(Test Bank) Physical Examination & Health Assessment

Jarvis, 7

Nursing

Test Bank

7th Edition

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Test Bank for Physical Examination & Health Assessment, The downloadable file consists of 901 pages, and the total size of the file is 6.62 MB. Purchase now only for highly discounted price.

Author(s): Jarvis

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Study Note Preview

Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 1 Table of Contents Physical Examination - Test Bank Jarvis Table of Contents 1 Chapter 01: Evidence -Based Assessment Chapter 02: Cultural Competence Chapter 03: The Interview Chapter 04: The Complete Health History Chapter 05: Mental Status Assessment Chapter 06: Substance Use Assessment Chapter 07: Domestic and Family Violence Assessments Chapter 08: Assessment Techniques and Safety in the Clinical Setting Chapter 09: General Survey, Measurement, Vital Signs Chapter 10: Pain Assessment: The Fifth Vital Sign Chapter 11: Nutritional Assessment Chapter 12: Skin, Hair, and Nails Chapter 13: Head, Face, and Neck, Including Regional Lymphatics Chapter 14: Eyes Chapter 15: Ears Chapter 16: Nose, Mouth, and Throat Chapter 17: Breasts and Regional Lymphatics Chapter 18: Thorax and Lungs Chapter 19: Heart and Neck Vessels Chapter 20: Peripheral Vascular System and Lymphatic System Chapter 21: Abdomen Chapter 22: Musculoskeletal System Chapter 23: Neurologic System Chapter 24: Male Genitourinary System Chapter 25: Anus, Rectum, and Prostate Chapter 26: Female Genitourinary System Chapter 27: The Complete Health Assessment: Adult Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent Chapter 29: Bedside Assessment of the Hospitalized Patient Chapter 30: The Pregnant Woman Chapter 31: Functional Assessment of the Older Adult 2 15 31 49 64 81 87 93 112 134 142 156 177 195 212 229 247 267 285 304 321 338 359 384 402 416 438 451 454 460 473 Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 2 Chapter 01: Evidence -Based Assessment MULTIPLE CHOICE 1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective. ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. The patients record, laboratory studies, objective data, and subjective data combine to form the: Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 3 a. Data base. b. Admitting data. Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 4 c. Financial statement. d. Discharge summary. ANS: A Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present. ANS: C When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors. ANS: B Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 5 Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 6 MSC: Client Needs: General 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning. ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: General 7. 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 clinicians experience. d. The patients own preferences are not important with EBP. ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists. DIF: Cognitive Level: Applying (Application) REF: p. 5 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 8. 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 Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 7 b. Newly diagnosed patient with diabetes who needs diabetic teaching Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 8 c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 9. 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 ANS: C Second -level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1). DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 10. 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 ANS: B Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 9 (Comprehension) REF: p. 2 MSC: Client Needs: Safe and Effective Care Environment: Management of Care Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 10 11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the diagnosis. a. Nursing b. Medical c. Admission d. Collaborati ve ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow -up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 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? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 11 d. Sleep, pain, and breathing ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second -level problems, and then third -level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2 MSC: Client Needs: General 15. Barriers to incorporating EBP include: 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. ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6 MSC: Client Needs: General Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 12 16. What step of the nursing process includes data collection by health history, physical examination, and interview? Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 13 a. Planning b. Diagnosis c. Evaluation d. Assessme nt ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessmen step of the nursing process (see Figure 1-2). DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2 MSC: Client Needs: General 17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence -based clinical decision making into their practice. Which sugges tion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies. ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 18. 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 patients health state. Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 14 d. Holistic health views the mind, body, and spirit as interdependent. ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners. ANS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7 MSC: Client Needs: General 20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm. ANS: D Objective data are the patients record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical Test Bank: Physical Examination & Health Assessment 7e (Jarvis 2015) 15 examination. The other responses reflect subjective data. DIF: Cognitive Level: Applying (Application) REF: p. 2