Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 1
Table of Contents o l o l
Table of Contents o l o l 1
Chapter 01: Evidence-Based o l o l 2
oAssessmentChapter 02: Cultural
l l
o ol o l 15
oCompetence Chapter 03: The Interview
l ol ol ol ol 31
Chapter 04: The Complete Health History
o l o l o l o l o l 49
Chapter 05: Mental Status Assessment
l
o o l o l o l o l 64
Chapter 06: Substance Use Assessment
ol o l o l o l o l 81
Chapter 07: Domestic and Family Violence Assessments
o l o l o l o l o l o l 87
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
o l o l o l o l o l o l o l o l o l 93
Chapter 09: General Survey, Measurement, Vital Signs
l
o ol ol ol ol ol ol 112
Chapter 10: Pain Assessment: The Fifth Vital SignChapter
o l o l o l o l o l o l o l l
o 134
11: Nutritional Assessment
ol ol ol 142
Chapter 12: Skin, Hair, and Nails
o l o l o l o l o l 156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
o l o l o l o l o l o l o l o l 177
Chapter 14: Eyes
l
o ol ol 195
Chapter 15: Ears o l o l 212
Chapter 16: Nose, Mouth, and Throat
ol ol o l o l o l 229
Chapter 17: Breasts and Regional Lymphatics
ol o l o l o l o l o l 247
Chapter 18: Thorax and Lungs
l
o ol ol ol ol 267
Chapter 19: Heart and Neck Vessels
o l o l o l o l o l 285
Chapter 20: Peripheral Vascular System and Lymphatic SystemChapter
o l o l o l o l o l o l o l l
o 304
21: Abdomen
ol ol 321
Chapter 22: Musculoskeletal System
o l o l o l 338
Chapter 23: Neurologic System
ol ol o l o l 359
Chapter 24: Male Genitourinary System
ol o l o l o l o l 384
Chapter 25: Anus, Rectum, and Prostate
o l o l o l o l o l 402
Chapter 26: Female Genitourinary System
ol o l o l o l o l 416
Chapter 27: The Complete Health Assessment: Adult
o l o l o l o l o l o l 438
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
o l o l o l o l o l o l o l o l o l 451
Chapter 29: Bedside Assessment of the Hospitalized Patient
l
o ol ol ol ol ol ol ol 454
Chapter 30: The Pregnant Woman
o l o l o l o l 460
Chapter 31: Functional Assessment of the Older Adult
o l o l o l o l o l o l o l 473
,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 2
Chapter 01: Evidence-Based Assessment o l o l o l
MULTIPLE CHOICE o l
1. Aftercompletinganinitialassessmentofapatient,thenursehaschartedthathisrespirationsareeupneicandhis pulse
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
is 58 beats per minute. These typesof datawould be:
ol ol ol ol ol ol ol ol ol ol ol
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:A ol
Objectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultatingduring
ol ol ol ol ol ol ol ol ol ol ol ol ol ol
the physical examination. Subjective data is what the person says about him or herself during historytaking. The
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
termsreflectiveandintrospective arenot used to describe data.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
2. Apatienttellsthenursethatheisverynervous,isnauseated,andfeelshot.Thesetypesofdatawouldbe:
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:C ol
Subjectivedataarewhatthepersonsaysabouthimorherselfduringhistorytaking.Objectivedataarewhatthehealth
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The
ol ol ol ol ol ol ol ol ol ol ol ol ol
termsreflectiveandintrospectiveare not usedtodescribe data.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
3. Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombinetoformthe:
ol ol ol ol ol ol ol ol ol ol ol ol ol
a. Database. ol
b. Admittingdata. ol
,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 3
c. Financial statement. o l
d. Dischargesummary. ol
ANS:A ol
Togetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataformthedatabase.Theother
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
items arenot part of thepatients record,laboratory studies,ordata.
ol ol ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Remembering(Knowledge)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
4. Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard.Thenursesnextaction
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
should be to:
ol ol ol
a. Immediatelynotifythepatientsphysician. ol ol ol ol
b. Documentthesoundexactlyasitwasheard. ol ol ol ol ol ol ol
c. Validatethedatabyaskingacoworkertolistentothebreathsounds. ol ol ol ol ol ol ol ol ol ol ol ol
d. Assessagainin20minutestonotewhetherthesoundisstillpresent. ol ol ol ol ol ol ol ol ol ol ol ol
ANS:C ol
Whenunsureofasoundheardwhilelisteningtoapatientsbreathsounds,thenursevalidatesthedatatoensureaccuracy.If
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
thenursehas lessexperienceinanarea,thenheorsheasksanexperttolisten.
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Analyzing(Analysis)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
5. Thenurse isconducting aclassfor new graduate nurses.Duringtheteachingsession,thenurseshould keepinmind
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
that novice nurses, without a background of skills and experience from which to draw, are more likely to make their
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
decisions using:
ol ol
a. Intuition.
b. Asetofrules.
ol ol ol
c. Articlesinjournals. ol ol
d. Advicefromsupervisors. ol ol
ANS:B ol
Novicenursesoperatefromasetofdefined,structuredrules.Theexpertpractitionerusesintuitivelinks.DIF:
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
Cognitive Level: Understanding (Comprehension) REF: p. 3
ol ol ol ol ol ol ol
, Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 4
MSC:ClientNeeds:General ol ol ol
6. Expertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.These
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
responses are referred to as:
ol ol ol ol ol
a. Intuition.
b. Thenursingprocess. ol ol
c. Clinicalknowledge. ol
d. Diagnosticreasoning. ol
ANS:A ol
Intuitionischaracterizedbypatternrecognitionexpertnurseslearntoattendtoapatternofassessmentdataandact
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
without consciously labeling it. Theother options are notcorrect.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.4
ol ol ol ol ol ol ol
MSC: ClientNeeds: General
ol ol ol ol
7. Thenurseisreviewinginformationaboutevidence-basedpractice(EBP).WhichstatementbestreflectsEBP?
ol ol ol ol ol ol ol ol ol ol ol ol ol
a. EBPreliesontraditionforsupportofbestpractices. ol ol ol ol ol ol ol ol
b. EBPissimplytheuseofbestpracticetechniquesforthetreatmentofpatients.
ol ol ol ol ol ol ol ol ol ol ol ol ol
c. EBPemphasizestheuseofbestevidencewiththecliniciansexperience. ol ol ol ol ol ol ol ol ol ol
d. ThepatientsownpreferencesarenotimportantwithEBP. ol ol ol ol ol ol ol ol
ANS: C
ol ol
EBPisasystematicapproachtopracticethatemphasizestheuseofbestevidenceincombinationwiththeclinicians
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
than simply using the best practice techniques to treat patients, and questioning traditionisimportant whenno
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
compellingandsupportiveresearchevidence exists.
ol ol ol ol ol ol
DIF:CognitiveLevel:Applying(Application)REF:p.5
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
8. Thenurseisconductingaclassonprioritysettingforagroupofnewgraduatenurses.Whichisanexampleof a first-
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
level priority problem?
ol ol
a. Patientwithpostoperativepain ol ol ol
b. Newlydiagnosedpatientwithdiabeteswhoneedsdiabeticteaching ol ol ol ol ol ol ol ol
ol ol ol ol ol l
o ol ol ol 1
Table of Contents o l o l
Table of Contents o l o l 1
Chapter 01: Evidence-Based o l o l 2
oAssessmentChapter 02: Cultural
l l
o ol o l 15
oCompetence Chapter 03: The Interview
l ol ol ol ol 31
Chapter 04: The Complete Health History
o l o l o l o l o l 49
Chapter 05: Mental Status Assessment
l
o o l o l o l o l 64
Chapter 06: Substance Use Assessment
ol o l o l o l o l 81
Chapter 07: Domestic and Family Violence Assessments
o l o l o l o l o l o l 87
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
o l o l o l o l o l o l o l o l o l 93
Chapter 09: General Survey, Measurement, Vital Signs
l
o ol ol ol ol ol ol 112
Chapter 10: Pain Assessment: The Fifth Vital SignChapter
o l o l o l o l o l o l o l l
o 134
11: Nutritional Assessment
ol ol ol 142
Chapter 12: Skin, Hair, and Nails
o l o l o l o l o l 156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
o l o l o l o l o l o l o l o l 177
Chapter 14: Eyes
l
o ol ol 195
Chapter 15: Ears o l o l 212
Chapter 16: Nose, Mouth, and Throat
ol ol o l o l o l 229
Chapter 17: Breasts and Regional Lymphatics
ol o l o l o l o l o l 247
Chapter 18: Thorax and Lungs
l
o ol ol ol ol 267
Chapter 19: Heart and Neck Vessels
o l o l o l o l o l 285
Chapter 20: Peripheral Vascular System and Lymphatic SystemChapter
o l o l o l o l o l o l o l l
o 304
21: Abdomen
ol ol 321
Chapter 22: Musculoskeletal System
o l o l o l 338
Chapter 23: Neurologic System
ol ol o l o l 359
Chapter 24: Male Genitourinary System
ol o l o l o l o l 384
Chapter 25: Anus, Rectum, and Prostate
o l o l o l o l o l 402
Chapter 26: Female Genitourinary System
ol o l o l o l o l 416
Chapter 27: The Complete Health Assessment: Adult
o l o l o l o l o l o l 438
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
o l o l o l o l o l o l o l o l o l 451
Chapter 29: Bedside Assessment of the Hospitalized Patient
l
o ol ol ol ol ol ol ol 454
Chapter 30: The Pregnant Woman
o l o l o l o l 460
Chapter 31: Functional Assessment of the Older Adult
o l o l o l o l o l o l o l 473
,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 2
Chapter 01: Evidence-Based Assessment o l o l o l
MULTIPLE CHOICE o l
1. Aftercompletinganinitialassessmentofapatient,thenursehaschartedthathisrespirationsareeupneicandhis pulse
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
is 58 beats per minute. These typesof datawould be:
ol ol ol ol ol ol ol ol ol ol ol
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:A ol
Objectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultatingduring
ol ol ol ol ol ol ol ol ol ol ol ol ol ol
the physical examination. Subjective data is what the person says about him or herself during historytaking. The
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
termsreflectiveandintrospective arenot used to describe data.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
2. Apatienttellsthenursethatheisverynervous,isnauseated,andfeelshot.Thesetypesofdatawouldbe:
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:C ol
Subjectivedataarewhatthepersonsaysabouthimorherselfduringhistorytaking.Objectivedataarewhatthehealth
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The
ol ol ol ol ol ol ol ol ol ol ol ol ol
termsreflectiveandintrospectiveare not usedtodescribe data.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
3. Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombinetoformthe:
ol ol ol ol ol ol ol ol ol ol ol ol ol
a. Database. ol
b. Admittingdata. ol
,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 3
c. Financial statement. o l
d. Dischargesummary. ol
ANS:A ol
Togetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataformthedatabase.Theother
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
items arenot part of thepatients record,laboratory studies,ordata.
ol ol ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Remembering(Knowledge)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
4. Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard.Thenursesnextaction
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
should be to:
ol ol ol
a. Immediatelynotifythepatientsphysician. ol ol ol ol
b. Documentthesoundexactlyasitwasheard. ol ol ol ol ol ol ol
c. Validatethedatabyaskingacoworkertolistentothebreathsounds. ol ol ol ol ol ol ol ol ol ol ol ol
d. Assessagainin20minutestonotewhetherthesoundisstillpresent. ol ol ol ol ol ol ol ol ol ol ol ol
ANS:C ol
Whenunsureofasoundheardwhilelisteningtoapatientsbreathsounds,thenursevalidatesthedatatoensureaccuracy.If
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
thenursehas lessexperienceinanarea,thenheorsheasksanexperttolisten.
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Analyzing(Analysis)REF:p.2
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
5. Thenurse isconducting aclassfor new graduate nurses.Duringtheteachingsession,thenurseshould keepinmind
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
that novice nurses, without a background of skills and experience from which to draw, are more likely to make their
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
decisions using:
ol ol
a. Intuition.
b. Asetofrules.
ol ol ol
c. Articlesinjournals. ol ol
d. Advicefromsupervisors. ol ol
ANS:B ol
Novicenursesoperatefromasetofdefined,structuredrules.Theexpertpractitionerusesintuitivelinks.DIF:
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
Cognitive Level: Understanding (Comprehension) REF: p. 3
ol ol ol ol ol ol ol
, Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
ol ol ol ol ol l
o ol ol ol 4
MSC:ClientNeeds:General ol ol ol
6. Expertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.These
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
responses are referred to as:
ol ol ol ol ol
a. Intuition.
b. Thenursingprocess. ol ol
c. Clinicalknowledge. ol
d. Diagnosticreasoning. ol
ANS:A ol
Intuitionischaracterizedbypatternrecognitionexpertnurseslearntoattendtoapatternofassessmentdataandact
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
without consciously labeling it. Theother options are notcorrect.
ol ol ol ol ol ol ol ol ol ol
DIF:CognitiveLevel:Understanding(Comprehension)REF:p.4
ol ol ol ol ol ol ol
MSC: ClientNeeds: General
ol ol ol ol
7. Thenurseisreviewinginformationaboutevidence-basedpractice(EBP).WhichstatementbestreflectsEBP?
ol ol ol ol ol ol ol ol ol ol ol ol ol
a. EBPreliesontraditionforsupportofbestpractices. ol ol ol ol ol ol ol ol
b. EBPissimplytheuseofbestpracticetechniquesforthetreatmentofpatients.
ol ol ol ol ol ol ol ol ol ol ol ol ol
c. EBPemphasizestheuseofbestevidencewiththecliniciansexperience. ol ol ol ol ol ol ol ol ol ol
d. ThepatientsownpreferencesarenotimportantwithEBP. ol ol ol ol ol ol ol ol
ANS: C
ol ol
EBPisasystematicapproachtopracticethatemphasizestheuseofbestevidenceincombinationwiththeclinicians
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
than simply using the best practice techniques to treat patients, and questioning traditionisimportant whenno
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
compellingandsupportiveresearchevidence exists.
ol ol ol ol ol ol
DIF:CognitiveLevel:Applying(Application)REF:p.5
ol ol ol ol ol ol ol
MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
ol ol ol ol ol ol ol ol ol ol
8. Thenurseisconductingaclassonprioritysettingforagroupofnewgraduatenurses.Whichisanexampleof a first-
ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol ol
level priority problem?
ol ol
a. Patientwithpostoperativepain ol ol ol
b. Newlydiagnosedpatientwithdiabeteswhoneedsdiabeticteaching ol ol ol ol ol ol ol ol
