TEST BANK
Physical Examination and Health Assessment, Canadian Edition
Carolyn Jarvis, Ann Eckhardt, Annette J. Browne, June MacDonald-Jenkins, and Marian Luctkar-Flude
4th Edition
,Table of Contents
Chapter 01 Critical Thinking and Evidence-Informed Assessment 1
Chapter 02 Health Promotion in the Context of Health Assessment 11
Chapter 03 A Relational Approach to Cultural and Social Considerations in Health
Assessment 18
Chapter 04 The Interview 29
Chapter 05 The Complete Health History 44
Chapter 06 Mental Health Assessment 57
Chapter 07 Substance Use and Health Assessment 66
Chapter 08 Interpersonal Violence and Health Assessment 73
Chapter 09 Assessment Techniques and the Clinical Setting 80
Chapter 10 General Survey, Measurement, and Vital Signs 94
Chapter 11 Pain Assessment 111
Chapter 12 Nutritional Assessment and Nursing Practice 118
Chapter 13 Skin, Hair, and Nails 132
Chapter 14 Head, Face, and Neck, Including Regional Lymphatic System 151
Chapter 15 Eyes 165
Chapter 16 Ears 178
Chapter 17 Nose, Mouth, and Throat 191
Chapter 18 Breasts and Regional Lymphatic System 205
Chapter 19 Thorax and Lungs 221
Chapter 20 Heart and Neck Vessels 236
Chapter 21 Peripheral Vascular System and Lymphatic System 251
Chapter 22 The Abdomen 264
Chapter 23 Anus, Rectum, and Prostate 277
Chapter 24 Musculo-Skeletal System 288
Chapter 25 Neurological System 304
Chapter 26 Male Genitourinary System 324
Chapter 27 Female Genitourinary System 338
Chapter 28 The Complete Health Assessment-Putting It All Together 355
Chapter 29 Bedside Assessment and Reporting 366
Chapter 30 Pregnancy 371
Chapter 31 Assessment of the Older Adult 382
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
Chapter 01: Critical Thinking and Evidence-Informed Assessment
Jarvis: Physical Examination and Health Assessment, 4th Canadian Edition
MULTIPLE CHOICE
1. Which type of data is collected by obtaining vital signs?
a. Objective
b. Reflecting
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 are what the person says
about themselves during history taking. The terms reflective and introspective are not used to
describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. During an assessment, a patient describes feeling warm, nauseated, and nervous. Which type
of data is collected?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data are what the person says about themselves 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. Which part of a patient’s health record is created when combining laboratory studies,
objective data, and subjective data?
a. Database
b. Admitting data
c. Triage form
d. Discharge summary
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data
form the database. The other items are not part of the patient’s record, laboratory studies, or
data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
4. Which action will the nurse complete if while listening to a patient’s breath sounds, they are
unsure of a sound heard?
a. Immediately notify the patient’s most responsible practitioner.
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 patient’s breath sounds, the nurse validates
the data to ensure accuracy. If the nurse has less experience in an area, then they would ask an
expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. Which approach do novice nurses utilize when making decisions?
a. Intuition
b. Clear-cut rules
c. Articles in journals
d. Advice from supervisors
ANS: B
Novice nurses operate from a set of defined, structured rules. Expert practitioners use critical
thinking and their substantial background of experience.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
6. Which method moves a nurse from novice to expert?
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANS: A
Critical thinking is a multidimensional, dynamic, and interactive thinking process by which
expert nurses assess and make decisions in the clinical area.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
7. Which statement reflects the meaning of evidence-informed practice (EIP)?
a. Best practice techniques to treat patients. Taking note solely from Registered
Nurses Association of Ontario (RNAO)
b. Clinician experience and expertise to guide practice. Sometimes reflecting on the
patient perspective
c. Life-long problem-solving approach to clinical decision making using best
available evidence
d. The patient’s own preferences are not important in EIP
ANS: C
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
EIP is more than the use of best practice techniques to treat patients; it can be defined as a
paradigm and lifelong problem-solving approach to clinical decision making that involves the
conscientious use of the best available evidence (including a systematic search for and critical
appraisal of the most relevant evidence to answer a clinical question) with one’s own clinical
expertise and patient values and preferences to improve outcomes for individuals, groups,
communities, and systems. EIP 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. Which example illustrates a first-level priority problem?
a. Postoperative pain
b. Newly diagnosed diabetes needing diabetic teaching
c. Small laceration on the sole of the foot
d. 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 – Identifying Immediate Priorities).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. Which critical thinking skill recognizes relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant data from irrelevant data
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which diagnosis is critical to develop appropriate nursing interventions for a patient?
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: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
11. Which steps are included in the nursing process?
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: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. A newly admitted patient is in acute pain, not sleeping well, and is having difficulty breathing.
In which sequence will the nurse prioritize the assessment?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
ANS: A
First-level priority problems are immediate priorities focused on airway and breathing,
followed by second-level problems, and then third-level problems.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. Which step of the nursing process involves data collection through health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
ANS: D
Data collection, including performing the health history, physical examination, and interview,
is the assessment step of the nursing process (see Figure 1.2).
DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General
14. Which concept is considered when undertaking a life-cycle approach to health assessment?
a. Consideration of the patient’s cultural view of health
b. Being responsive to the patient’s gestures to build a relationship
c. Acknowledgement of the effect of poverty on health
d. Awareness of age-specific developmental factors
ANS: D
A life-cycle approach requires familiarity with the usual and expected developmental tasks for
various age groups. Being aware of age-specific data can be helpful in determining normal
and abnormal findings.
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
15. Which statement outlines the purpose for a nurse identifying priorities and assessing risk
factors in patients?
a. Identify patterns to discover missing information.
b. Determine areas for health promotion and disease prevention.
c. Distinguish normal from abnormal findings.
d. Determine treatment for a medical diagnosis.
ANS: B
Identifying and working with patients to manage known risk factors for their age group and
social context supports disease prevention and health promotion.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
16. Which information is an example of objective data?
a. Patient’s history of allergies
b. Patient’s 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 patient’s 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. Which type of database is appropriate for a visiting nurse to use when making an initial home
visit with a patient who has many chronic medical problems?
a. A follow-up database to evaluate changes at appropriate intervals
b. An episodic database because of the continuing, complex medical problems of this
patient
c. A complete health database because of the nurse’s primary responsibility for
monitoring the patient’s health
d. An emergency database because of the need to collect information and make
accurate diagnoses rapidly
ANS: C
The complete database is collected in a primary care setting, such as a pediatric or family
practice clinic, independent or group private practice, college health service, women’s health
care agency, visiting nurse agency, or community health agency. In these settings, the nurse is
the first health care professional to see the patient and has the primary responsibility for
monitoring the person’s health care.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. Which situation is most appropriate for the collection of episodic or problem-centred data?
a. Admission to a long-term care facility
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
b. Sudden and severe shortness of breath
c. Admission to the hospital for surgery the next day
d. An outpatient clinic where patients have cold and influenza-like symptoms
ANS: D
In compiling the episodic or problem-centered database, the nurse collects a “mini-database,”
which is smaller in scope compared with the complete database. This mini database primarily
concerns one problem, one cue complex, or one body system.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. A patient is at the clinic to have their blood pressure checked. They have been coming to the
clinic weekly since changing medications two months ago. Which action will the nurse
perform?
a. Collect a follow-up database and then check blood pressure.
b. Ask patient to read health record and indicate any changes since last visit.
c. Check only blood pressure because the complete health history was documented
two months ago.
d. Obtain a complete health history before checking blood pressure because much of
the history information may have changed.
ANS: A
A follow-up database is used in all settings to monitor short-term or chronic health problems.
The other responses are not appropriate for the situation.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. Which method will the nurse take to collect data for a patient brought to the emergency
department by ambulance with multiple injuries after an automobile accident? The patient is
alert, cooperative, with severe injuries.
a. Collect history information first and then perform the physical examination and
institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and
initiating life-saving measures.
c. Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the
patient is transferred to the intensive care unit.
ANS: B
The emergency database calls for a rapid collection of the database, and often data are
compiled concurrently with administration of life-saving measures. The other responses are
not appropriate for the situation.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
21. Which example illustrates the new national and provincial guidelines developed for particular
populations?
a. Pain assessments
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
b. Human papillomavirus (HPV) vaccine guidelines
c. Antipsychotic medications
d. Acute urinary elimination treatments
ANS: B
In Canada, there are various guidelines for disease prevention and health promotion. New
national and provincial guidelines are developed regularly for particular populations; an
example is the updated recommendations on human papillomavirus (HPV) vaccine guidelines.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential
22. Which action will a nurse take during the clinical assessment of a 68-year-old patient?
a. Remind the patient use medication wisely.
b. Perform a tuberculin skin test.
c. Discuss body image and dieting.
d. Helping the consumer choose a healthier lifestyle.
ANS: A
For individuals aged 65 years and greater, reminding about medication safety is critical to
prevent injury (e.g., polypharmacy).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential
23. Which planned intervention with the nurse implement for the nursing diagnosis of acute pain?
a. Establish priorities for the patient and their care.
b. Identify expected outcomes for the nurse.
c. Evaluate patient’s condition and compare actual outcomes with expected
outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.
ANS: C
Evaluation is the next step after the implementation phase of the nursing process. During this
step, the nurse evaluates the individual’s condition and compares the actual outcomes with
expected outcomes.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
24. Which statement describes an experienced nurse?
a. Little experience with a specified population and uses rules to guide performance.
b. Takes a linear approach to the nursing process.
c. Is focused only on a patient’s disease process.
d. Understands a patient as a whole and recognizes long-term goals for the patient.
ANS: D
A nurse, who has more experience compared with the novice nurse, can understand a patient’s
situation as a whole, rather than as a list of tasks. Further, can see how today’s nursing actions
can apply to the point the nurse wants the patient to reach at a future time.
DIF: Cognitive Level: Applying (Application) MSC: Client Needs: General
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
25. In which type of problem, does the treatment involve multiple disciples, nurses having the
primary responsibility to diagnose and monitor change in status?
a. First-level priority problems
b. Second-level priority problems
c. Third-level priority problems
d. Collaborative problems
ANS: D
Collaborative problems are those in which the approach to treatment involves multiple
disciplines, and nurses often have the primary responsibility to diagnose the onset and monitor
the changes in status. For example, the data regarding financial strain and food security
represent a collaborative problem and require interprofessional team efforts to support
people’s health in the context of poverty. First-level priority problems are those that are
emergencies, life-threatening, and immediate, such as establishing an airway or supporting
breathing. Second-level priority problems are those that are next in urgency: those
necessitating your prompt intervention to forestall further deterioration, such as mental status
change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal
laboratory values, risks of infection, or risk to safety or security. Third-level priority problems
are those that are important to the patient’s health but can be addressed after more urgent
health problems are addressed. Referrals and interventions to address these problems are
lengthier, and the response to treatment is expected to take more time.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
26. Which concept is the collection of data about an individual’s health state?
a. Objective data
b. Subjective data
c. Assessment
d. The nursing process
ANS: C
Assessment is the collection of data about an individual’s health state. A clear idea of an
individual patient’s health status is important because it determines which assessment data
should be collected. In general, the list of data that must be collected has lengthened as the
concept of health has broadened.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. Which data listed below is considered to have related cues and would be clustered together
during analysis? (Select all that apply.)
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
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Physical Examination and Health Assessment, Canadian Edition
Carolyn Jarvis, Ann Eckhardt, Annette J. Browne, June MacDonald-Jenkins, and Marian Luctkar-Flude
4th Edition
,Table of Contents
Chapter 01 Critical Thinking and Evidence-Informed Assessment 1
Chapter 02 Health Promotion in the Context of Health Assessment 11
Chapter 03 A Relational Approach to Cultural and Social Considerations in Health
Assessment 18
Chapter 04 The Interview 29
Chapter 05 The Complete Health History 44
Chapter 06 Mental Health Assessment 57
Chapter 07 Substance Use and Health Assessment 66
Chapter 08 Interpersonal Violence and Health Assessment 73
Chapter 09 Assessment Techniques and the Clinical Setting 80
Chapter 10 General Survey, Measurement, and Vital Signs 94
Chapter 11 Pain Assessment 111
Chapter 12 Nutritional Assessment and Nursing Practice 118
Chapter 13 Skin, Hair, and Nails 132
Chapter 14 Head, Face, and Neck, Including Regional Lymphatic System 151
Chapter 15 Eyes 165
Chapter 16 Ears 178
Chapter 17 Nose, Mouth, and Throat 191
Chapter 18 Breasts and Regional Lymphatic System 205
Chapter 19 Thorax and Lungs 221
Chapter 20 Heart and Neck Vessels 236
Chapter 21 Peripheral Vascular System and Lymphatic System 251
Chapter 22 The Abdomen 264
Chapter 23 Anus, Rectum, and Prostate 277
Chapter 24 Musculo-Skeletal System 288
Chapter 25 Neurological System 304
Chapter 26 Male Genitourinary System 324
Chapter 27 Female Genitourinary System 338
Chapter 28 The Complete Health Assessment-Putting It All Together 355
Chapter 29 Bedside Assessment and Reporting 366
Chapter 30 Pregnancy 371
Chapter 31 Assessment of the Older Adult 382
,______________________________________________________________________________________________
Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
Chapter 01: Critical Thinking and Evidence-Informed Assessment
Jarvis: Physical Examination and Health Assessment, 4th Canadian Edition
MULTIPLE CHOICE
1. Which type of data is collected by obtaining vital signs?
a. Objective
b. Reflecting
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 are what the person says
about themselves during history taking. The terms reflective and introspective are not used to
describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. During an assessment, a patient describes feeling warm, nauseated, and nervous. Which type
of data is collected?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: C
Subjective data are what the person says about themselves 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. Which part of a patient’s health record is created when combining laboratory studies,
objective data, and subjective data?
a. Database
b. Admitting data
c. Triage form
d. Discharge summary
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data
form the database. The other items are not part of the patient’s record, laboratory studies, or
data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
4. Which action will the nurse complete if while listening to a patient’s breath sounds, they are
unsure of a sound heard?
a. Immediately notify the patient’s most responsible practitioner.
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 patient’s breath sounds, the nurse validates
the data to ensure accuracy. If the nurse has less experience in an area, then they would ask an
expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. Which approach do novice nurses utilize when making decisions?
a. Intuition
b. Clear-cut rules
c. Articles in journals
d. Advice from supervisors
ANS: B
Novice nurses operate from a set of defined, structured rules. Expert practitioners use critical
thinking and their substantial background of experience.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
6. Which method moves a nurse from novice to expert?
a. Critical thinking
b. The nursing process
c. Clinical knowledge
d. Diagnostic reasoning
ANS: A
Critical thinking is a multidimensional, dynamic, and interactive thinking process by which
expert nurses assess and make decisions in the clinical area.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
7. Which statement reflects the meaning of evidence-informed practice (EIP)?
a. Best practice techniques to treat patients. Taking note solely from Registered
Nurses Association of Ontario (RNAO)
b. Clinician experience and expertise to guide practice. Sometimes reflecting on the
patient perspective
c. Life-long problem-solving approach to clinical decision making using best
available evidence
d. The patient’s own preferences are not important in EIP
ANS: C
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,______________________________________________________________________________________________
Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
EIP is more than the use of best practice techniques to treat patients; it can be defined as a
paradigm and lifelong problem-solving approach to clinical decision making that involves the
conscientious use of the best available evidence (including a systematic search for and critical
appraisal of the most relevant evidence to answer a clinical question) with one’s own clinical
expertise and patient values and preferences to improve outcomes for individuals, groups,
communities, and systems. EIP 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)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. Which example illustrates a first-level priority problem?
a. Postoperative pain
b. Newly diagnosed diabetes needing diabetic teaching
c. Small laceration on the sole of the foot
d. 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 – Identifying Immediate Priorities).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. Which critical thinking skill recognizes relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant data from irrelevant data
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which diagnosis is critical to develop appropriate nursing interventions for a patient?
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: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
11. Which steps are included in the nursing process?
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: Remembering
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. A newly admitted patient is in acute pain, not sleeping well, and is having difficulty breathing.
In which sequence will the nurse prioritize the assessment?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
ANS: A
First-level priority problems are immediate priorities focused on airway and breathing,
followed by second-level problems, and then third-level problems.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
13. Which step of the nursing process involves data collection through health history, physical
examination, and interview?
a. Planning
b. Diagnosis
c. Evaluation
d. Assessment
ANS: D
Data collection, including performing the health history, physical examination, and interview,
is the assessment step of the nursing process (see Figure 1.2).
DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General
14. Which concept is considered when undertaking a life-cycle approach to health assessment?
a. Consideration of the patient’s cultural view of health
b. Being responsive to the patient’s gestures to build a relationship
c. Acknowledgement of the effect of poverty on health
d. Awareness of age-specific developmental factors
ANS: D
A life-cycle approach requires familiarity with the usual and expected developmental tasks for
various age groups. Being aware of age-specific data can be helpful in determining normal
and abnormal findings.
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,______________________________________________________________________________________________
Test Bank - Physical Examination and Health Assessment, 4th Canadian Edition (Jarvis, 2024)
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
15. Which statement outlines the purpose for a nurse identifying priorities and assessing risk
factors in patients?
a. Identify patterns to discover missing information.
b. Determine areas for health promotion and disease prevention.
c. Distinguish normal from abnormal findings.
d. Determine treatment for a medical diagnosis.
ANS: B
Identifying and working with patients to manage known risk factors for their age group and
social context supports disease prevention and health promotion.
DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
16. Which information is an example of objective data?
a. Patient’s history of allergies
b. Patient’s 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 patient’s 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. Which type of database is appropriate for a visiting nurse to use when making an initial home
visit with a patient who has many chronic medical problems?
a. A follow-up database to evaluate changes at appropriate intervals
b. An episodic database because of the continuing, complex medical problems of this
patient
c. A complete health database because of the nurse’s primary responsibility for
monitoring the patient’s health
d. An emergency database because of the need to collect information and make
accurate diagnoses rapidly
ANS: C
The complete database is collected in a primary care setting, such as a pediatric or family
practice clinic, independent or group private practice, college health service, women’s health
care agency, visiting nurse agency, or community health agency. In these settings, the nurse is
the first health care professional to see the patient and has the primary responsibility for
monitoring the person’s health care.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. Which situation is most appropriate for the collection of episodic or problem-centred data?
a. Admission to a long-term care facility
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b. Sudden and severe shortness of breath
c. Admission to the hospital for surgery the next day
d. An outpatient clinic where patients have cold and influenza-like symptoms
ANS: D
In compiling the episodic or problem-centered database, the nurse collects a “mini-database,”
which is smaller in scope compared with the complete database. This mini database primarily
concerns one problem, one cue complex, or one body system.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. A patient is at the clinic to have their blood pressure checked. They have been coming to the
clinic weekly since changing medications two months ago. Which action will the nurse
perform?
a. Collect a follow-up database and then check blood pressure.
b. Ask patient to read health record and indicate any changes since last visit.
c. Check only blood pressure because the complete health history was documented
two months ago.
d. Obtain a complete health history before checking blood pressure because much of
the history information may have changed.
ANS: A
A follow-up database is used in all settings to monitor short-term or chronic health problems.
The other responses are not appropriate for the situation.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. Which method will the nurse take to collect data for a patient brought to the emergency
department by ambulance with multiple injuries after an automobile accident? The patient is
alert, cooperative, with severe injuries.
a. Collect history information first and then perform the physical examination and
institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and
initiating life-saving measures.
c. Collect all information on the history form, including social support patterns,
strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the
patient is transferred to the intensive care unit.
ANS: B
The emergency database calls for a rapid collection of the database, and often data are
compiled concurrently with administration of life-saving measures. The other responses are
not appropriate for the situation.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
21. Which example illustrates the new national and provincial guidelines developed for particular
populations?
a. Pain assessments
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b. Human papillomavirus (HPV) vaccine guidelines
c. Antipsychotic medications
d. Acute urinary elimination treatments
ANS: B
In Canada, there are various guidelines for disease prevention and health promotion. New
national and provincial guidelines are developed regularly for particular populations; an
example is the updated recommendations on human papillomavirus (HPV) vaccine guidelines.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential
22. Which action will a nurse take during the clinical assessment of a 68-year-old patient?
a. Remind the patient use medication wisely.
b. Perform a tuberculin skin test.
c. Discuss body image and dieting.
d. Helping the consumer choose a healthier lifestyle.
ANS: A
For individuals aged 65 years and greater, reminding about medication safety is critical to
prevent injury (e.g., polypharmacy).
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Reduction of Risk Potential
23. Which planned intervention with the nurse implement for the nursing diagnosis of acute pain?
a. Establish priorities for the patient and their care.
b. Identify expected outcomes for the nurse.
c. Evaluate patient’s condition and compare actual outcomes with expected
outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.
ANS: C
Evaluation is the next step after the implementation phase of the nursing process. During this
step, the nurse evaluates the individual’s condition and compares the actual outcomes with
expected outcomes.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
24. Which statement describes an experienced nurse?
a. Little experience with a specified population and uses rules to guide performance.
b. Takes a linear approach to the nursing process.
c. Is focused only on a patient’s disease process.
d. Understands a patient as a whole and recognizes long-term goals for the patient.
ANS: D
A nurse, who has more experience compared with the novice nurse, can understand a patient’s
situation as a whole, rather than as a list of tasks. Further, can see how today’s nursing actions
can apply to the point the nurse wants the patient to reach at a future time.
DIF: Cognitive Level: Applying (Application) MSC: Client Needs: General
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25. In which type of problem, does the treatment involve multiple disciples, nurses having the
primary responsibility to diagnose and monitor change in status?
a. First-level priority problems
b. Second-level priority problems
c. Third-level priority problems
d. Collaborative problems
ANS: D
Collaborative problems are those in which the approach to treatment involves multiple
disciplines, and nurses often have the primary responsibility to diagnose the onset and monitor
the changes in status. For example, the data regarding financial strain and food security
represent a collaborative problem and require interprofessional team efforts to support
people’s health in the context of poverty. First-level priority problems are those that are
emergencies, life-threatening, and immediate, such as establishing an airway or supporting
breathing. Second-level priority problems are those that are next in urgency: those
necessitating your prompt intervention to forestall further deterioration, such as mental status
change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal
laboratory values, risks of infection, or risk to safety or security. Third-level priority problems
are those that are important to the patient’s health but can be addressed after more urgent
health problems are addressed. Referrals and interventions to address these problems are
lengthier, and the response to treatment is expected to take more time.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
26. Which concept is the collection of data about an individual’s health state?
a. Objective data
b. Subjective data
c. Assessment
d. The nursing process
ANS: C
Assessment is the collection of data about an individual’s health state. A clear idea of an
individual patient’s health status is important because it determines which assessment data
should be collected. In general, the list of data that must be collected has lengthened as the
concept of health has broadened.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. Which data listed below is considered to have related cues and would be clustered together
during analysis? (Select all that apply.)
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
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