,Table of Contents
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1
2
Chapter 01: Evidence-Based Assessment
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15
Chapter 02: Cultural Assessment
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Chapter 03: The Interview
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31
Chapter 04: The Complete Health History
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49
Chapter 05: Mental Status Assessment
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64
Chapter 06: Substance Use Assessment
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80
Chapter 07: Domestic and Family Violence Assessment
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86
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
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92
Chapter 09: General Survey and Measurement
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111
Chapter 10: Vital Signs
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133
Chapter 11: Pain Assessment
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Chapter 12: Nutrition Assessment
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141
Chapter 13: Skin, Hair, and Nails
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155
Chapter 14: Head, Face, Neck, and Regional Lymphatics
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176
Chapter 15: Eyes
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194
Chapter 16: EarsL
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211
Chapter 17: Nose, Mouth, and Throat
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228
Chapter 18: Breasts, Axillae, and Regional Lymphatics Chapter
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246
19: Thorax and Lungs
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266
Chapter 20: Heart and Neck Vessels
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284
Chapter 21: Peripheral Vascular System and Lymphatic System Chapter
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303
22: Abdomen
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320
Chapter 23: Musculoskeletal System
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337
Chapter 24: Neurologic System
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358
TChapter 25: Male Genitourinary System
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382
Chapter 26: Anus, Rectum, and Prostate
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400
Chapter 27: Female Genitourinary System
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414
Chapter 28: The Complete Health Assessment: Adult
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436
Chapter 29: The Complete Physical Assessment: Infant, Child, and Adolescent
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449
Chapter 30: Bedside Assessment and Electronic Documentation
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452
Chapter 31: The Pregnant Woman
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458
Chapter 32: Functional Assessment of the Older Adult
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471
,Chapter 01: Evidence-Based Assessment L
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MULTIPLE CHOICE T L
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
T L T L T L L
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his pulse is 58 beats per minute. These types of data wouldbe:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A T L
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
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during the physical examination. Subjective data is what the person says about him or herself during history
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taking. The terms reflective and introspective are not used to describe data.
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DIF: Cognitive Level: Understanding (Comprehension)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C T L
Subjective data are what the person says about him or herself during history taking. Objective data are what the
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health professional observes by inspecting, percussing, palpating, and auscultating during the physical
L
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T T L T L T L
examination. The terms reflective and introspective are not used to describe data.
L
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DIF: Cognitive Level: Understanding (Comprehension)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
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a. Data base. L
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b. Admitting data. T L
, c. Financial statement. T L
d. Discharge summary. T L
ANS: A T L
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
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The other items are not part of the patients record, laboratory studies, or data.
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DIF: Cognitive Level: Remembering (Knowledge)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L L
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action should be to:
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a. Immediately notify the patients physician. T L T L T L T L
b. Document the sound exactly as it was heard. L
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c. Validate the data by asking a coworker to listen to the breath sounds. T L T L T L T L T L T L T L T L T L T L T L T L
d. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C T L
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure
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accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
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DIF: Cognitive Level: Analyzing (Analysis)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should
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keep in mind that novice nurses, without a background of skills and experience from which to draw, are
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Tmore likely to make their decisions using:
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a. Intuition.
b. A set of rules. L
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c. Articles in journals. T L T L
d. Advice from supervisors. T L T L
ANS: B T L
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
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T T L T L L
T L
T T L T L T L L
T T L T L
L
T DIF: Cognitive Level: Understanding (Comprehension)
T L T L T L T L
L
T L
T
1
2
Chapter 01: Evidence-Based Assessment
L
T L
T L
T
15
Chapter 02: Cultural Assessment
L
T L
T L
T L
T
Chapter 03: The Interview
L
T T L L
T
31
Chapter 04: The Complete Health History
L
T L
T L
T L
T L
T
49
Chapter 05: Mental Status Assessment
L
T L
T L
T T L L
T
64
Chapter 06: Substance Use Assessment
L
T L
T L
T L
T L
T
80
Chapter 07: Domestic and Family Violence Assessment
L
T L
T L
T L
T L
T L
T
86
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
L
T L
T L
T L
T L
T L
T L
T L
T L
T
92
Chapter 09: General Survey and Measurement
L
T L
T L
T L
T L
T L
T
111
Chapter 10: Vital Signs
T L L
T T L
118
133
Chapter 11: Pain Assessment
L
T L
T L
T L
T
Chapter 12: Nutrition Assessment
L
T L
T L
T
141
Chapter 13: Skin, Hair, and Nails
L
T L
T L
T T L L
T L
T
155
Chapter 14: Head, Face, Neck, and Regional Lymphatics
L
T L
T L
T L
T L
T L
T L
T
176
Chapter 15: Eyes
L
T L
T L
T
194
Chapter 16: EarsL
T T L
211
Chapter 17: Nose, Mouth, and Throat
L
T L
T T L T L L
T
228
Chapter 18: Breasts, Axillae, and Regional Lymphatics Chapter
L
T L
T T L L
T L
T L
T L
T
246
19: Thorax and Lungs
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T L
T L
T L
T
266
Chapter 20: Heart and Neck Vessels
L
T T L L
T L
T L
T
284
Chapter 21: Peripheral Vascular System and Lymphatic System Chapter
L
T L
T L
T L
T L
T L
T L
T L
T
303
22: Abdomen
L
T L
T
320
Chapter 23: Musculoskeletal System
T L L
T T L
337
Chapter 24: Neurologic System
L
T T L L
T T L
358
TChapter 25: Male Genitourinary System
L L
T L
T L
T L
T
382
Chapter 26: Anus, Rectum, and Prostate
L
T L
T L
T L
T L
T L
T
400
Chapter 27: Female Genitourinary System
L
T L
T L
T L
T
414
Chapter 28: The Complete Health Assessment: Adult
L
T T L L
T L
T L
T L
T
436
Chapter 29: The Complete Physical Assessment: Infant, Child, and Adolescent
L
T L
T L
T L
T L
T L
T L
T L
T L
T
449
Chapter 30: Bedside Assessment and Electronic Documentation
L
T L
T L
T L
T L
T L
T L
T
452
Chapter 31: The Pregnant Woman
L
T T L L
T L
T
458
Chapter 32: Functional Assessment of the Older Adult
L
T L
T L
T L
T L
T L
T L
T
471
,Chapter 01: Evidence-Based Assessment L
T L
T L
T
MULTIPLE CHOICE T L
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
T L T L T L L
T T L T L L
T L
T T L L
T T L T L T L T L T L T L T L
his pulse is 58 beats per minute. These types of data wouldbe:
L
T L
T T L L
T L
T L
T T L L
T T L L
T T L L
T
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A T L
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
T L T L L
T T L T L T L L
T T L T L T L T L T L T L
during the physical examination. Subjective data is what the person says about him or herself during history
L
T T L L
T L
T T L T L L
T L
T T L T L T L L
T T L T L T L T L T L
taking. The terms reflective and introspective are not used to describe data.
L
T T L T L T L T L T L T L T L T L T L T L T L
DIF: Cognitive Level: Understanding (Comprehension)
T L T L T L T L
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
T L T L T L T L T L T L T L T L T L T L
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C T L
Subjective data are what the person says about him or herself during history taking. Objective data are what the
T L T L T L T L L
T T L T L L
T T L L
T L
T T L T L T L T L T L L
T T L
health professional observes by inspecting, percussing, palpating, and auscultating during the physical
L
T L
T T L T L T L T L T L T L L
T T L T L T L
examination. The terms reflective and introspective are not used to describe data.
L
T T L T L L
T L
T T L L
T T L L
T T L T L T L
DIF: Cognitive Level: Understanding (Comprehension)
T L T L T L T L
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
T L T L T L T L T L T L T L T L T L T L
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
T L T L T L T L T L T L T L T L T L T L T L T L T L
a. Data base. L
T
b. Admitting data. T L
, c. Financial statement. T L
d. Discharge summary. T L
ANS: A T L
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
T L T L T L T L T L T L L
T T L T L T L L
T T L L
T L
T T L L
T
The other items are not part of the patients record, laboratory studies, or data.
L
T L
T T L L
T T L L
T T L T L T L T L T L T L L
T T L
DIF: Cognitive Level: Remembering (Knowledge)
T L T L T L T L
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
T L T L T L T L T L T L T L T L T L T L
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
T L T L T L T L T L T L T L T L T L T L T L T L T L T L T L L
T T L T L T L
action should be to:
L
T L
T L
T T L
a. Immediately notify the patients physician. T L T L T L T L
b. Document the sound exactly as it was heard. L
T T L L
T T L L
T L
T L
T
c. Validate the data by asking a coworker to listen to the breath sounds. T L T L T L T L T L T L T L T L T L T L T L T L
d. Assess again in 20 minutes to note whether the sound is still present.
T L T L T L T L T L T L T L T L T L T L T L T L
ANS: C T L
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure
T L T L L
T T L T L T L T L L
T L
T T L L
T T L L
T T L T L T L L
T T L T L
accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
L
T T L T L T L T L L
T T L T L T L L
T L
T T L L
T T L L
T T L T L T L L
T
DIF: Cognitive Level: Analyzing (Analysis)
T L T L T L T L
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
T L T L T L T L T L T L T L T L T L T L
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should
T L L
T T L T L T L T L L
T T L T L T L T L T L L
T L
T T L T L
keep in mind that novice nurses, without a background of skills and experience from which to draw, are
L
T T L T L T L T L T L T L T L T L T L T L T L T L T L L
T T L T L T L
Tmore likely to make their decisions using:
L T L T L T L T L T L T L
a. Intuition.
b. A set of rules. L
T T L L
T
c. Articles in journals. T L T L
d. Advice from supervisors. T L T L
ANS: B T L
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
T L T L T L T L L
T T L T L L
T L
T T L T L T L L
T T L T L
L
T DIF: Cognitive Level: Understanding (Comprehension)
T L T L T L T L
