,TableofContents
Chapter 01 Understanding Health Assessment _____________________________________________________ 1
t7 t7 t7 t7
Chapter 02 Interviewing the Patient forthe Health History
t7 t7 t7 t7 t7 t7 t7
11 Chapter 03 Taking the Health History __________________________________________ 40 t7 t7 t7 t7 t7
Chapter 04 Assessing Nutrition and Anthropometric Measurements
t7 t7 t7 t7 t7 t7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7
t 7 t 7 61 Chapter05AssessmentTechniques _______________________________________________ 88
t 7 t 7 t 7 t7 t 7 t7 t7
Chapter 06 General Survey and Assessing Vital Signs
t7 t7 t7 t7 t7 t7 t7
99 Chapter 07 Assessing Pain __________________ 128 t7 t7 t7 b3
Chapter08 Assessing the Skin, Hair, and Nails ____________________________________________________ 149
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Chapter 09 Assessing the Head,Face, Mouth, and Neck
t7 t7 t7 t7 t7 t7 b3
188 Chapter 10 Assessing the Ears______________________________________________ 229
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Chapter11 Assessing the Eyes ________________________________________________________________ 250
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Chapter 12 Assessing the Respiratory System
t7 t7 t7 t7 281 t7
Chapter 13 Assessing the Cardiovascular System
t7 t7 t7 t7 308 t7
Chapter 14 Assessing the Abdomen
t7 t7 t7 t7 335
Chapter 15 Assessing the Peripheral Vascular System and Regional Lymph System
t 7 t7 t 7 363 t7 t7 t 7 t7 t7 t7
atic
Chapter 16 Assessing the Musculoskeletal System
t7 t7 t7 t7 391 t7
Chapter 17 Assessing the Neurological System
t7 t7 t7 t7417 t7
Chapter 18 Assessing the Female Breasts, Axillae, and Reproductive System
t7 vt7 v t7 t7 451 t7 t7 t7 t7 t7
Chapter 19 Assessing the Male Breasts and Reproductive System
t7 t7 v# t7 477 t7 t7 b3 t7
Chapter 20 Assessing the Anus and Rectum
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Chapter 21 Assessing the Newborn
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t7
Chapter 22 Assessing theChild and Adolescent
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Chapter 23 Assessing the Pregnant Woman
t7 t7 v# t7 583 t7
Chapter 24 Assessing the Older Adult
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, Testt 7 Bankt 7 t 7 -
Chapter1:UnderstandingHealth Assessment t7
1. The World Health Organization (WHO) established a global strategy called “Health for All.
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” The goal for this strategy is:
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1. All individuals to get thesame health care throughout theirlifespans.
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2. Thegovernment to supply money to care for all the people in the world.
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3. Resourcesforhealth care tobe evenlydistributed andaccessible.
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4. Health-care providers can never deny patients health care.
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ANS:3
Page: 1 t7
Feedback
1. This is incorrect.“Health forAll”doesnot meanthat all individuals get thesame
t7 b3 t7 t7 t7 t7 t7 t7 t7
he
alth care throughout their life spans.
t7 b3 t7 t7 t7
2. This is incorrect. “Health forAll” does not mean thegovernment will supply money
t7 t7 t7 v# t7 t7 t7 t7 t7 t7 t7
to
care for all the people in the world.
t7 t7 t7 t7 t7 t7 t7
3. This iscorrect. “HealthforAll”means that resources forhealth care are evenly
b3 t7 t7 t7 b3 t7 vt7 v# t7
dis tribu ted t7 t7 v#
and accessible toeveryone.
t 7 t7 t7
4. This is incorrect. “Health forAll”doesnot mean that health-
b3 t7 t7 t7 t7 t7 t7 t7
care providers can deny patients health care.
t7 t7 t7 t7 t7 t7
2. Health assessment is a foundational and priority nursing skill. This essential skill require
t7 b3 t7 t7 t7 b3 t7 b3 t7 t7 t7 t7 t7
s registered nurses (RNs) to:
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1. Diagnose and treat patients.t7 t7 t 7
2. Identifynormal and abnormal findings. t7 t7 t7
3. Referpatients withabnormalfindings. v#
4. Counselpatients withpsychosocial needs. v# b3 t7
ANS:2
Page: 5-6
t7
Feedback
1. This is incorrect. The roleof the RNis not to diagnoseand treat patients.
t7 b3 t7 t7 t7 b3 t7 v# t7 t7 t7 v#
2. Thisis correct. Assessing patients andbeingableto identifynormalfrom abnormal
v# t7 v# t7 v# t7 t7 t7 v#
fin
dings is an essential role of the RN.
t7 t7 t7 t7 t7 t7 b3
3. This is incorrect.RNs in collaboration with thehealth-
v# t7 t7 v# vt7 t7
careprovidersdo refer patients.This is not the essential and foundational role i
t7 t7 t 7 t7 b3 t7 v# t7 t7 v# t7 b3
4. This is incorrect. RNs do counsel patients, but it is not theessentialand foundational
t7 b3 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 v#
ro
le in health assessment.
t7 t7 t7
3
, Testt 7 Bankt 7 t 7 -
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police pres
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 b3 t7 t7 t7 t7 b3 t7
ence outside his door because thepatient is aknown drug dealer in the community. You know that n
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 b3 t7 b3
urses must treat all patients as persons. This is called:
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1. Caring.
2. Holisticprocess.
3. Person-centered care (PCC). t7 t7
4. Standards of care. t7 vt 7
ANS:3
Page: 2 t7
Feedback
1. This is incorrect. Caring is displaying a concern for patients.
t7 t7 t7 t7 t7 t7 t7 t7 t7
2. This isincorrect. The holistic caring processisa relational process; thenurse
b3 t7 b3 t7 b3 t7 t7 v# t7 t7
coll aborate t7 t
s with the individual to pursue goals for health and well-being.
7 t7 t7 t7 t7 t7 t7 t7 t7 t7 v#
3. This iscorrect. Thenew movement in healthcare is person-
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centeredcare(PCC), which emphasizes the intrinsic valueoftreating all patients as t 7 t 7 v# t7 t7 v# t7 b3
4. Thisisincorrect.Standardsofcareidentifystandards ofprofessionalnursing t7
pr
actice.
4.Thescience-
basedframeworkupdated every10years bytheU.S.Department ofHealthand t7 b3 t7
HumanServices that h b3 t7 t
7as set national goals and objectives for health promotion and disease
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 prevention is: t7
1. HealthyPeople.
2. HealthyPeople2020.
3. U.S. Preventive Task Force.
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4. World Health Organization.
v# v#
ANS:2
Page: 2 t7
Feedback
1. This is incorrect. HealthyPeopleis the general title for the nation’s federal initiative.
b3 v# t7 t7 t7 t7 t7 t7 t7 t7 t7
2. This is correct. HealthyPeople2020specifically identifies science-
t7 t7 t7 t7 t7
based, national goalsandobjectiveswith10-
t7
yeartargets designed toguidenationalhealthpromotion t7 t7
anddisease prevention efforts t o imp t7 t7 b3 t7 t7 t7
r ove the health of all people in the United
t7 t7 t7 States. t7 t7 t7 t7 t7 t7
3. This isincorrect. TheU.S. Preventive Services Task Force’s goal is to useevidence
t7 t7 t7 t7 b3 t7 vt7 t7 t7 b3 t7 t7
-
based medicine to improve the health of all Americans by making evidence-
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7
based
recommendationsabout clinicalpreventive servicessuchasscreenings,counselin g ser t7 v t7 t7 t
vices, and preventivemedications.
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4
Chapter 01 Understanding Health Assessment _____________________________________________________ 1
t7 t7 t7 t7
Chapter 02 Interviewing the Patient forthe Health History
t7 t7 t7 t7 t7 t7 t7
11 Chapter 03 Taking the Health History __________________________________________ 40 t7 t7 t7 t7 t7
Chapter 04 Assessing Nutrition and Anthropometric Measurements
t7 t7 t7 t7 t7 t7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7 t 7
t 7 t 7 61 Chapter05AssessmentTechniques _______________________________________________ 88
t 7 t 7 t 7 t7 t 7 t7 t7
Chapter 06 General Survey and Assessing Vital Signs
t7 t7 t7 t7 t7 t7 t7
99 Chapter 07 Assessing Pain __________________ 128 t7 t7 t7 b3
Chapter08 Assessing the Skin, Hair, and Nails ____________________________________________________ 149
t7 t7 t7 v# t7 t7 v#
Chapter 09 Assessing the Head,Face, Mouth, and Neck
t7 t7 t7 t7 t7 t7 b3
188 Chapter 10 Assessing the Ears______________________________________________ 229
t7 t7 t7 t7 b3
Chapter11 Assessing the Eyes ________________________________________________________________ 250
t7 t7 t7 t7
Chapter 12 Assessing the Respiratory System
t7 t7 t7 t7 281 t7
Chapter 13 Assessing the Cardiovascular System
t7 t7 t7 t7 308 t7
Chapter 14 Assessing the Abdomen
t7 t7 t7 t7 335
Chapter 15 Assessing the Peripheral Vascular System and Regional Lymph System
t 7 t7 t 7 363 t7 t7 t 7 t7 t7 t7
atic
Chapter 16 Assessing the Musculoskeletal System
t7 t7 t7 t7 391 t7
Chapter 17 Assessing the Neurological System
t7 t7 t7 t7417 t7
Chapter 18 Assessing the Female Breasts, Axillae, and Reproductive System
t7 vt7 v t7 t7 451 t7 t7 t7 t7 t7
Chapter 19 Assessing the Male Breasts and Reproductive System
t7 t7 v# t7 477 t7 t7 b3 t7
Chapter 20 Assessing the Anus and Rectum
t7 vt 7 vt7 t7 501 t7 t7
Chapter 21 Assessing the Newborn
t7 t7 t 7 517
t7
Chapter 22 Assessing theChild and Adolescent
t7 v# t7 t7 555 t7 v#
Chapter 23 Assessing the Pregnant Woman
t7 t7 v# t7 583 t7
Chapter 24 Assessing the Older Adult
t7 t7 b3 t7 612 t7
, Testt 7 Bankt 7 t 7 -
Chapter1:UnderstandingHealth Assessment t7
1. The World Health Organization (WHO) established a global strategy called “Health for All.
t7 t7 b3 t7 t7 t7 b3 t7 t7 t7 t7 t7
” The goal for this strategy is:
t7 t7 t7 t7 t7
1. All individuals to get thesame health care throughout theirlifespans.
b3 t7 t7 v# b3 t7 b3 b3
2. Thegovernment to supply money to care for all the people in the world.
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7
3. Resourcesforhealth care tobe evenlydistributed andaccessible.
t7 b3 b3 t7 t7 t7
4. Health-care providers can never deny patients health care.
t7 t7 t7 t7 t7 t7 t7
ANS:3
Page: 1 t7
Feedback
1. This is incorrect.“Health forAll”doesnot meanthat all individuals get thesame
t7 b3 t7 t7 t7 t7 t7 t7 t7
he
alth care throughout their life spans.
t7 b3 t7 t7 t7
2. This is incorrect. “Health forAll” does not mean thegovernment will supply money
t7 t7 t7 v# t7 t7 t7 t7 t7 t7 t7
to
care for all the people in the world.
t7 t7 t7 t7 t7 t7 t7
3. This iscorrect. “HealthforAll”means that resources forhealth care are evenly
b3 t7 t7 t7 b3 t7 vt7 v# t7
dis tribu ted t7 t7 v#
and accessible toeveryone.
t 7 t7 t7
4. This is incorrect. “Health forAll”doesnot mean that health-
b3 t7 t7 t7 t7 t7 t7 t7
care providers can deny patients health care.
t7 t7 t7 t7 t7 t7
2. Health assessment is a foundational and priority nursing skill. This essential skill require
t7 b3 t7 t7 t7 b3 t7 b3 t7 t7 t7 t7 t7
s registered nurses (RNs) to:
t7 t7 t7 t7
1. Diagnose and treat patients.t7 t7 t 7
2. Identifynormal and abnormal findings. t7 t7 t7
3. Referpatients withabnormalfindings. v#
4. Counselpatients withpsychosocial needs. v# b3 t7
ANS:2
Page: 5-6
t7
Feedback
1. This is incorrect. The roleof the RNis not to diagnoseand treat patients.
t7 b3 t7 t7 t7 b3 t7 v# t7 t7 t7 v#
2. Thisis correct. Assessing patients andbeingableto identifynormalfrom abnormal
v# t7 v# t7 v# t7 t7 t7 v#
fin
dings is an essential role of the RN.
t7 t7 t7 t7 t7 t7 b3
3. This is incorrect.RNs in collaboration with thehealth-
v# t7 t7 v# vt7 t7
careprovidersdo refer patients.This is not the essential and foundational role i
t7 t7 t 7 t7 b3 t7 v# t7 t7 v# t7 b3
4. This is incorrect. RNs do counsel patients, but it is not theessentialand foundational
t7 b3 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 v#
ro
le in health assessment.
t7 t7 t7
3
, Testt 7 Bankt 7 t 7 -
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police pres
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 b3 t7 t7 t7 t7 b3 t7
ence outside his door because thepatient is aknown drug dealer in the community. You know that n
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 b3 t7 b3
urses must treat all patients as persons. This is called:
t7 t7 t 7 t7 t7 t7 t7 t7 t7
1. Caring.
2. Holisticprocess.
3. Person-centered care (PCC). t7 t7
4. Standards of care. t7 vt 7
ANS:3
Page: 2 t7
Feedback
1. This is incorrect. Caring is displaying a concern for patients.
t7 t7 t7 t7 t7 t7 t7 t7 t7
2. This isincorrect. The holistic caring processisa relational process; thenurse
b3 t7 b3 t7 b3 t7 t7 v# t7 t7
coll aborate t7 t
s with the individual to pursue goals for health and well-being.
7 t7 t7 t7 t7 t7 t7 t7 t7 t7 v#
3. This iscorrect. Thenew movement in healthcare is person-
t7 t7 t 7 t 7 t7 t 7 t 7
centeredcare(PCC), which emphasizes the intrinsic valueoftreating all patients as t 7 t 7 v# t7 t7 v# t7 b3
4. Thisisincorrect.Standardsofcareidentifystandards ofprofessionalnursing t7
pr
actice.
4.Thescience-
basedframeworkupdated every10years bytheU.S.Department ofHealthand t7 b3 t7
HumanServices that h b3 t7 t
7as set national goals and objectives for health promotion and disease
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 prevention is: t7
1. HealthyPeople.
2. HealthyPeople2020.
3. U.S. Preventive Task Force.
t7 t7 t7
4. World Health Organization.
v# v#
ANS:2
Page: 2 t7
Feedback
1. This is incorrect. HealthyPeopleis the general title for the nation’s federal initiative.
b3 v# t7 t7 t7 t7 t7 t7 t7 t7 t7
2. This is correct. HealthyPeople2020specifically identifies science-
t7 t7 t7 t7 t7
based, national goalsandobjectiveswith10-
t7
yeartargets designed toguidenationalhealthpromotion t7 t7
anddisease prevention efforts t o imp t7 t7 b3 t7 t7 t7
r ove the health of all people in the United
t7 t7 t7 States. t7 t7 t7 t7 t7 t7
3. This isincorrect. TheU.S. Preventive Services Task Force’s goal is to useevidence
t7 t7 t7 t7 b3 t7 vt7 t7 t7 b3 t7 t7
-
based medicine to improve the health of all Americans by making evidence-
t7 t7 t7 t7 t7 t7 t7 t7 t7 t7 t7
based
recommendationsabout clinicalpreventive servicessuchasscreenings,counselin g ser t7 v t7 t7 t
vices, and preventivemedications.
7 t7 b3
4