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1. Evidence-Based Assessment st
2. Cultural Assessment st
3. The Interview
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4. The Complete Health History
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5. Mental Status Assessment st st
6. Substance Use Assessment st st
7. Family Violence and Human Trafficking
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8. Assessment Techniques and Safety in the Clinical Setting st st st st st st st
9. General Survey and Measurement st st st
10. Vital Signs st
11. Pain Assessment
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12. Nutrition Assessment st
13. Skin, Hair, and Nails
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14. Head, Face, Neck, and Regional Lymphatics
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15. Eyes
16. Ears
17. Nose, Mouth, and Throatst st st
18. Breasts, Axillae, and Regional Lymphatics st st st st
19. Thorax and Lungs st st
20. Heart and Neck Vessels st st st
21. Peripheral Vascular System and Lymphatic System st st st st st
22. Abdomen
23. Musculoskeletal System st
24. Neurologic System st
25. Male Genitourinary System
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26. Anus, Rectum, and Prostate
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27. Female Genitourinary System st st
28. The Complete Health Assessment: Adult
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29. The Complete Physical Assessment: Infant, Young Child, and Adolescent
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30. Bedside Assessment and Electronic Documentation
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31. Pregnancy
32. Functional Assessment of the Older Adult st st st st st
,Chapter 01: Evidence-Based Assessment
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Jarvis: Physical Examination & Health Assessment, 9th Edition
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MULTIPLE CHOICE st
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
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eupneic and his pulse is 58 beats per minute. These types of data would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A s t
Objective data are what the health professional observes by inspecting, percussing, palpating, an
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d auscultating during the physical examination. Subjective data is what the person says about hi
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m or herself during history taking. The terms reflective and introspective are not used to describe
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data.
2. A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of dat
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a would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C s t
Subjective data are what the person says about him or herself during history taking. Objective dat
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a are what the health professional observes by inspecting, percussing, palpating, and auscultatin
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g during the physical examination. The terms reflective and introspective are not used to describ
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e data.
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3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the
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:
a. Data base. st
b. Admitting data. st
c. Financial statement. st
d. Discharge summary. st
ANS: A s t
Together with the patient’s record and laboratory studies, the objective and subjective data form
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the data base. The other items are not part of the patient’s record, laboratory studies, or data.
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4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nur
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se’s next action should be to:
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a. Immediately notify the patient’s physician. st st st st
b. Document the sound exactly as it was heard. st st st st st st st
, c. Validate the data by asking a coworker to listen to the breath sounds. st st st st st st st st st st st st
d. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C s t
When unsure of a sound heard while listening to a patient’s breath sounds, the nurse validates the
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data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert t
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o listen.
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse
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should keep in mind that novice nurses, without a background of skills and experience from whi
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ch to draw, are more likely to make their decisions using:
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a. Intuition.
b. A set of rules. st st st
c. Articles in journals. st st
d. Advice from supervisors. st st
ANS: B s t
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitiv
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e links.
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6. Expert nurses learn to attend to a pattern of assessment data and act without consciously lab
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eling it. These responses are referred to as:
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a. Intuition.
b... The nursing process. st st
c. Clinical knowledge. st
d. Diagnostic reasoning. st
ANS: A s t
Intuition is characterized by pattern recognition— st st st st st
expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The ot
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her options are not correct.
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7. The nurse is reviewing information about evidence-
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based practice (EBP). Which statement best reflects EBP?
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a. EBP relies on tradition for support of best practices. st st st st st st st st
b. EBP is simply the use of best practice techniques for the treatment of patients.
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c. EBP emphasizes the use of best evidence with the clinician’s experience.
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d... The patient’s own preferences are not important with EBP.
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ANS: C s t
EBP is a systematic approach to practice that emphasizes the use of best evidence in combinatio
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n with the clinician’s experience, as well as patient preferences and values, when making decision
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s about care and treatment. EBP is more than simply using the best practice techniques to treat pat
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ients, and questioning tradition is important when no compelling and supportive research eviden
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ce exists.
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8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is a
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n example of a first-level priority problem?
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a. Patient with postoperative pain st st st