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EXAMINATION BY

JARVIS EXAMINATION

STUDY GUIDE LAEST

UPDATED 2024/

EXAMINATION BY JARVIS

EXAMINATION STUDY GUIDE

LAEST UPDATED 2024/

Table of Contents

Table of Contents

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

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b. Admitting data.

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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

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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

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b. Newly diagnosed patient with diabetes who needs diabetic teaching

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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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. Collaborative

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

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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

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MSC: Client Needs: General

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

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c. Nurses are responsible for a patients health state.

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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 examination. The other responses reflect subjective data.

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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

a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly

ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens 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 the primary responsibility for monitoring the persons health care. DIF: Cognitive Level: Applying (Application) REF: p. 6 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history?

a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms.

ANS: D In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system. DIF: Cognitive Level: Applying (Application) REF: p. 7 MSC: Client Needs: Safe and Effective Care Environment: Management of Care

23. 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:

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a. Collect a follow-up data base and then check her blood pressure.