TEST BANK
l
,Table lof lContents 1
Chapter l01: lEvidence-Based lAssessment 2
lChapter l02: lCultural lAssessment 15
Chapter l03: lThe lInterview 31
Chapter l04: lThe lComplete lHealth lHistory 49
lChapter l05: lMental lStatus lAssessment 64
lChapter l06: lSubstance lUse lAssessment 80
Chapter l07: lDomestic land lFamily lViolence lAssessment 86
Chapter l08: lAssessment lTechniques land lSafety lin lthe lClinical lSetting 92
lChapter l09: lGeneral lSurvey land lMeasurement 111
Chapter l10: lVital lSigns 118
lChapter l11: lPain lAssessment 133
Chapter l12: lNutrition lAssessment 141
lChapter l13: lSkin, lHair, land lNails 155
Chapter l14: lHead, lFace, lNeck, land lRegional lLymphatics 176
lChapter l15: lEyes 194
Chapter l16: lEars 211
Chapter l17: lNose, lMouth, land lThroat 228
Chapter l18: lBreasts, lAxillae, land lRegional lLymphatics 246
lChapter l19: lThorax land lLungs 266
Chapter l20: lHeart land lNeck lVessels 284
Chapter l21: lPeripheral lVascular lSystem land lLymphatic lSystem 303
lChapter l22: lAbdomen 320
Chapter l23: lMusculoskeletal lSystem 337
lChapter l 24: lNeurologic l System 358
l Chapter l25: lMale lGenitourinary 382
lSystem lChapter l26: lAnus, lRectum, land 400
lProstate 414
Chapter l27: lFemale lGenitourinary lSystem 436
Chapter l28: lThe lComplete lHealth lAssessment: lAdult 449
Chapter l29: lThe lComplete lPhysical lAssessment: lInfant, lChild, land lAdolescent 452
lChapter l30: lBedside lAssessment land lElectronic lDocumentation 458
Chapter l31: lThe lPregnant lWoman 471
Chapter l32: lFunctional lAssessment lof lthe lOlder lAdult
,Chapter 01: Evidence-Based Assessment
l l l
MULTIPLE l CHOICE
1. After lcompleting lan linitial lassessment lof la lpatient, lthe lnurse lhas lcharted lthat lhis lrespirations lare leupneic
land lhis lpulse lis l58 lbeats lper lminute. lThese ltypes lof ldata lwouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: l A
Objective ldata lare lwhat lthe lhealth lprofessional lobserves lby linspecting, lpercussing, lpalpating, land
lauscultating lduring lthe lphysical lexamination. lSubjective ldata lis lwhat lthe lperson lsays labout lhim lor lherself
lduring lhistory ltaking. l The l terms l reflective l and l introspective l are l not l used l to l describe l data.
DIF: l Cognitive l Level: l Understanding l (Comprehension)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
2. A lpatient ltells lthe lnurse lthat lhe lis l very lnervous, lis lnauseated, land lfeels lhot. lThese ltypes l of ldata lwould
l be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: l C
Subjective ldata lare lwhat lthe lperson lsays labout lhim lor lherself lduring lhistory ltaking. lObjective ldata lare
lwhat lthe lhealth lprofessional lobserves lby linspecting, lpercussing, lpalpating, land lauscultating lduring lthe
lphysical lexamination. lThe lterms lreflective land lintrospective lare lnot lused lto ldescribe ldata.
DIF: l Cognitive l Level: l Understanding l (Comprehension)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
3. The l patients l record, l laboratory l studies, l objective l data, l and lsubjective l data l combine l to l form l the:
a. Data lbase.
b. Admitting l data.
, c. Financial l statement.
d. Discharge l summary.
ANS: l A
Together lwith lthe lpatients lrecord land llaboratory lstudies, lthe lobjective land lsubjective ldata lform lthe ldata
lbase. lThe lother litems lare lnot lpart lof lthe lpatients lrecord, llaboratory lstudies, lor ldata.
DIF: l Cognitive l Level: l Remembering l (Knowledge)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
4. When llistening lto la lpatients lbreath lsounds, lthe lnurse lis lunsure lof la lsound lthat lis lheard. lThe lnurses
lnext laction lshould lbe lto:
a. Immediately l notify l the l patients l physician.
b. Document lthe lsound lexactly las lit lwas lheard.
c. Validate lthe ldata lby lasking la lcoworker lto llisten lto lthe l breath lsounds.
d. Assess lagain lin l20 lminutes lto lnote lwhether lthe lsound lis lstill lpresent.
ANS: l C
When lunsure lof la lsound lheard lwhile llistening lto la lpatients lbreath lsounds, lthe lnurse lvalidates lthe ldata lto
lensure laccuracy. lIf lthe lnurse lhas lless lexperience lin lan larea, lthen lhe lor lshe lasks lan lexpert lto llisten.
DIF: l Cognitive l Level: l Analyzing l (Analysis)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
5. The lnurse lis lconducting l a lclass lfor lnew l graduate lnurses. l During lthe lteaching lsession, lthe lnurse lshould
lkeep l in l mind l that l novice l nurses, l without l a l background l of l skills l and l experience l from lwhich l to l draw,
l are l more l likely lto lmake ltheir ldecisions lusing:
a. Intuition.
b. A lset lof lrules.
c. Articles l in l journals.
d. Advice l from l supervisors.
ANS: l B
Novice lnurses loperate lfrom la lset lof ldefined, lstructured lrules. lThe lexpert lpractitioner luses lintuitive
l links. lDIF: lCognitive lLevel: lUnderstanding l(Comprehension)
l
,Table lof lContents 1
Chapter l01: lEvidence-Based lAssessment 2
lChapter l02: lCultural lAssessment 15
Chapter l03: lThe lInterview 31
Chapter l04: lThe lComplete lHealth lHistory 49
lChapter l05: lMental lStatus lAssessment 64
lChapter l06: lSubstance lUse lAssessment 80
Chapter l07: lDomestic land lFamily lViolence lAssessment 86
Chapter l08: lAssessment lTechniques land lSafety lin lthe lClinical lSetting 92
lChapter l09: lGeneral lSurvey land lMeasurement 111
Chapter l10: lVital lSigns 118
lChapter l11: lPain lAssessment 133
Chapter l12: lNutrition lAssessment 141
lChapter l13: lSkin, lHair, land lNails 155
Chapter l14: lHead, lFace, lNeck, land lRegional lLymphatics 176
lChapter l15: lEyes 194
Chapter l16: lEars 211
Chapter l17: lNose, lMouth, land lThroat 228
Chapter l18: lBreasts, lAxillae, land lRegional lLymphatics 246
lChapter l19: lThorax land lLungs 266
Chapter l20: lHeart land lNeck lVessels 284
Chapter l21: lPeripheral lVascular lSystem land lLymphatic lSystem 303
lChapter l22: lAbdomen 320
Chapter l23: lMusculoskeletal lSystem 337
lChapter l 24: lNeurologic l System 358
l Chapter l25: lMale lGenitourinary 382
lSystem lChapter l26: lAnus, lRectum, land 400
lProstate 414
Chapter l27: lFemale lGenitourinary lSystem 436
Chapter l28: lThe lComplete lHealth lAssessment: lAdult 449
Chapter l29: lThe lComplete lPhysical lAssessment: lInfant, lChild, land lAdolescent 452
lChapter l30: lBedside lAssessment land lElectronic lDocumentation 458
Chapter l31: lThe lPregnant lWoman 471
Chapter l32: lFunctional lAssessment lof lthe lOlder lAdult
,Chapter 01: Evidence-Based Assessment
l l l
MULTIPLE l CHOICE
1. After lcompleting lan linitial lassessment lof la lpatient, lthe lnurse lhas lcharted lthat lhis lrespirations lare leupneic
land lhis lpulse lis l58 lbeats lper lminute. lThese ltypes lof ldata lwouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: l A
Objective ldata lare lwhat lthe lhealth lprofessional lobserves lby linspecting, lpercussing, lpalpating, land
lauscultating lduring lthe lphysical lexamination. lSubjective ldata lis lwhat lthe lperson lsays labout lhim lor lherself
lduring lhistory ltaking. l The l terms l reflective l and l introspective l are l not l used l to l describe l data.
DIF: l Cognitive l Level: l Understanding l (Comprehension)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
2. A lpatient ltells lthe lnurse lthat lhe lis l very lnervous, lis lnauseated, land lfeels lhot. lThese ltypes l of ldata lwould
l be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: l C
Subjective ldata lare lwhat lthe lperson lsays labout lhim lor lherself lduring lhistory ltaking. lObjective ldata lare
lwhat lthe lhealth lprofessional lobserves lby linspecting, lpercussing, lpalpating, land lauscultating lduring lthe
lphysical lexamination. lThe lterms lreflective land lintrospective lare lnot lused lto ldescribe ldata.
DIF: l Cognitive l Level: l Understanding l (Comprehension)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
3. The l patients l record, l laboratory l studies, l objective l data, l and lsubjective l data l combine l to l form l the:
a. Data lbase.
b. Admitting l data.
, c. Financial l statement.
d. Discharge l summary.
ANS: l A
Together lwith lthe lpatients lrecord land llaboratory lstudies, lthe lobjective land lsubjective ldata lform lthe ldata
lbase. lThe lother litems lare lnot lpart lof lthe lpatients lrecord, llaboratory lstudies, lor ldata.
DIF: l Cognitive l Level: l Remembering l (Knowledge)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
4. When llistening lto la lpatients lbreath lsounds, lthe lnurse lis lunsure lof la lsound lthat lis lheard. lThe lnurses
lnext laction lshould lbe lto:
a. Immediately l notify l the l patients l physician.
b. Document lthe lsound lexactly las lit lwas lheard.
c. Validate lthe ldata lby lasking la lcoworker lto llisten lto lthe l breath lsounds.
d. Assess lagain lin l20 lminutes lto lnote lwhether lthe lsound lis lstill lpresent.
ANS: l C
When lunsure lof la lsound lheard lwhile llistening lto la lpatients lbreath lsounds, lthe lnurse lvalidates lthe ldata lto
lensure laccuracy. lIf lthe lnurse lhas lless lexperience lin lan larea, lthen lhe lor lshe lasks lan lexpert lto llisten.
DIF: l Cognitive l Level: l Analyzing l (Analysis)
MSC: l Client l Needs: l Safe l and l Effective l Care l Environment: l Management l of l Care
5. The lnurse lis lconducting l a lclass lfor lnew l graduate lnurses. l During lthe lteaching lsession, lthe lnurse lshould
lkeep l in l mind l that l novice l nurses, l without l a l background l of l skills l and l experience l from lwhich l to l draw,
l are l more l likely lto lmake ltheir ldecisions lusing:
a. Intuition.
b. A lset lof lrules.
c. Articles l in l journals.
d. Advice l from l supervisors.
ANS: l B
Novice lnurses loperate lfrom la lset lof ldefined, lstructured lrules. lThe lexpert lpractitioner luses lintuitive
l links. lDIF: lCognitive lLevel: lUnderstanding l(Comprehension)
