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Test Bank - Physical Examination and Health Assessment, 9th
Edition (Jarvis, 2024), Chapter 1-32 + NCLEX Case Studies with
answers | All Chapters A+ LATEST
After completing an initial assessment of a patient, the nurse has
charted that his respirationsare eupneic and his pulse is 58 beats
per minute. What type of assessment data is this?
a. Objective
b. Reflective
c. Subjective
d. Introspective - Answer--a. Objective
The nurse is conducting a class for new graduate nurses. While teaching the class, what would
the nurse keep in mind regarding what novice nurses, without a background of skills and
experience from which to draw upon, are more likely to base their decisions on?
a. Intuition
b. A set of rules
c. Articles in journals
d. Advice from supervisors - Answer--b. A set of rules
The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinician's experience.
d. EBP does not consider the patient's own preferences as important. - Answer--c. EBP emphasizes the use of best evidence with the clinician's experience.
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which
is an example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress - Answer--d. Individual with shortness of breath and respiratory distress
When considering priority setting of problems, the nurse keeps in mind that second-level
priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs - Answer--c. Abnormal laboratory values
Which critical-thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant - Answer--b. Clustering related cues
- When listening to a patient's breath sounds, the nurse is unsure of a sound that is heard.
Which action would the nurse take next?
a. Notify the patient's physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking another nurse to listen to the breath sounds.
d. Assess again in 20 minutes to note whether the sound is still present. - Answer--c. Validate the data by asking another nurse to listen to the breath sounds.
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?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing - Answer--ANS: A
First-level priority problems are immediate priorities, remembering the ABCs (airway,
breathing, and circulation), followed by second-level problems (e.g., mental status change,
acute pain, acute urinary elimination problems, untreated medical problems, abnormal
laboratory values, risks of infection, or risk to safety or security), and then third-level
problems (those that are important to the patient's health but can be attended to after more
urgent health problems are addressed).
Which statement best describes a proficient nurse?
a. Has little experience with a specified population and uses rules to guide
performance.
b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate
solution.
c. Sees actions in the context of daily plans for patients.
Understands a patient situation as a whole rather than a list of tasks and recognizes
the long-term goals for the patient - Answer--ANS: D
The proficient nurse, with more time and experience than the novice nurse, is able to
understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is
able to see how today's nursing actions can apply to the point the nurse wants the patient to
reach at a future time. A nurse that has little experience with a specified population and uses
rules to guide performance is a novice nurse. A nurse that has an intuitive grasp of a clinical
situation and quickly identifies the accurate solution is an expert nurse. Seeing actions in the
context of daily plans for patients describes competency or a competent nurse.
he nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis?
(Select all that apply.)
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - Answer--ANS: A, C, E, F
Clustering related cues helps the nurse recognize relationships among the data. The cues
related to the patient's respiratory status (e.g., wheezes, cough, report of dyspnea, respiration
rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to
- First-level priority problem
- Second-level priority problem
- Third-level priority problem
a. A teenager who was stung by a bee during a soccer match is having trouble breathing.
b. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his
own blood glucose levels with a glucometer.
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c. An older adult with a urinary tract infection is also showing signs of confusion and
agitation - Answer--ANS:
A, C, B
First-level priority problems are immediate priorities, such as trouble breathing (remember the
airway, breathing, circulation priorities). Second-level priority problems are next in urgency,
but not life-threatening. Third-level priorities (e.g., patient education) are important to a
patient's health but can be addressed after more urgent health problems are addressed.
Which is a barrier to incorporating EBP?
a. Nurses' lack of research skills in evaluating the quality of research studies
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills - Answer--Nurses' lack of research skills in evaluating the quality of research studies
During a staff meeting, nurses discuss the problems with identifying evidence-based practices
to incorporate into their practice. Which suggestion by the nurse manager would best help
these problems?
a. Form a committee to conduct research studies.
b. Post published research studies on the unit's bulletin boards.
c. Teach the nurses how to conduct research.
d. Ensuring time for staff to review current literature. - Answer--d. Ensuring time for staff to review current literature.
When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a. Disease originates from the external environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient's health state.
d. Holistic health views the mind, body, and spirit as interdependent. - Answer--ANS: D
Consideration of the whole person is the essence of holistic health, which views the mind,
body, and spirit as interdependent and functioning as a whole within the environment. The
basis of disease originates from both the external environment and from within the person; the
individual human is an open system, continually changing and adapting; and each person is
responsible for his or her own personal health state (not the nurse)
The nurse is performing a physical assessment on a newly admitted patient. Which is an
example of objective information obtained during the physical assessment?
a. Patient's history of allergies
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b. Patient's use of medications at home
c. Last menstrual period 1 month ago
d. 2 ´ 5 cm scar on the right lower forearm - Answer--d. 2 ´ 5 cm scar on the right lower forearm
smaller in scope than the complete database. This mini database primarily concerns one
problem, one cue complex, or one body system. A complete database should be conducted for
a patient being admitted to a long-term care facility or being admitted for a scheduled surgery.
An emergency database should be conducted for a patient with sudden and severe shortness of
breath.
The clinic nurse is caring for a patient who has been coming to the clinic weekly for blood
pressure checks since changing medications 2 months ago. Which is the most appropriate
action for the nurse to take?
a. Collect a follow-up database and then check the patient's blood pressure.
b. Ask the patient to read her health record and indicate any changes since her last
visit.
c. Check the patient's blood pressure.
d. Obtain a complete health history on the patient before checking her blood pressure. - Answer--ANS: A
A follow-up database is used in all settings to follow up on short-term or chronic health
problems. The other responses are not appropriate for the situation. Asking the patient to read
her health history and indicate any changes since her last visit is not appropriate. Just
checking the patient's blood pressure without following up on or assessing for any changes in
the patient's condition is inappropriate. It is not necessary to conduct a complete health
history as one was conducted 2 months ago. Rather a follow-up assessment regarding the
patient's blood pressure and factors associated with it are necessary
A patient is brought by ambulance to the emergency department with multiple injuries
received in an automobile accident. The patient is alert and cooperative, but their injuries are
quite severe. How would the nurse proceed with data collection?
a. Collect history information first then perform the physical examination and
institute lifesaving measures.
b. Simultaneously ask history questions while performing the examination and
initiating lifesaving measures.
c. Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
d. Perform lifesaving measures and delay asking any history questions until the
patient is transferred to the intensive care unit. - Answer--ANS: B
The emergency database calls for a rapid collection of data, often concurrently compiled with
lifesaving measures. The other responses are not appropriate for the situation. This is an
emergency situation and an emergency database with rapid collection of the data compiled
concurrently with lifesaving measures
