(Test Bank) Physical Examination And History Taking

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Test Bank

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Test Bank for Physical Examination And History Taking, The downloadable file consists of 302 pages, and the total size of the file is 1.08 MB. Purchase now only for highly discounted price.

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Guide To Physical Examination and History Test Bank MULTIPLE CHO ICE 1. After completing an initial assessment O,f a Patient, the nurse has charted that his resPiratiO,ns are eupneic and his Pulse is 58 beats Per minute, These tyPes O,f data wO,uld be: a , O,bjective, b , Reflective, c , Subjective, d , IntrO,sPective, ANS: A O,bjective data are what the health PrO,fessiO,nal O,bserves by insPecting, Percussing, PalPating, and auscultating during the Physical examinatiO,n, Subjective data is what the PersO,n says abO,ut him O,r herself during histO,ry taking, The terms reflective and intrO,sPective are nO,t used tO, describe data, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 2 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 2. A Patient tells the nurse that he is very nervO,us, is nauseated, and feels hO,t, These tyPes O,f data wO,uld be: a , O,bjective, b , Reflective, c , Subjective, d , IntrO,sPective, ANS: C Subjective data are what the PersO,n says abO,ut him O,r herself during histO,ry taking, O,bjective data are what the health PrO,fessiO,nal O,bserves by insPecting, Percussing, PalPating, and auscultating during the Physical examinatiO,n, The terms reflective and intrO,sPective are nO,t used tO, describe data, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 2 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 3. The Patients recO,rd, labO,ratO,ry studies, O,bjective data, and subjective data cO,mbine tO, fO, rm the: a , Data base, b , Admitting data, c , Financial statement, d , Discharge summary, ANS: A TO,gether with the Patients recO,rd and labO,ratO,ry studies, the O,bjective and subjective data fO,rm the data base, The O,ther items are nO,t Part O,f the Patients recO,rd, labO,ratO,ry studies, O,r data, DIF: CO,gnitive Level: Remembering (KnO,wledge) REF: P, 2 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 4. When listening tO, a Patients breath sO,unds, the nurse is unsure O,f a sO,und that is heard, The nurses next actiO,n shO,uld be tO,: a , Immediately nO,tify the Patients Physician, b , DO,cument the sO,und exactly as it was heard, c , Validate the data by asking a cO,wO,rker tO, listen tO, the breath sO,unds, d , Assess again in 20 minutes tO, nO,te whether the sO,und is still Present, ANS: C When unsure O,f a sO,und heard while listening tO, a Patients breath sO,unds, the nurse validates the data tO, ensure accuracy, If the nurse has less exPerience in an area, then he O,r she asks an exPert tO, listen, DIF: CO,gnitive Level: Analyzing (Analysis) REF: P, 2 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 5. The nurse is cO,nducting a class fO,r new graduate nurses, During the teaching se ssiO,n, the nurse shO,uld keeP in mind that nO,vice nurses, withO,ut a backgrO,und O,f skills and exPerience frO,m which tO, draw, are mO,re likely tO, make their decisiO,ns using: a , IntuitiO,n, b , A set O,f rules, c , Articles in jO,urnals, d , Advice frO,m suPervisO,rs, ANS: B NO,vice nurses O,Perate frO,m a set O,f defined, structured rules, The exPert PractitiO,ner uses intuitive links, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 3 MSC: Client Needs: General 6. ExPert nurses le arn tO, attend tO, a Pattern O,f assessment data and act withO,ut cO,nsciO,usly labeling it, These resPO,nses are referred tO, as: a , IntuitiO,n, b , The nursing PrO,cess, c , Clinical knO,wledge, d , DiagnO,stic reasO,ning, ANS: A IntuitiO,n is cha racterized by Pattern recO,gnitiO,nexPert nurses learn tO, attend tO, a Pattern O,f assessment data and act withO,ut cO,nsciO,usly labeling it, The O,ther O,PtiO,ns are nO,t cO,rrect, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 4 MSC: Client Needs: General 7. The nurse is reviewing infO,rmatiO,n abO,ut evidence -based Practice (EBP), Which statement best reflects EBP? a , EBP relies O,n traditiO,n fO,r suPPO,rt O,f best Practices, b , EBP is simPly the use O,f best Practice techniques fO,r the treatment O,f Patients, c , EBP emPhasizes the use O,f best evidence with the clinicians exPerience, d , The Patients O,wn Preferences are nO,t imPO,rtant with EBP, ANS: C EBP is a systematic aPPrO,ach tO, Practice that emPhasizes the use O,f best evidence in cO,mbinatiO,n with the clinicians exPerience, as well as Patient Preferences and values, when making decisiO,ns abO,ut care and treatment, EBP is mO,re than simPly using the best Practice techniques tO, treat Patients, and questiO,ning traditi O,n is imPO,rtant when nO, cO,mPelling and suPPO,rtive research evidence exists, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 5 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 8. The nurse is conducting a class o n Pri ority setting for a grouP o f new graduate nurses, Which is an examPle o f a first -level Priority Problem? a , Patient with PostO,Perative Pain b , Newly diagnO,sed Patient with diabetes wh o needs diabetic teaching c , Individual with a small laceration o n the sole of the foo t d , Individual with sho rtness of breath and respirato ry distress ANS: D First-level Priority Problems are tho se that are emergent, life threatening, and immediate (e,g,, establishing an airwa y, suppo rting bre athing, maintain ing circulation, monitoring abno rmal vital signs) DIF: Co gnitive Level: Understanding (ComPrehensio n) MSC: Client Needs: Safe and Effective Care Enviro nment: Management of Care 9. When considering PriO, 10. rity setting O,f PrO,blems, the nurse keePs in mind that secO,nd -level PriO,rity PrO,blems include which O,f these asPects? a , LO,w self-esteem b , Lack O,f knO,wledge c , AbnO,rmal labO,ratO,ry values d , Severely abnO,rmal vital signs ANS: C SecO,nd -level PriO,rity PrO,blems are thO,se that require PrO,mPt interventiO,n tO, fO,restall further deteriO,ratiO,n (e,g,, mental status change, acute Pain, abnO,rmal labO,ratO,ry values, risks tO, safety O,r security) (see Table 1-1), DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 4 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 11. Which critical thinking skill helPs the nurse see relatiO,nshiPs amO,ng the data? a , ValidatiO,n b , Clustering related cues c , Identifying gaPs in data d , Distinguishing relevant frO,m irrelevant ANS: B Clustering related cues helPs the nurse see relatiO,nshiPs amO,ng the data, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 2 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 12. The nurse knO,ws that develO,Ping aPPrO,Priate nursing interventiO,ns fO,r a Patient relies O,n the aPPrO,Priateness O,f the diagnO,sis, a Nursing , b Medical , c AdmissiO,n , d CO,llabO,rative , ANS: A An accu rate nursing diagnO,sis PrO,vides the basis fO,r the selectiO,n O,f nursing interventiO,ns tO, achieve O,utcO,mes fO,r which the nurse is accO,untable, The O,ther items dO, nO,t cO,ntribute tO, the develO,Pment O,f aPPrO,Priate nursing interventiO,ns, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 6 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 13. The nursing PrO,cess is a sequential methO,d O,f PrO,blem sO,lving that nurses use and includes which stePs? a Asses sment, treatment, Planning, evaluatiO,n, discharge, and fO,llO,w -uP , b AdmissiO,n, assessment, diagnO,sis, treatment, and discharge Planning , c AdmissiO,n, diagnO,sis, treatment, evaluatiO,n, and discharge Planning , d Assessment, diagnO,sis, O,utcO,m e identificatiO,n, Planning, imPlementatiO,n, and , evaluatiO,n ANS: D The nursing PrO,cess is a methO,d O,f PrO,blem sO,lving that includes assessment, diagnO,sis, O,utcO,me identificatiO,n, Planning, imPlementatiO,n, and evaluatiO,n, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 3 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 14. A newly admitted Patient is in acute Pain, has nO,t been sleePing well lately, and is having difficulty breathing, HO,w shO,uld the nurse PriO,ritize these PrO,blems? a , Breathing, Pain, and sleeP b , Breathing, sleeP, and Pain c , SleeP, breathing, and Pain d SleeP, Pain, and breathing , ANS: A First-level PriO,rity PrO,blems are immediate PriO,rities, remembering the ABCs (airway, breathing, and circulatiO,n), fO,llO,wed by secO,nd -level PrO,blems, and then third -level PrO,blems, DIF: CO,gnitive Level: Analyzing (Analysis) REF: P, 4 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 15. Which O,f these wO,uld be fO,rmulated by a nurse using diagnO,stic reasO,ning? a , Nursing diagnO,sis b , Medical diagnO,sis c , DiagnO,stic hyPO,thesis d , DiagnO,stic assessment ANS: C DiagnO,stic reasO,ning calls fO,r the nurse tO, fO,rmulate a diagnO,stic hyPO,t hesis; the nursing PrO,cess calls fO,r a nursing diagnO,sis, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 2 MSC: Client Needs: General 16. Barriers tO, incO,rPO,rating EBP include: a , Nurses lack O,f research skills in evaluating the quali ty O,f research studies, b , Lack O,f significant research studies, c , Insufficient clinical skills O,f nurses, d , Inadequate Physical assessment skills, ANS: A As individuals, nurses lack research skills in evaluating the quality O,f research studi es, are isO,lated frO,m O,ther cO,lleagues whO, are knO,wledgeable in research, and O,ften lack the time tO, visit the library tO, read research, The O,ther resPO,nses are nO,t cO,nsidered barriers, DIF: CO,gnitive Level: Understanding (CO,mPrehensiO,n) REF: P, 6 MSC: Client Needs: General 17. What steP O,f the nursing PrO,cess includes data cO,llectiO,n by health histO,ry, Physical examinatiO,n, and interview? a Planning , b DiagnO,sis , c EvaluatiO,n , d Assessment , ANS: D Data cO,llectiO,n, includin g PerfO,rming the health histO,ry, Physical examinatiO,n, and interview, is the assessment steP O,f the nursing PrO,cess (see Figure 1 -2), DIF: CO,gnitive Level: Remembering (KnO,wledge) REF: P, 2 MSC: Client Needs: General 18. During a staff meeting, nurses discuss the PrO,blems with accessing research studies tO, incO,rPO,rate evidence -based clinical decisiO,n making intO, their Practice, Which suggestiO,n by the nurse manager wO,uld best helP these PrO,blems? a , FO,rm a cO,mmittee tO, cO,nduct research studies, b , PO,st Published research studies O,n the units bulletin bO,ards, c , EncO,urage the nurses tO, visit the library tO, review studies, d , Teach the nurses hO,w tO, cO,nduct electrO,nic searches fO,r research studies, ANS: D Facilitating suPP O,rt fO,r EBP wO,uld include teaching the nurses hO,w tO, cO,nduct electrO,nic searches; time tO, visit the library may nO,t be available fO,r many nurses, Actually cO,nducting research studies may be helPful in the lO,ng -run but nO,t an immediate sO,lutiO ,n tO, reviewing existing research, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 6 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 19. When reviewing the cO,ncePts O,f health, the nurse recalls that the cO,mPO,nents O,f hO,listic health include which O,f these? a , Disease O,riginates frO,m the external envirO,nment, b , The individual human is a clO,sed system, c , Nurses are resPO,nsible fO,r a Patients health state, d , HO,listic health views the mind, bO,dy, and sPirit as interdePendent, ANS: D CO,nsideratiO,n O,f the whO,le PersO,n is the essence O,f hO,listic health, which views the mind, bO,dy, and sPirit as interdePendent, The basis O,f disease O,riginates frO,m bO,th the external envirO,nment and frO,m with in the PersO,n, BO,th the individual human and the external envirO,nment are O,Pen systems, cO,ntinually changing and adaPting, and each PersO,n is resPO,nsible fO,r his O,r her O,wn PersO,nal health state, DIF: CO,gnitive Level: Understanding (CO,mPrehen siO,n) REF: P, 7 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 20. The nurse recO,gnizes that the cO,ncePt O,f PreventiO,n in describing health is essential because: a , Disease can be Prevented by treating the external envirO,n ment, b , The majO,rity O,f deaths amO,ng Americans under age 65 years are nO,t Preventable, c , PreventiO,n Places the emPhasis O,n the link between health and PersO,nal behaviO,r, d , The means tO, PreventiO,n is thrO,ugh treatment PrO,vided by Primar y health care PractitiO,ners, ANS: C A natural PrO,gressiO,n tO, PreventiO,n rO,unds O,ut the Present cO,ncePt O,f health, Guidelines tO, PreventiO,n Place the emPhasis O,n the link between health and PersO,nal behaviO,r, DIF: CO,gnitive Level: Understa nding (CO,mPrehensiO,n) REF: P, 7 MSC: Client Needs: General 21. The nurse is PerfO,rming a Physical assessment O,n a newly admitted Patient, An examPle O,f O,bjective infO,rmatiO,n O,btained during the Physical assessment includes the: a , Patients histO,ry O,f allergies, b , Patients use O,f medicatiO,ns at hO,me, c , Last menstrual PeriO,d 1 mO,nth agO,, d , 2 5 cm scar O,n the right lO,wer fO,rearm, ANS: D O,bjective data are the Patients recO,rd, labO,ratO,ry studies, and cO,nditiO,n that the health PrO,fessiO,nal O,bserves by insPecting, Percussing, PalPating, and auscultating during the Physical examinatiO,n, The O,ther resPO,nses reflect subjective data, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 2 MSC: Client Needs: Safe and Effectiv e Care EnvirO,nment: Management O,f Care 22. A visiting nurse is making an initial hO,me visit fO,r a Patient whO, has many chrO,nic medical PrO,blems, Which tyPe O,f data base is mO,st aPPrO,Priate tO, cO,llect in this setting? a , A fO,llO,w -uP data base tO, evaluate changes at aPPrO,Priate intervals b , An ePisO,dic data base because O,f the cO,ntinuing, cO,mPlex medical PrO,blems O,f this Patient c , A cO,mPlete health data base because O,f the nurses Primary resPO,nsibility fO,r mO,nitO,ring the Patient s health d , An emergency data base because O,f the need tO, cO,llect infO,rmatiO,n and make accurate diagnO,ses raPidly ANS: C The cO,mPlete data base is cO,llected in a Primary care setting, such as a Pediatric O,r family Practice clinic, indePendent O,r grO,uP Private Practice, cO,llege health service, wO,mens health care agency, visiting nurse agency, O,r cO,mmunity health agency, In these settings, the nurse is the first health PrO,fessiO,nal tO, see the Patient and has the Primary resPO,nsibility fO,r mO,nitO,ring the PersO,ns health care, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 6 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 23. Which situatiO,n is mO,st aPPrO,Priate during which the nurse PerfO,rms a fO,cused O,r PrO,blem - centered histO,ry? a , Patient is admitted tO, a lO,ng -term care facility, b , Patient has a sudden and severe shO,rtness O,f breath, c , Patient is admitted tO, the hO,sPital fO,r surgery the fO,llO,wing day, d , Patient in an O,utP atient clinic has cO,ld and influenza -like symPtO,ms, ANS: D In a fO,cused O,r PrO,blem -centered data base, the nurse cO,llects a mini data base, which is smaller in scO,Pe than the cO,mPleted data base, This mini data base Primarily cO,ncerns O,ne PrO,b lem, O,ne cue cO,mPlex, O,r O,ne bO,dy system, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 7 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 24. A Patient is at the clinic tO, have her blO,O,d Pressure checked, She has been cO,ming tO, the clinic weekly since she changed medicatiO,ns 2 mO,nths agO,, The nurse shO,uld: a , CO,llect a fO,llO,w -uP data base and then check her blO,O,d Pressure, b , Ask her tO, read her health recO,rd and indicate any changes since her last visit, c , Check O,nly her blO,O,d Pressure because her cO,mPlete health histO,ry was dO,cumented 2 mO,nths agO,, d , O,btain a cO,mPlete health histO,ry befO,re checking her blO,O,d Pressure because much O,f her histO,ry infO,rmatiO,n may have changed, ANS: A A fO,llO,w -uP data base is used in all settings tO, fO,llO,w uP shO,rt -term O,r chrO,nic health PrO,blems, The O,ther resPO,nses are nO,t aPPrO,Priate fO,r the situatiO,n, DIF: CO,gnitive Level: APPlying (APPlicatiO,n) REF: P, 7 MSC: Client Need s: Safe and Effective Care EnvirO,nment: Management O,f Care 25. A Patient is brO,ught by ambulance tO, the emergency dePartment with multiPle traumas received in an autO,mO,bile accident, He is alert and cO,O,Perative, but his injuries are quite severe, HO,w wO,uld the nurse PrO,ceed with data cO,llectiO,n? a CO,llect histO,ry infO,rmatiO,n first, then PerfO,rm the Physical examinatiO,n and , institute life-saving measures, b , SimultaneO,usly ask histO,ry questiO,ns while PerfO,rming the examinatiO,n and initiating life-saving measures, c , CO,llect all infO,rmatiO,n O,n the histO,ry fO,rm, including sO,cial suPPO,rt Patterns, strengths, and cO,Ping Patterns, d , PerfO,rm life -saving measures and delay asking any histO,ry questiO,ns until the Patient is transferred tO, the intensive care unit, ANS: B The emergency data base calls fO,r a raPid cO,llectiO,n O,f the data base, O,ften cO,ncurrently cO,mPiled with life -saving measures, The O,ther resPO,nses are nO,t aPPrO,Priate fO,r the situatiO,n, DIF: CO,gnitive Level: Analyzing (Analysis) REF: P, 7 MSC: Client Needs: Safe and Effective Care EnvirO,nment: Management O,f Care 26. A 42 -year-O,ld Patient O,f Asian descent is being seen at the clinic fO,r an initial examinatiO,n, The nurse knO,ws that including cultural infO,rmatiO,n in his health assessment is imPO,rtant tO,: a Identify the cause O,f his illness, , b Make accurate disease diagnO,ses, , c PrO,vide cultural health rights fO,r the individual, , d PrO,vide culturally sensitive and aPPrO,Priate care, , ANS: D The inclusiO,n O,f cultural cO,nsideratiO,ns in the health assessment is O,f ParamO,unt imPO,rtance tO, gathering data that are accurate and meaningful and tO, intervening with culturally sensitive and aPPrO,Priate care, CHAPTER 2 Evaluating Clinical Evidence MULTIPLE CHO,ICE 1. When PerfO,rming a Physical assessment, the first technique the nurse will always use is: a , PalPatiO,n, b , InsPectiO,n, c , PercussiO,n,