Jarvis Physical Examination Health Assessment Chap_01

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Chapter 01: Critical Thinking in Health Assessment Text Bank

MULTIPLE CHOICE

1. After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

1. objective. 2. reflective. 3. subjective. 4. introspective. ANS: 1

Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical exam.

DIF: Comprehension REF: Page: 2

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.” This type of data would be:

1. objective. 2. reflective. 3. subjective. 4. introspective. ANS: 3

Subjective data are what the person says about himself or herself during history taking.

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3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the: 1. database. 2. admitting data. 3. financial statement. 4. discharge summary. ANS: 1

Together with the patient’s record and laboratory studies, the objective and subjective data form the database.

DIF: Knowledge REF: Page: 2 MSC: NCLEX: General

4. When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard. The nurse should:

1. notify the patient’s physician immediately. 2. document the sound exactly as it was heard.

3. validate the data by asking a coworker to listen to the breath sounds. 4. assess again in 20 minutes to note whether the sound is still present. ANS: 3

Validate any data that you need to make sure are accurate. If you have less experience in an area, ask an expert to listen.

DIF: Analysis REF: Page: 2

5. Novice nurses, without a background of skills and experience to draw from, are more likely to make their decisions using:

1. intuition. 2. a set of rules. 3. articles in journals. 4. advice from supervisors. ANS: 2

Novice nurses operate from a set of rules (such as the nursing process).

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6. Expert nurses learn to attend to a pattern of assessment data and to act without consciously labeling it. This is referred to as:

1. intuition.

2. the nursing process. 3. clinical knowledge. 4. diagnostic reasoning. ANS: 1

Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it.

DIF: Comprehension REF: Page: 3 MSC: NCLEX: General

7. Critical thinking in the expert nurse is greatly enhanced by opportunities to: 1. apply theory in real situations.

2. work with physicians to provide patient care. 3. follow physician orders in providing patient care.

4. develop nursing diagnoses for commonly occurring illnesses. ANS: 1

The depth and breadth of expert knowledge, largely gained from opportunities to apply theory in real situations, greatly enhances a nurse’s critical thinking ability.

DIF: Comprehension REF: Pages: 3-4 MSC: NCLEX: General

8. Which of the following is an example of a first-level priority problem? 1. A patient with postoperative pain

2. A newly diagnosed diabetic who needs diabetic teaching 3. An individual with a small laceration on the sole of the foot 4. An individual with shortness of breath and respiratory distress ANS: 4

First-level priority problems are those that are emergent, life-threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, and

monitoring abnormal vital signs).

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9. Second-level priority problems include which of the following? 1. Low self-esteem

2. Lack of knowledge

3. Abnormal laboratory values 4. Severely abnormal vital signs ANS: 3

Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, or risks to safety or security).

MSC: NCLEX: Safe and Effective Care Environment: Management of Care 10. Which critical thinking skill helps the nurse to see relationships among the data?

1. Validation

2. Clustering related cues 3. Identifying gaps in data

4. Distinguishing relevant from irrelevant ANS: 2

Clustering related cues helps the nurse to see relationships among the data.

11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the: 1. nursing diagnosis. 2. medical diagnosis. 3. admission diagnosis. 4. collaborative diagnosis. ANS: 1

An accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

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12. The nursing process is a sequential method of problem solving that includes which five steps? 1. Assessment, treatment, evaluation, discharge, follow-up

2. Admission, assessment, diagnosis, treatment, discharge planning 3. Admission, diagnosis, treatment, evaluation, discharge planning 4. Assessment, diagnosis, planning, implementation, evaluation ANS: 4

The nursing process is a method of problem solving that includes assessment, diagnosis, planning, implementation, and evaluation.

13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

1. Breathing, pain, sleep 2. Breathing, sleep, pain 3. Sleep, breathing, pain 4. Sleep, pain, breathing ANS: 1

First-level priority problems are immediate priorities (remember the ABCs), followed by second-level problems and then third-level problems.

14. Which of the following would be formulated by a nurse using diagnostic reasoning? 1. Nursing diagnosis

2. Medical diagnosis 3. Diagnostic hypothesis 4. Diagnostic assessment ANS: 3

Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis.

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15. A nursing diagnosis made by a critical thinker using a dynamic nursing process would diagnose the actual problem and would also:

1. continue to reassess. 2. predict potential problems.

3. check the appropriateness of goals. 4. modify the diagnosis if necessary. ANS: 2

A dynamic nursing process, as used by a critical thinker, would include underdiagnoses, diagnoses of actual problems, prediction of potential problems, and identification of strengths.

16. What is the step of the nursing process that includes data collection by health history, physical examination, and interview?

1. Planning 2. Diagnosis 3. Evaluation 4. Assessment ANS: 4

Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process.

17. Which statement illustrates the biomedical model of Western traditional views? 1. Health is viewed as the absence of disease.

2. Optimal health is viewed as high-level wellness. 3. Health and disease are considered a cyclical process. 4. The treatment of disease is nursing’s primary focus. ANS: 1

The biomedical model of Western tradition views health as the absence of disease.

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18. The public’s concept of health has changed since the 1950s. Which of the following statements most accurately describes this change?

1. Lifestyle, personal habits, exercise, and nutrition are essential to health. 2. Assessment of health is critical to identifying disease-causing pathogens.

3. Accurate diagnosis and treatment by a physician are essential for all health care. 4. An individual is considered healthy when signs and symptoms of disease have

been eliminated. ANS: 1

The accurate diagnosis and treatment of illness are important parts of health care, but the public’s concept of health has expanded since the 1950s. We have an increasing interest in lifestyle, personal habits, exercise and nutrition, and the social and natural environment.

19. Why is the concept of prevention essential in describing health? 1. Disease can be prevented by treating the external environment. 2. The majority of deaths among Americans under age 65 years are not

preventable.

3. Prevention places emphasis on the link between health and personal behavior. 4. The means to prevention is through treatment provided by primary health care

practitioners. ANS: 3

A natural progression to prevention now rounds out our concept of health. Guidelines to prevention place emphasis on the link between health and personal behavior.

20. Which statement about nursing diagnoses is true? They: 1. evaluate the etiology of disease.

2. are a process based on the medical diagnosis.

3. evaluate the response of the whole person to actual or potential health problems. 4. focus on the function and malfunction of a specific organ system in response to

disease. ANS: 3

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Nursing diagnoses are used to evaluate the response of the whole person to actual or potential health problems.

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21. An example of objective information obtained during the physical assessment includes the: 1. patient’s history of allergies.

2. patient’s use of medications at home. 3. last menstrual period 1 month ago.

4. 2 × 5 cm scar present on the right lower forearm. ANS: 4

Objective data are the patient’s record, laboratory studies, and information that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination.

DIF: Application REF: Page: 2

22. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of database is most appropriate to collect in this setting?

1. A follow-up database to evaluate changes at appropriate intervals

2. An episodic database because of the continuing, complex medical problems of this patient

3. A complete health database because of the nurse’s primary responsibility for monitoring the patient’s health

4. An emergency database because of the need to rapidly collect information and make accurate diagnoses

ANS: 3

The complete database is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency, or community health agency. In these settings the nurse is the first health professional to see the patient and has primary responsibility for monitoring the person’s health care.

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23. Which situation is most appropriate for an episodic history? 1. A patient’s admission to a long-term care facility 2. A patient has sudden, severe shortness of breath

3. A patient’s admission to the hospital for surgery the following day 4. A patient in an outpatient clinic has cold and flu-like symptoms ANS: 4

In an episodic or problem-centered database, the nurse collects a “mini” database, smaller in scope than the completed database. It concerns mainly one problem, one cue complex, or one body system.

24. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:

1. collect a follow-up database and then check her blood pressure.

2. ask her to read her health record and indicate any changes since her last visit. 3. check only her blood pressure because her complete health history was

documented 2 months ago.

4. obtain a complete health history before checking her blood pressure because much of her history information may have changed.

ANS: 1

A follow-up database is used in all settings to follow up short-term or chronic health problems.

25. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with the data collection?

1. Collect history information first, then perform the physical examination and institute life-saving measures.

2. Simultaneously ask history questions while performing the examination and initiating life-saving measures.

3. Collect all information on the history form, including social support patterns, strengths, and coping patterns.

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4. Perform life-saving measures and not ask any history questions until he is transferred to the intensive care unit.

ANS: 2

The emergency database calls for a rapid collection of the database, often compiled concurrently with life-saving measures.

26. Which statement correctly describes the age-specific charts for the periodic health examination? 1. They are used to help identify the diagnosis of an illness.

2. They are helpful in identifying developmental delays in children.

3. They recommend that every individual receive an annual physical exam.

4. They list a frequency schedule for periodic health visits for a specific age group. ANS: 4

The age-specific charts for the periodic health examination define a lifetime schedule of health care, organized into packages for eight specific age groups.

DIF: Knowledge REF: Page: 8

27. A 42-year-old Asian patient is being seen at the clinic for an initial examination. The nurse knows that it is important to include cultural information in his health assessment to: 1. identify the cause of his illness.

2. make accurate disease diagnoses.

3. provide cultural health rights for the individual. 4. provide culturally sensitive and appropriate care. ANS: 4

The inclusion of cultural considerations in health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.

MSC: NCLEX: Psychosocial Integrity

28. In the health promotion model, the focus of the health professional includes: 1. changing the patient’s perceptions of disease.

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2. identification of biomedical model interventions. 3. identifying negative health acts of the consumer. 4. helping the consumer choose a healthier lifestyle. ANS: 4

In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle.

DIF: Knowledge REF: Page: 7

MSC: NCLEX: Health Promotion and Maintenance

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29. Which of the following would be included in a holistic model of assessment? 1. Nursing goals for the patient

2. Anticipated growth and development patterns 3. A patient’s perception of his or her health status 4. The nurse’s perception of disease related to the patient ANS: 3

Holistic health views the mind, body, and spirit as functioning as a whole within the environment. A holistic model includes the patient’s perception of his or her health status, not the nurse’s perception or goals.

MSC: NCLEX: Health Promotion and Maintenance

30. When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?

1. Identifying existing levels of wellness 2. Evaluating previous problems and goals

3. Identifying potential problems the individual may develop

4. Focusing on strengths and reflecting an individual’s transition to higher levels of wellness

ANS: 3

Risk diagnoses are potential problems that an individual does not currently have but is particularly vulnerable to develop.

DIF: Application REF: Page: 5 MSC: NCLEX: General

31. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

1. Establish priorities.

2. Identify expected outcomes.

3. Evaluate the individual’s condition and compare actual outcomes with expected outcomes.

4. Interpret data and then identify clusters of cues and make inferences. ANS: 3

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Evaluation is the next step after the implementation phase of the nursing process.

During this step, the nurse should evaluate the individual’s condition and compare actual outcomes with expected outcomes.

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32. Which term best describes a proficient nurse?

1. A nurse who has little experience with a specified population and uses rules to guide performance

2. A nurse who has an intuitive grasp of a clinical situation and quickly identifies the accurate solution

3. A nurse who sees actions in the context of daily plans for patients

4. A nurse who understands a patient situation as a whole rather than a list of tasks and sees long-term goals for the patient

ANS: 4

The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than a list of tasks and is able to see how today’s nursing actions apply to the point the nurse wants the patient to reach at a future time.

DIF: Application REF: Page: 3 MSC: NCLEX: General

MATCHING

Put the following patient situations in order according to level of priority:

1. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.

2. A teenager who was stung by a bee during a soccer match is having trouble breathing.

3. An older adult with a urinary tract infection is also showing signs of confusion and agitation.

1. A = first-level priority problem 2. B = second-level priority problem 3. C = third-level priority problem

1. ANS: 2 DIF: Analysis REF: Page: 5