,b andbeach bperson bis bresponsiblebfor bhis
borbher bown bpersonalbhealthbstate.b DIF:b CognitivebLevel:b Understandingb(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
19. Thebnursebrecognizes bthatbthebconceptbof bpreventionbin bdescribingbhealthbis b essentialbbecause:
a. Diseasebcanbbebpreventedbbybtreatingbthebexternal b environment.
b. Thebmajorityb of bdeaths bamong bAmericans bunder bageb65byears barebnotbpreventable.
c. Prevention bplaces bthebemphasis bonbtheblinkb between bhealth bandbpersonalbbehavior.
d. Thebmeans btobpreventionbis bthrough btreatment bprovidedbby bprimarybhealthbcarebpr
actitioners. b ANS: bC
Abnatural bprogression btobprevention brounds boutbthebpresent bconcept bof bhealth. bGuidelines btobpreventionbplace
thebemphasis bon btheblinkbbetween bhealthbandbpersonal bbehavior. bDIF:bCognitive bLevel: bUnderstanding b(Compr
ehension) b MSC:bClientb Needs:bGeneral
20. Thebnursebis b performing babphysical b assessment b onbab newlyb admittedbpatient. bAn bexample
bof b objectiveb informationb obtainedb during bthebphysicalb assessmentb includes bthe:
a. Patients bhistoryb of b allergies.
b. Patients buseb of b medications b at bhome.
c. Lastbmenstrualbperiod b1 bmonth bago.
d. 2b5bcmbscar bon bthebrightblower bfo
rearm.b ANS: bD
Objectivebdatabarebthebpatients brecord,blaboratorybstudies, b and bcondition bthat bthebhealthbprofessional b
observes bbyb inspecting, b percussing, b palpating, band bauscultating bduring bthebphysical b examination. bThe
bother bresponses breflectb subjectivebdata.bDIF:b CognitivebLevel:b Applyingb(Application)
Testb Bank b-
bPhysicalbExaminationb and bHealthb Assessmentb 8eb(bybJarvis)b9b MSC:
bClientbNeeds:bSafebandbEffectivebCarebEnvironment:bManagementbof bC
are
21. Abvisitingbnursebis b makingban binitialbhomebvisit b for b abpatientb whobhas b manybchronic bmedical bproblems. bW hichbtype bofbdatabbase
bis b mostb appropriateb tobcollectbinbthis bsetting?
a. Abfollow-up bdatabbasebtobevaluate bchanges batbappropriatebintervals
b. An bepisodic bdatabbasebbecausebof bthebcontinuing, bcomplex bmedicalbproblems b of bthis bpatient
c. Abcompletebhealthbdatabbasebbecausebof bthebnurses bprimarybresponsibilitybfor bmo
nitoringbtheb patients bhealth
d. Anbemergencybdatabbaseb because bof bthebneed btobcollect binformation band bmakebaccurat
eb diagnoses b rapidly
ANS:bC
Thebcompletebdatabbasebis bcollected binbab primarybcarebsetting, bsuch bas b abpediatric b or bfamilyb pra
cticebclinic, b independent b or b group bprivatebpractice, bcollege bhealthbservice,b womens b healthbcarebag
ency,b visiting bnurseb agency,b or bcommunityb healthb agency. bInbthesebsettings, bthebnursebis bthebfirst
bhealthbprofessional btobseebthe
patient band bhas bthebprimarybresponsibility bfor bmonitoringbthebpersons bhealth bcare. bDIF:bCognitivebLevel: bApplyingb(Application)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
22. Whichbsituationbis bmostbappropriate bduring bwhich bthebnursebperforms b abfocused bor bproble
m-centeredb history?
a. Patientb is b admittedbtobablong-termbcarebfacility.
b. Patientbhas babsuddenband bsevere bshortness b of bbreath.
c. Patientbis b admittedbtobthebhospital bfor bsurgerybthebfollowing bday.
d. Patientbin ban boutpatient bclinic bhas bcold band binfluenza-
likebsymptoms. b ANS:bD
Inbabfocused b orbproblem-
centered bdatabbase,bthebnursebcollects babmini bdatab base,b whichbis bsmaller bin bscopebthanb thebcom
pletedbdatabbase.bThis bminibdata b basebprimarilybconcerns b onebproblem, b onebcuebcomplex, b or b oneb
about:blank 3/167
, 11/11/23,b6:40bPM TestbBankb-
Physical Examination and HealthbAssessmentb8eb(bybJarvis)b1b…
b b Level:b Applying
bodyb system. bDIF:bCognitive b b(Application) b b
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
about:blank 4/167
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b Chap
ter b 01:b Evidence-Basedb Assessment
MULTIPLEb CHOICE
1. After bcompleting banbinitialbassessment b of b abpatient, bthebnursebhas bcharted bthat bhis brespirations b are
b eupneic b andb his bpulsebis b58 bbeats bper b minute. bThesebtypes b of bdatab wouldb be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
b ANS: bA
Objectivebdatabarebwhatbthebhealth bprofessionalbobserves bbybinspecting, bpercussing, b palpating, b andba
uscultating b duringbtheb physicalbexamination. bSubjectiveb databis b what bthebpersonbsays b aboutbhimb or
bherself bduringbhistory
taking. bThebterms breflectiveb andbintrospective b arebnotbused btobdescribebdata. bDIF:bCognitivebLevel: bUnderstanding b(C
omprehension) b MSC:b ClientbNeeds: b Safeb andb EffectivebCareb Environment: b Management b of bCare
2. Abpatientbtells b thebnursebthatb hebis b veryb nervous, bis b nauseated, b andbfeels bhot.b Thesebtypes b of bdatab wouldbbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
b ANS: bC
Subjectiveb datab areb whatbthebperson bsays b aboutbhimb or bherself bduringbhistorybtaking. bObjectivebdata
bareb whatbtheb health bprofessionalbobserves b bybinspecting, bpercussing,bpalpating,b and bauscultating bd
uringbthebphysical
examination. bThebterms breflective b and bintrospective barebnot busedbtobdescribebdata. bDIF:bCognitivebLevel: bUnderstanding b(Com
prehension) b MSC:bClient bNeeds: bSafeb and bEffectiveb CarebEnvironment: b Management b of bCare
3. Thebpatients brecord,blaboratory bstudies, bobjectivebdata,b and bsubjectiveb databcombinebtobformbthe:
a. Databbase.
b. Admittingbdata.
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b2
c. Financialb statement.
d. Dischargebsummary
.b ANS:bA
Together b withbthebpatients brecord band blaboratorybstudies, bthebobjectivebandbsubjectivebdatabform bthebdatab base.bThe bother bitems b ar
ebnotb partb of btheb patients brecord, blaboratorybstudies, b or bdata. bDIF:bCognitiveb Level: bRememberingb(Knowledge)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
4. When blisteningbtob abpatients bbreathbsounds, bthebnursebis b unsurebof babsoundbthatbis bheard.bT
hebnurses bnextb action bshouldb bebto:
a. Immediatelybnotifyb thebpatients b physician.
b. Document bthebsoundb exactlyb as bitb was bheard.
c. Validatebthebdatab byb askingb abcoworker btoblisten btobthebbreath bsounds.
d. Assess bagain binb20b minutes btobnoteb whether bthebsoundbis bstil
lbpresent. b ANS: bC
When bunsurebof b absoundbheard bwhileblistening btobab patients bbreathbsounds, b thebnurseb validates bthebdatabtob ensure
accuracy. bIf bthebnursebhas bless b experiencebinbanbarea, bthen bhebor bshebasks b an bexpertbtoblisten. bDIF:b CognitivebLevel: b Anal
yzingb(Analysis) b MSC:bClientbNeeds: bSafeb andbEffectivebCarebEnvironment: b Management b of bCare
5. Theb nursebis bconductingbabclass bfor bnew b graduateb nurses.bDuringbthebteaching bsession, bthebnurs
ebshouldbkeepb inbmindbthatbnoviceb nurses,b without b abbackground bof bskills b andbexperiencebfrom b wh
ichbtobdraw, b arebmoreblikely
tobmakebtheir bdecisions b using:
a. Intuition.
b. Absetb of b rules.
c. Articles b inbjournals.
d. Advicebfrom bsupervisor
s.b ANS: bB
Noviceb nurses b operatebfromb abset b of bdefined, bstructuredbrules.bThebexpertb practitioner buses bintuitiveblinks. bDIF:bCognitivebLevel: b Und
erstandingb (Comprehension)
TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b3b MSC
:bClientbNeeds:bGeneral
6. Expertb nurses blearnbtob attend btobabpattern bof b assessment b datab andb actb without bconsciouslyblabe
lingbit.bTheseb responses b arebreferred btob as:
a. Intuition.
b. Theb nursingb process.
c. Clinicalbknowledge.
d. Diagnosticbreasoning.
b ANS: bA
Intuitionbis bcharacterized bbyb pattern brecognitionexpert bnurses blearn btob attendbtobabpatternbof b assessment bdatab and
actb without bconsciouslyblabeling bit.bThebother boptions b arebnotbcorrect. bDIF:bCognitivebLevel: bUnderstanding b(Compr
ehension) b MSC:bClientb Needs:bGeneral
7. Thebnursebis breviewingbinformation baboutbevidence-based bpracticeb(EBP).bW hichbstatement b bestbreflects
EBP?
a. EBP brelies b onbtradition bfor bsupport b ofbbestbpractices.
b. EBPbis bsimplybtheb useb of b best b practicebtechniques bfor bthe btreatment b of bpatients.
c. EBPb emphasizes bthebuseb of bbestbevidenceb withbthebclinicians b experience.
d. Thebpatients bown bpreferences barebnotbimportant bwith
bEBP.b ANS:bC
EBPbis b absystematic b approachbtob practicebthatb emphasizes bthebusebof bbest b evidencebinbcombinatio
nbwithbtheb clinicians b experience, b as b wellb as bpatientb preferences b andb values, b when bmakingbdecision
s baboutbcarebandb treatment. bEBP bis b morebthanbsimplybusingbthebbestbpracticebtechniques btobtreat
bpatients,band bquestioning
traditionbis bimportant b whenbnobcompelling bandbsupportivebresearchb evidencebexists. bDIF:bCognitivebLevel: bApplyingb
(Application) b MSC:b ClientbNeeds: b Safeb and bEffectivebCare bEnvironment: b Management b of bCare
8. Theb nursebis bconductingbabclass b on bprioritybsetting bfor bab groupb of bnew bgraduatebnurses. bW hich
bis banb exampleb of b abfirst-level bpriorityb problem?
about:blank 1/167
,11/11/23,b6:40bPM TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
a. Patientbwithbpostoperative bpain
b. Newlybdiagnosed bpatientb with bdiabetes b whob needs bdiabetic bteac
hingb TestbBankb-
bPhysicalbExamination bandbHealth bAssessment b8eb(bybJarvis)b4
c. Individualbwith babsmallblaceration bonbthebsolebof b thebfoot
d. Individual bwith bshortness bof bbreath bandbrespiratorybdi
stress b ANS: bD
First-level bprioritybproblems barebthose bthat barebemergent, blifebthreatening, b and bimmediateb(e.g.,b establishing ban
airway, bsupporting bbreathing, bmaintaining bcirculation, bmonitoring babnormal bvital bsigns). bDIF:bCognitivebLevel: bUnderstanding b(Compre
hension) b MSC:bClientbNeeds:b Safeb andb EffectivebCarebEnvironment: b Management b of bCare
9. When bconsidering bprioritybsetting bof bproblems, bthebnursebkeeps binbmind bthat bsecond-
level bprioritybproblems b includeb whichb of btheseb aspects?
a. Lowbself-esteem
b. Lack b of b knowledge
c. Abnormalb laboratoryb values
d. Severelybabnormal bvital bsi
gns b ANS: bC
Second-
level bprioritybproblems b arebthose bthatbrequirebpromptbintervention btobforestall bfurther bdeterioration b(e.g.,b mentalbstatus bchange, b acutebp
ain,b abnormal blaboratoryb values, brisks btobsafetyb or bsecurity). bDIF:bCognitive bLevel: bUnderstanding b(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
10. Whichbcriticalbthinking bskillbhelps b thebnursebseebrelationships bamong bthebdata?
a. Validation
b. Clusteringb relatedb cues
c. Identifyingbgaps b in bdata
d. Distinguishingbrelevantbfrombirreleva
ntb ANS: bB
Clusteringbrelated bcues bhelps bthebnursebseebrelationships bamongbthebdata.b DIF: bCognitivebLevel: bUnderstanding b(Comp
rehension) b MSC:b ClientbNeeds:b Safeb andb EffectivebCareb Environment: b Management b of bCare
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b5
11. Thebnursebknows bthatbdeveloping bappropriatebnursing binterventions bfor babpatientbrel
ies bon btheb appropriateness b of btheb diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
b ANS: bA
An baccuratebnursing bdiagnosis bprovides bthebbasis bfor bthebselectionbof bnursing binterventions btobachie
veboutcomes b for bwhichbthebnursebis b accountable. bThebother bitems b dobnotbcontributebtobthebdevelo
pmentb of b appropriatebnursingb interventions. bDIF:bCognitiveb Level: bUnderstanding b(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
12. Thebnursingbprocess bis b absequential bmethod bof bproblem bsolving bthat bnurses buseband bincludes bwhich bsteps?
a. Assessment, btreatment, bplanning, bevaluation, bdischarge, band bfollow-up
b. Admission, bassessment, bdiagnosis, btreatment, b and bdischarge bplanning
c. Admission,b diagnosis,b treatment,b evaluation, b andb dischargeb planning
d. Assessment, bdiagnosis, boutcome bidentification, bplanning, bimplementation, band beval
uationb ANS: bD
Theb nursingbprocess bis b ab method b of bproblem bsolving bthatb includes b assessment, bdiagnosis, b outcom
eb identification, bplanning, bimplementation, band bevaluation. bDIF:bCognitivebLevel: bUnderstanding b(Com
prehension) b MSC:bClient bNeeds: bSafeb and bEffectiveb CarebEnvironment: b Management b of bCare
13. Abnewlyb admitted bpatientbis binbacutebpain,b has b notb been bsleepingb well blately,b andbis bh
aving bdifficultyb breathing. bHow bshould bthebnurseb prioritizeb thesebproblems?
a. Breathing, b pain,b andb sleep
b. Breathing, b sleep,b andb pain
c. Sleep,b breathing,b andb pain
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b6
d. Sleep,bpain,b andbbreathi
ngb ANS: bA
First-levelb priorityb problems b areb immediateb priorities,b rememberingb theb ABCsb (airway, b breathing,b and
circulation), bfollowed bbybsecond-level bproblems, b andbthenbthird-
level bproblems. bDIF:bCognitivebLevel: bAnalyzing b(Analysis) b MSC:bClientbNeeds: bSafeb andbEffectiveb CarebEnv
ironment: b Management b of bCare
14. Whichbof bthesebwouldb bebformulated bbyb ab nursebusingbdiagnostic breasoning?
a. Nursingb diagnosis
b. Medicalbdiagnosis
c. Diagnostic bhypothesis
d. Diagnostic bassessmen
tb ANS:bC
Diagnostic breasoning bcalls bfor bthebnursebtobformulateb abdiagnostic bhypothesis; bthebnursingbprocess bc
alls bfor b ab nursingbdiagnosis. bDIF: bCognitiveb Level: bUnderstanding b(Comprehension)
MSC:b ClientbNeeds:b General
15. Barriersb tobincorporatingb EBP b include:
a. Nurses blackb of bresearchbskills binb evaluatingbthebqualityb of bresearchbstudies.
b. Lackbof bsignificant bresearch bstudies.
c. Insufficient b clinicalbskills b of b nurses.
d. Inadequatebphysicalbassessment bskil
ls.b ANS: bA
As bindividuals, bnurses black bresearch bskills binbevaluatingbthebqualityb of bresearchbstudies, b arebisolated
bfromb otherb colleagues b whob arebknowledgeablebin bresearch,b andboftenblackbthebtimebtobvisitbthebli
brarybtobreadbresearch. bTheb other bresponses b arebnotbconsideredbbarriers. bDIF:bCognitivebLevel: b Un
derstandingb(Comprehension)
MSC:b ClientbNeeds:b General
16. Whatbstep bof bthebnursingbprocess bincludes bdatabcollectionbbybhealth bhistory, bphysical bexami
nation, bandb interview?
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,11/11/23,b6:40bPM TestbBankb-
bPhysicalbExaminationbandbHealthbAssessmentb8eb(bybJarvis)b1b…
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b7
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
b ANS: bD
Databcollection, bincluding bperforming bthebhealth bhistory, bphysicalbexamination, band binterview, bis bthebassessment
step bof bthebnursing bprocess. b DIF: bCognitivebLevel: bRemembering b(Kno
wledge) b MSC:b Clientb Needs:bGeneral
17. Duringb abstaff bmeeting, bnurses b discuss btheb problems b withb accessingbresearch bstudies btobin
corporateb evidence-
based bclinical bdecisionbmakingbinto btheir bpractice. bW hichbsuggestion bbybthebnursebmanager bwou
ldb bestb helpbtheseb problems?
a. Formb abcommitteebtobconduct bresearchbstudies.
b. Postbpublished bresearch bstudies bonbthebunits bbulletin bboards.
c. Encouragebthebnurses btobvisit btheblibraryb tobreview bstudies.
d. Teach bthebnurses bhow btobconduct b electronic bsearches bfor bresearch
bstudies.b ANS: bD
Facilitating bsupportbfor bEBP b would bincludebteaching bthebnurses bhow btobconduct b electronic bsearche
s;btimebtob visitbtheblibraryb maybnot bbebavailablebfor bmany bnurses. bActuallybconductingbresearchb
studies b mayb bebhelpfulbin
theblong-
runbbut bnot b anbimmediatebsolution btobreviewing bexisting bresearch. bDIF:bCognitive bLevel: bApplyingb(Application)
b MSC:bClientbNeeds:bSafeb andbEffectiveb CarebEnvironment:bManagementb of bCare
18. When breviewing bthebconcepts b of bhealth, bthebnursebrecalls bthatbthebcomponents bof bholistic bh
ealth bincludeb whichb of bthese?
a. Diseaseboriginates bfrombthebexternal benvironment.
b. Thebindividualbhumanbis babclosed bsystem.
c. Nurses b arebresponsiblebfor babpatients b healthbstate.
TestbBankb- bPhysicalbExamination bandbHealthbAssessment b 8eb(bybJarvis) b8
d. Holistic bhealth bviews bthebmind, bbody,b andbspirit bas binterdep
endent. b ANS:bD
Consideration bof bthebwholebperson bis bthebessencebof b holistic bhealth, b whichbviews bthebmind,b body,b and bspiritb as
interdependent. bThebbasis b of bdisease boriginates bfromb both bthebexternalbenvironment b andbfromb withinbthebperson. bBoth bthebindividual
bhuman band btheb externalbenvironment barebopen bsystems,bcontinuallybchanging band badapting,b andbeach bperson bis bresponsiblebfor bhis
borbher bown bpersonalbhealthbstate.b DIF:b CognitivebLevel:b Understandingb(Comprehension)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
19. Thebnursebrecognizes bthatbthebconceptbof bpreventionbin bdescribingbhealthbis b essentialbbecause:
a. Diseasebcanbbebpreventedbbybtreatingbthebexternal b environment.
b. Thebmajorityb of bdeaths bamong bAmericans bunder bageb65byears barebnotbpreventable.
c. Prevention bplaces bthebemphasis bonbtheblinkb between bhealth bandbpersonalbbehavior.
d. Thebmeans btobpreventionbis bthrough btreatment bprovidedbby bprimarybhealthbcarebpr
actitioners. b ANS: bC
Abnatural bprogression btobprevention brounds boutbthebpresent bconcept bof bhealth. bGuidelines btobpreventionbplace
thebemphasis bon btheblinkbbetween bhealthbandbpersonal bbehavior. bDIF:bCognitive bLevel: bUnderstanding b(Compr
ehension) b MSC:bClientb Needs:bGeneral
20. Thebnursebis b performing babphysical b assessment b onbab newlyb admittedbpatient. bAn bexample
bof b objectiveb informationb obtainedb during bthebphysicalb assessmentb includes bthe:
a. Patients bhistoryb of b allergies.
b. Patients buseb of b medications b at bhome.
c. Lastbmenstrualbperiod b1 bmonth bago.
d. 2b5bcmbscar bon bthebrightblower bfo
rearm.b ANS: bD
Objectivebdatabarebthebpatients brecord,blaboratorybstudies, b and bcondition bthat bthebhealthbprofessional b
observes bbyb inspecting, b percussing, b palpating, band bauscultating bduring bthebphysical b examination. bThe
bother bresponses breflectb subjectivebdata.bDIF:b CognitivebLevel:b Applyingb(Application)
Testb Bank b-
bPhysicalbExaminationb and bHealthb Assessmentb 8eb(bybJarvis)b9b MSC:
bClientbNeeds:bSafebandbEffectivebCarebEnvironment:bManagementbof bC
are
21. Abvisitingbnursebis b makingban binitialbhomebvisit b for b abpatientb whobhas b manybchronic bmedical bproblems. bW hichbtype bofbdatabbase
bis b mostb appropriateb tobcollectbinbthis bsetting?
a. Abfollow-up bdatabbasebtobevaluate bchanges batbappropriatebintervals
b. An bepisodic bdatabbasebbecausebof bthebcontinuing, bcomplex bmedicalbproblems b of bthis bpatient
c. Abcompletebhealthbdatabbasebbecausebof bthebnurses bprimarybresponsibilitybfor bmo
nitoringbtheb patients bhealth
d. Anbemergencybdatabbaseb because bof bthebneed btobcollect binformation band bmakebaccurat
eb diagnoses b rapidly
ANS:bC
Thebcompletebdatabbasebis bcollected binbab primarybcarebsetting, bsuch bas b abpediatric b or bfamilyb pra
cticebclinic, b independent b or b group bprivatebpractice, bcollege bhealthbservice,b womens b healthbcarebag
ency,b visiting bnurseb agency,b or bcommunityb healthb agency. bInbthesebsettings, bthebnursebis bthebfirst
bhealthbprofessional btobseebthe
patient band bhas bthebprimarybresponsibility bfor bmonitoringbthebpersons bhealth bcare. bDIF:bCognitivebLevel: bApplyingb(Application)
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
22. Whichbsituationbis bmostbappropriate bduring bwhich bthebnursebperforms b abfocused bor bproble
m-centeredb history?
a. Patientb is b admittedbtobablong-termbcarebfacility.
b. Patientbhas babsuddenband bsevere bshortness b of bbreath.
c. Patientbis b admittedbtobthebhospital bfor bsurgerybthebfollowing bday.
d. Patientbin ban boutpatient bclinic bhas bcold band binfluenza-
likebsymptoms. b ANS:bD
Inbabfocused b orbproblem-
centered bdatabbase,bthebnursebcollects babmini bdatab base,b whichbis bsmaller bin bscopebthanb thebcom
pletedbdatabbase.bThis bminibdata b basebprimarilybconcerns b onebproblem, b onebcuebcomplex, b or b oneb
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Physical Examination and HealthbAssessmentb8eb(bybJarvis)b1b…
b b Level:b Applying
bodyb system. bDIF:bCognitive b b(Application) b b
MSC:b Client bNeeds:bSafebandbEffective bCarebEnvironment: bManagement bof bCare
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