1
Table of Contents
Tablec of 1
Contents
Chapterc 01:c Evidence-Based 2
AssessmentjChapterc 02:c Cultural 15
Assessment 31
Chapterc 03:c Thec Interview 49
Chapterc 04:c Thec Completec Health 64
HistoryChapterc 05:c Mentalc StatuscAsses 80
smentc Chapterc 06:c SubstancecUsec Ass 86
essment 92
Chapterc 07:c Domesticc andc Familyc Violencec Assessment 111
Chapterc 08:c Assessmentc Techniquesc andc Safetyc inc the Clinical 118
SettingChapterc 09:c Generalc Surveyc andc Measurement 133
Chapterc 10:c Vitalc Signs 141
Chapterc 11:c Pain 155
Assessment 176
Chapterc 12:c Nutrition 194
AssessmentChapterc 13:c Skin, 211
Hair,c andc Nails 228
Chapterc 14:c Head,c Face,c Neck,c andc Regional 246
LymphaticsChapterc 15:c Eyes 266
Chapter 16: Ears 284
Chapterc 17:c Nose,c Mouth,c andc ThroatcChapter 303
c 18:c Breasts,c Axillae,c andc RegionalcLymphatic 320
sChapterc 19:c Thoraxc andc LungscChapterc 20:c 337
Heartc andc Neckc Vessels 358
Chapterc 21:c Peripheralc Vascularc Systemc andc Lymphaticc SystemcChapter 382
c 22:c Abdomen 400
Chapterc 23:c Musculoskeletalc Systemc 414
Chapterc 24: Neurologic 436
SystemcChapterc 25:c M 449
alec GenitourinarycSystem 452
Chapterc 26:c Anus,c Rectum,c andc ProstatecCha 458
pterc 27:c Femalec Genitourinaryc System 471
Chapterc 28:c Thec Completec Healthc Assessment:c Adult
Chapterc 29:c Thec Completec Physicalc Assessment:c Infant,c Child,c andcAdoles
centChapterc 30:c Bedsidec Assessmentc andc Electronicc DocumentationcChapterc
31:c Thec Pregnantc Woman
Chapterc 32:c Functionalc Assessmentc ofc thec Olderc Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEc CHOICE
1. Afterc completingc anc initialc assessmentc ofc ac patient,c thec nursec hasc chartedc thatc hisc respirationsc arece
upneicc andhisc pulsec isc 58c beatsc perc minute.c Thesec typesc ofc datac wouldc be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:c A
Objectivec datac arec whatc thec healthc professionalc observesc byc inspecting,c percussing,c palpating,c andcausc
ultatingduringc thec physicalc examination.c Subjectivec datac isc whatc thec personc saysc aboutc himc orc herself
c duringc historytaking. c Thec termsc reflectivec andc introspectivec arec notc usedc toc describec data.
DIF:c Cognitivec Level:c Understandingc (Comprehension)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
2. Ac patientc tellsc thec nursec thatc hec isc veryc nervous,c isc nauseated,c andc feelsc hot.c Thesec typesc ofc datac
wouldc be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:c C
Subjectivec datac arec whatc thec personc saysc aboutc himc orc herselfc duringc historyc taking.c Objectivec datac arecwh
atc thehealthc professionalc observesc byc inspecting,c percussing,c palpating,c andc auscultatingc duringc thecphysical
c examination. c Thec termsc reflectivec andc introspectivec arec notc usedc toc describe c data.
DIF:c Cognitivec Level:c Understandingc (Comprehension)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
3. Thec patientsc record,c laboratoryc studies,c objectivec data,c andc subjectivec datac combinec toc formc the:
a. Datac base.
b. Admittingc data.
, 3
c. Financialc statement.
d. Dischargec summary.
ANS:c A
Togetherc withc thec patientsc recordc andc laboratoryc studies,c thec objectivec andc subjectivec datac formc thecdata
c base.The c otherc itemsc arec notc partc ofc thec patients c record,c laboratory c studies,c orc data.
DIF:c Cognitivec Level:c Rememberingc (Knowledge)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
4. Whenc listeningc toc ac patientsc breathc sounds,c thec nursec isc unsurec ofc ac soundc thatc isc heard.c Thecn
ursesc nextactionc shouldc bec to:
a. Immediatelyc notifyc thec patientsc physician.
b. Documentc thec soundc exactlyc asc itc wasc heard.
c. Validatec thec datac byc askingc ac coworkerc toc listenc toc thec breathc sounds.
d. Assessc againc inc 20c minutesc toc notec whetherc thec soundc isc stillc present.
ANS:c C
Whenc unsurec ofc ac soundc heardc whilec listeningc toc ac patientsc breathc sounds,c thec nursec validatesc thec datact
oc ensureaccuracy.c Ifc thec nursec hasc lessc experiencec inc anc area,c thenc hec orc shec asksc anc expertc toc listen.
DIF:c Cognitivec Level:c Analyzingc (Analysis)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
5. Thec nursec isc conductingc ac classc forc newc graduatec nurses.c Duringc thec teachingc session,c thec nursecshou
ldc keepcinc mindc thatc novicec nurses,c withoutc ac backgroundc ofc skillsc andc experiencec fromc whichc tocdraw,
c arec morec likelyto c makec theirc decisions c using:
a. Intuition.
b. Ac setc ofc rules.
c. Articlesc inc journals.
d. Advicec fromc supervisors.
ANS:c B
Novicec nursesc operatec fromc ac setc ofc defined,c structuredc rules.c Thec expertc practitionerc usesc intuitiveclinks.DIF
:c Cognitivec Level:c Understandingc (Comprehension)
, 4
MSC:c Clientc Needs:c General
6. Expertc nursesc learnc toc attendc toc ac patternc ofc assessmentc datac andc actc withoutc consciouslyc labelingcit
.c Theseresponsesc arec referredc toc as:
a. Intuition.
b. Thec nursingc process.
c. Clinicalc knowledge.
d. Diagnosticc reasoning.
ANS:c A
Intuitionc isc characterizedc byc patternc recognitionexpertc nursesc learnc toc attendc toc ac patternc ofc assessmentcd
atac andactc withoutc consciouslyc labelingc it.c Thec otherc optionsc arec notc correct.
DIF:c Cognitivec Level:c Understandingc(Comprehensi
on)MSC:c Clientc Needs:c General
7. Thec nursec isc reviewingc informationc aboutc evidence-
basedc practicec (EBP).c Whichc statementc bestcreflectsEBP?
a. EBPc reliesc onc traditionc forc supportc ofc bestc practices.
b. EBPc isc simplyc thec usec ofc bestc practicec techniquesc forc thec treatmentc ofc patients.
c. EBPc emphasizesc thec usec ofc bestc evidencec withc thec cliniciansc experience.
d. Thec patientsc ownc preferencesc arec notc importantc with
EBP.ANS:c C
EBPc isc ac systematicc approachc toc practicec thatc emphasizesc thec usec ofc bestc evidencec inc combinationc withcth
ecliniciansc experience,c asc wellc asc patientc preferencesc andc values,c whenc makingc decisionsc aboutccare
c andc treatment.c EBP c isc morec thanc simply c usingc thec bestc practice c techniques c toc treatc patients,candc q
uestioningc traditionc isc importantc whenc noc compellingc andc supportivec researchc evidencec exists.
DIF:c Cognitivec Level:c Applyingc (Application)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
8. Thec nursec isc conductingc ac classc onc priorityc settingc forc ac groupc ofc newc graduatec nurses.c Whichc isca
nc exampleofc ac first-levelc priorityc problem?
a. Patientc withc postoperativec pain
b. Newlyc diagnosedc patientc withc diabetesc whoc needsc diabeticc teaching
Table of Contents
Tablec of 1
Contents
Chapterc 01:c Evidence-Based 2
AssessmentjChapterc 02:c Cultural 15
Assessment 31
Chapterc 03:c Thec Interview 49
Chapterc 04:c Thec Completec Health 64
HistoryChapterc 05:c Mentalc StatuscAsses 80
smentc Chapterc 06:c SubstancecUsec Ass 86
essment 92
Chapterc 07:c Domesticc andc Familyc Violencec Assessment 111
Chapterc 08:c Assessmentc Techniquesc andc Safetyc inc the Clinical 118
SettingChapterc 09:c Generalc Surveyc andc Measurement 133
Chapterc 10:c Vitalc Signs 141
Chapterc 11:c Pain 155
Assessment 176
Chapterc 12:c Nutrition 194
AssessmentChapterc 13:c Skin, 211
Hair,c andc Nails 228
Chapterc 14:c Head,c Face,c Neck,c andc Regional 246
LymphaticsChapterc 15:c Eyes 266
Chapter 16: Ears 284
Chapterc 17:c Nose,c Mouth,c andc ThroatcChapter 303
c 18:c Breasts,c Axillae,c andc RegionalcLymphatic 320
sChapterc 19:c Thoraxc andc LungscChapterc 20:c 337
Heartc andc Neckc Vessels 358
Chapterc 21:c Peripheralc Vascularc Systemc andc Lymphaticc SystemcChapter 382
c 22:c Abdomen 400
Chapterc 23:c Musculoskeletalc Systemc 414
Chapterc 24: Neurologic 436
SystemcChapterc 25:c M 449
alec GenitourinarycSystem 452
Chapterc 26:c Anus,c Rectum,c andc ProstatecCha 458
pterc 27:c Femalec Genitourinaryc System 471
Chapterc 28:c Thec Completec Healthc Assessment:c Adult
Chapterc 29:c Thec Completec Physicalc Assessment:c Infant,c Child,c andcAdoles
centChapterc 30:c Bedsidec Assessmentc andc Electronicc DocumentationcChapterc
31:c Thec Pregnantc Woman
Chapterc 32:c Functionalc Assessmentc ofc thec Olderc Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEc CHOICE
1. Afterc completingc anc initialc assessmentc ofc ac patient,c thec nursec hasc chartedc thatc hisc respirationsc arece
upneicc andhisc pulsec isc 58c beatsc perc minute.c Thesec typesc ofc datac wouldc be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:c A
Objectivec datac arec whatc thec healthc professionalc observesc byc inspecting,c percussing,c palpating,c andcausc
ultatingduringc thec physicalc examination.c Subjectivec datac isc whatc thec personc saysc aboutc himc orc herself
c duringc historytaking. c Thec termsc reflectivec andc introspectivec arec notc usedc toc describec data.
DIF:c Cognitivec Level:c Understandingc (Comprehension)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
2. Ac patientc tellsc thec nursec thatc hec isc veryc nervous,c isc nauseated,c andc feelsc hot.c Thesec typesc ofc datac
wouldc be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:c C
Subjectivec datac arec whatc thec personc saysc aboutc himc orc herselfc duringc historyc taking.c Objectivec datac arecwh
atc thehealthc professionalc observesc byc inspecting,c percussing,c palpating,c andc auscultatingc duringc thecphysical
c examination. c Thec termsc reflectivec andc introspectivec arec notc usedc toc describe c data.
DIF:c Cognitivec Level:c Understandingc (Comprehension)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
3. Thec patientsc record,c laboratoryc studies,c objectivec data,c andc subjectivec datac combinec toc formc the:
a. Datac base.
b. Admittingc data.
, 3
c. Financialc statement.
d. Dischargec summary.
ANS:c A
Togetherc withc thec patientsc recordc andc laboratoryc studies,c thec objectivec andc subjectivec datac formc thecdata
c base.The c otherc itemsc arec notc partc ofc thec patients c record,c laboratory c studies,c orc data.
DIF:c Cognitivec Level:c Rememberingc (Knowledge)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
4. Whenc listeningc toc ac patientsc breathc sounds,c thec nursec isc unsurec ofc ac soundc thatc isc heard.c Thecn
ursesc nextactionc shouldc bec to:
a. Immediatelyc notifyc thec patientsc physician.
b. Documentc thec soundc exactlyc asc itc wasc heard.
c. Validatec thec datac byc askingc ac coworkerc toc listenc toc thec breathc sounds.
d. Assessc againc inc 20c minutesc toc notec whetherc thec soundc isc stillc present.
ANS:c C
Whenc unsurec ofc ac soundc heardc whilec listeningc toc ac patientsc breathc sounds,c thec nursec validatesc thec datact
oc ensureaccuracy.c Ifc thec nursec hasc lessc experiencec inc anc area,c thenc hec orc shec asksc anc expertc toc listen.
DIF:c Cognitivec Level:c Analyzingc (Analysis)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
5. Thec nursec isc conductingc ac classc forc newc graduatec nurses.c Duringc thec teachingc session,c thec nursecshou
ldc keepcinc mindc thatc novicec nurses,c withoutc ac backgroundc ofc skillsc andc experiencec fromc whichc tocdraw,
c arec morec likelyto c makec theirc decisions c using:
a. Intuition.
b. Ac setc ofc rules.
c. Articlesc inc journals.
d. Advicec fromc supervisors.
ANS:c B
Novicec nursesc operatec fromc ac setc ofc defined,c structuredc rules.c Thec expertc practitionerc usesc intuitiveclinks.DIF
:c Cognitivec Level:c Understandingc (Comprehension)
, 4
MSC:c Clientc Needs:c General
6. Expertc nursesc learnc toc attendc toc ac patternc ofc assessmentc datac andc actc withoutc consciouslyc labelingcit
.c Theseresponsesc arec referredc toc as:
a. Intuition.
b. Thec nursingc process.
c. Clinicalc knowledge.
d. Diagnosticc reasoning.
ANS:c A
Intuitionc isc characterizedc byc patternc recognitionexpertc nursesc learnc toc attendc toc ac patternc ofc assessmentcd
atac andactc withoutc consciouslyc labelingc it.c Thec otherc optionsc arec notc correct.
DIF:c Cognitivec Level:c Understandingc(Comprehensi
on)MSC:c Clientc Needs:c General
7. Thec nursec isc reviewingc informationc aboutc evidence-
basedc practicec (EBP).c Whichc statementc bestcreflectsEBP?
a. EBPc reliesc onc traditionc forc supportc ofc bestc practices.
b. EBPc isc simplyc thec usec ofc bestc practicec techniquesc forc thec treatmentc ofc patients.
c. EBPc emphasizesc thec usec ofc bestc evidencec withc thec cliniciansc experience.
d. Thec patientsc ownc preferencesc arec notc importantc with
EBP.ANS:c C
EBPc isc ac systematicc approachc toc practicec thatc emphasizesc thec usec ofc bestc evidencec inc combinationc withcth
ecliniciansc experience,c asc wellc asc patientc preferencesc andc values,c whenc makingc decisionsc aboutccare
c andc treatment.c EBP c isc morec thanc simply c usingc thec bestc practice c techniques c toc treatc patients,candc q
uestioningc traditionc isc importantc whenc noc compellingc andc supportivec researchc evidencec exists.
DIF:c Cognitivec Level:c Applyingc (Application)
MSC:c Clientc Needs:c Safec andc Effectivec Carec Environment:c Managementc ofc Care
8. Thec nursec isc conductingc ac classc onc priorityc settingc forc ac groupc ofc newc graduatec nurses.c Whichc isca
nc exampleofc ac first-levelc priorityc problem?
a. Patientc withc postoperativec pain
b. Newlyc diagnosedc patientc withc diabetesc whoc needsc diabeticc teaching
