p p p p p p
Chapter 01: Evidence-Based Assessment
p p p
MULTIPLEpCHOICE
1. Afterpcompletingpanpinitialpassessmentpofpappatient,pthepnursephaspchartedpthatphisprespirationsparep
eupneicpandphisppulsepisp58pbeatspperpminute.pTheseptypespofpdatapwouldpbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:pA
p
Objectivepdataparepwhatpthephealthpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpausculta
tingpduringpthepphysicalpexamination.pSubjectivepdatapispwhatptheppersonpsayspaboutphimporpherselfpduringphi
storyptaking.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p2
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
2. Appatientptellspthepnursepthatphepispverypnervous,pispnauseated,pandpfeelsphot.pTheseptypespofpdatapwouldp
be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:pC
p
Subjectivepdataparepwhatptheppersonpsayspaboutphimporpherselfpduringphistoryptaking.pObjectivepdataparep
whatpthephealthpprofessionalpobservespbypinspecting,ppercussing,ppalpating,pandpauscultatingpduringpthep
physicalpexamination.pTheptermspreflectivepandpintrospectiveparepnotpusedptopdescribepdata.
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p2
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
3. Theppatientsprecord,plaboratorypstudies,pobjectivepdata,pandpsubjectivepdatapcombineptopformpthe:
a. Datapbase.
b. Admittingpdata.
,TestpBank:pPhysicalpExaminationp&pHealthpAssessmentp7ep(Jarvisp2015)p3
c. Financialpstatement.
d. Dischargepsummary.
ANS:pA
p
Togetherpwithptheppatientsprecordpandplaboratorypstudies,pthepobjectivepandpsubjectivepdatapformpthepdatapba
se.pThepotherpitemsparepnotppartpofptheppatientsprecord,plaboratorypstudies,porpdata.
DIF:pCognitivepLevel:pRememberingp(Knowledge)pREF:pp.p2
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
4. Whenplisteningptopappatientspbreathpsounds,pthepnursepispunsurepofpapsoundpthatpispheard.pThepnursespnextp
actionpshouldpbepto:
a. Immediatelypnotifyptheppatientspphysician.
b. Documentpthepsoundpexactlypaspitpwaspheard.
c. Validatepthepdatapbypaskingpapcoworkerptoplistenptopthepbreathpsounds.
d. Assesspagainpinp20pminutesptopnotepwhetherpthepsoundpispstillppresent.p
ANS:pC
Whenpunsurepofpapsoundpheardpwhileplisteningptopappatientspbreathpsounds,pthepnursepvalidatespthepdataptopens
urepaccuracy.pIfpthepnursephasplesspexperiencepinpanparea,pthenpheporpshepaskspanpexpertptoplisten.
DIF:pCognitivepLevel:pAnalyzingp(Analysis)pREF:pp.p2
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
5. Thepnursepispconductingpapclasspforpnewpgraduatepnurses.pDuringpthepteachingpsession,pthepnursepshouldpk
eeppinpmindpthatpnovicepnurses,pwithoutpapbackgroundpofpskillspandpexperiencepfrompwhichptopdraw,parepmor
eplikelyptopmakeptheirpdecisionspusing:
a. Intuition.
b. Apsetpofprules.
c. Articlespinpjournals.
d. Advicepfrompsupervisors.
p ANS:pB
Novicepnursespoperatepfrompapsetpofpdefined,pstructuredprules.pThepexpertppractitionerpusespintuitiveplinks.p
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p3
,TestpBank:pPhysicalpExaminationp&pHealthpAssessmentp7ep(Jarvisp2015)p4
MSC:pClientpNeeds:pGeneral
6. Expertpnursesplearnptopattendptopappatternpofpassessmentpdatapandpactpwithoutpconsciouslyplabelingpit.p
Thesepresponsesparepreferredptopas:
a. Intuition.
b. Thepnursingpprocess.
c. Clinicalpknowledge.
d. Diagnosticpreasoning.p
ANS:pA
Intuitionpispcharacterizedpbyppatternprecognitionexpertpnursesplearnptopattendptopappatternpofpassessmentpdat
apandpactpwithoutpconsciouslyplabelingpit.pThepotherpoptionsparepnotpcorrect.
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p4p
MSC:pClientpNeeds:pGeneral
7. Thepnursepispreviewingpinformationpaboutpevidence-
basedppracticep(EBP).pWhichpstatementpbestpreflectspEBP?
a. EBPpreliesponptraditionpforpsupportpofpbestppractices.
b. EBPpispsimplypthepusepofpbestppracticeptechniquespforptheptreatmentpofppatients.
c. EBPpemphasizespthepusepofpbestpevidencepwithpthepclinicianspexperience.
d. TheppatientspownppreferencesparepnotpimportantpwithpEBP.p
ANS:pC
EBPpispapsystematicpapproachptoppracticepthatpemphasizespthepusepofpbestpevidencepinpcombinationpwithpthepc
linicianspexperience,paspwellpasppatientppreferencespandpvalues,pwhenpmakingpdecisionspaboutpcarepandptreat
ment.pEBPpispmorepthanpsimplypusingpthepbestppracticeptechniquesptoptreatppatients,pandpquestioningptraditio
npispimportantpwhenpnopcompellingpandpsupportivepresearchpevidencepexists.
DIF:pCognitivepLevel:pApplyingp(Application)pREF:pp.p5
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
8. Thepnursepispconductingpapclassponpprioritypsettingpforpapgrouppofpnewpgraduatepnurses.pWhichpispanp
examplepofpapfirst-levelpprioritypproblem?
a. Patientpwithppostoperativeppain
b. Newlypdiagnosedppatientpwithpdiabetespwhopneedspdiabeticpteaching
, TestpBank:pPhysicalpExaminationp&pHealthpAssessmentp7ep(Jarvisp2015)p5
c. Individualpwithpapsmallplacerationponpthepsolepofpthepfoot
d. Individualpwithpshortnesspofpbreathpandprespiratorypdistressp
ANS:pD
First-
levelpprioritypproblemsparepthosepthatparepemergent,plifepthreatening,pandpimmediatep(e.g.,pestablishingpanp
airway,psupportingpbreathing,pmaintainingpcirculation,pmonitoringpabnormalpvitalpsigns)p(seepTablep1-1).
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p4
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
9. Whenpconsideringpprioritypsettingpofpproblems,pthepnursepkeepspinpmindpthatpsecond-
levelpprioritypproblemspincludepwhichpofpthesepaspects?
a. Lowpself-esteem
b. Lackpofpknowledge
c. Abnormalplaboratorypvalues
d. Severelypabnormalpvitalpsignsp
ANS:pC
Second-
levelpprioritypproblemsparepthosepthatprequireppromptpinterventionptopforestallpfurtherpdeteriorationp(e.g.,pme
ntalpstatuspchange,pacuteppain,pabnormalplaboratorypvalues,prisksptopsafetyporpsecurity)p(seepTablep1-1).
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p4
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare
10. Whichpcriticalpthinkingpskillphelpspthepnursepseeprelationshipspamongpthepdata?
a. Validation
b. Clusteringprelatedpcues
c. Identifyingpgapspinpdata
d. Distinguishingprelevantpfrompirrelevant
p ANS:pB
Clusteringprelatedpcuesphelpspthepnursepseeprelationshipspamongpthepdata.p
DIF:pCognitivepLevel:pUnderstandingp(Comprehension)pREF:pp.p2
MSC:pClientpNeeds:pSafepandpEffectivepCarepEnvironment:pManagementpofpCare