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Test Bank: Physical Examination & Health Assessment 7 Edition 1
(Jarvis 2015)
Table of Contents
Table of Contents 1
Chapter 01: Evidence-Based Assessment 2
Chapter 02: Cultural Competence 15
Test Bank:
Chapter 03: The Interview 31
Chapter 04: The Complete Health History 49
Chapter 05: Mental Status Assessment 64
Chapter 06: Substance Use Assessment 81
Chapter 07: Domestic and Family Violence Assessments 87
Chapter 08: Assessment Techniques and Safety in the Clinical Setting 93
Physical
Chapter 09: General Survey, Measurement, Vital Signs 112
Chapter 10: Pain Assessment: The Fifth Vital Sign 134
Chapter 11: Nutritional Assessment 142
Chapter 12: Skin, Hair, and Nails 156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics 177
Chapter 14: Eyes 195
Examination
Chapter 15: Ears 212
Chapter 16: Nose, Mouth, and Throat 229
Chapter 17: Breasts and Regional Lymphatics 247
Chapter 18: Thorax and Lungs 267
Chapter 19: Heart and Neck Vessels 285
Chapter 20: Peripheral Vascular System and Lymphatic System 304
& Health
Chapter 21: Abdomen 321
Chapter 22: Musculoskeletal System 338
Chapter 23: Neurologic System 359
Chapter 24: Male Genitourinary System 384
Chapter 25: Anus, Rectum, and Prostate 402
Chapter 26: Female Genitourinary System 416
Chapter 27: The Complete Health Assessment: Adult 438
Assessment
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent 451
Chapter 29: Bedside Assessment of the Hospitalized Patient 454
Chapter 30: The Pregnant Woman 460
Chapter 31: Functional Assessment of the Older Adult 473
th
7 Edition
(Jarvis )
CHAPTERS 1-31 COMPLETE
TESTBANK
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Test Bank: Physical Examination & Health Assessment 7 Edition 2 Test Bank: Physical Examination & Health Assessment 7 Edition 3
(Jarvis 2015) (Jarvis 2015)
Chapter 01: Evidence-Based Assessment c. Financial statement.
MULTIPLE CHOICE
d. Discharge summary.
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
his pulse is 58 beats per minute. These types of data would be:
ANS: A
a. Objective.
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
The other items are not part of the patients record, laboratory studies, or data.
b. Reflective.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
c. Subjective. MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
d. Introspective. action should be to:
ANS: A a. Immediately notify the patients physician.
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
b. Document the sound exactly as it was heard.
during the physical examination. Subjective data is what the person says about him or herself during history
taking. The terms reflective and introspective are not used to describe data.
c. Validate the data by asking a coworker to listen to the breath sounds.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Assess again in 20 minutes to note whether the sound is still present.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
ANS: C
a. Objective.
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure
accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
b. Reflective.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2
c. Subjective. MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep
d. Introspective. in mind that novice nurses, without a background of skills and experience from which to draw, are more likely
to make their decisions using:
ANS: C
a. Intuition.
Subjective data are what the person says about him or herself 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. b. A set of rules.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
c. Articles in journals.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. Advice from supervisors.
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base. ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
b. Admitting data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
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(Jarvis 2015) (Jarvis 2015)
MSC: Client Needs: General c. Individual with a small laceration on the sole of the foot
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These
responses are referred to as: d. Individual with shortness of breath and respiratory distress
a. Intuition. ANS: D
First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an
b. The nursing process. airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
c. Clinical knowledge.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. Diagnostic reasoning.
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems
include which of these aspects?
ANS: A
a. Low self-esteem
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and
act without consciously labeling it. The other options are not correct.
b. Lack of knowledge
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: General c. Abnormal laboratory values
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects
EBP? d. Severely abnormal vital signs
a. EBP relies on tradition for support of best practices. ANS: C
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g.,
b. EBP is simply the use of best practice techniques for the treatment of patients. mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
c. EBP emphasizes the use of best evidence with the clinicians experience.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. The patients own preferences are not important with EBP. 10. Which critical thinking skill helps the nurse see relationships among the data?
ANS: C a. Validation
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the
clinicians experience, as well as patient preferences and values, when making decisions about care and b. Clustering related cues
treatment. EBP 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.
c. Identifying gaps in data
DIF: Cognitive Level: Applying (Application) REF: p. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Distinguishing relevant from irrelevant
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example
of a first-level priority problem? ANS: B
Clustering related cues helps the nurse see relationships among the data.
a. Patient with postoperative pain
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
b. Newly diagnosed patient with diabetes who needs diabetic teaching MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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(Jarvis 2015) (Jarvis 2015)
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the d. Sleep, pain, and breathing
appropriateness of the diagnosis.
ANS: A
a. Nursing
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and
circulation), followed by second-level problems, and then third-level problems.
b. Medical
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4
c. Admission
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. Which of these would be formulated by a nurse using diagnostic reasoning?
d. Collaborative
a. Nursing diagnosis
ANS: A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes b. Medical diagnosis
for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing
interventions.
c. Diagnostic hypothesis
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Diagnostic assessment
12. The nursing process is a sequential method of problem solving that nurses use and includes which steps?
ANS: C
a. Assessment, treatment, planning, evaluation, discharge, and follow-up Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a
nursing diagnosis.
b. Admission, assessment, diagnosis, treatment, and discharge planning DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: General
c. Admission, diagnosis, treatment, evaluation, and discharge planning
15. Barriers to incorporating EBP include:
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
a. Nurses lack of research skills in evaluating the quality of research studies.
ANS: D
b. Lack of significant research studies.
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome
identification, planning, implementation, and evaluation.
c. Insufficient clinical skills of nurses.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Inadequate physical assessment skills.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty
breathing. How should the nurse prioritize these problems? ANS: A
As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other
a. Breathing, pain, and sleep colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The
other responses are not considered barriers.
b. Breathing, sleep, and pain DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: General
c. Sleep, breathing, and pain
16. What step of the nursing process includes data collection by health history, physical examination, and
interview?
th
Test Bank: Physical Examination & Health Assessment 7 Edition 1
(Jarvis 2015)
Table of Contents
Table of Contents 1
Chapter 01: Evidence-Based Assessment 2
Chapter 02: Cultural Competence 15
Test Bank:
Chapter 03: The Interview 31
Chapter 04: The Complete Health History 49
Chapter 05: Mental Status Assessment 64
Chapter 06: Substance Use Assessment 81
Chapter 07: Domestic and Family Violence Assessments 87
Chapter 08: Assessment Techniques and Safety in the Clinical Setting 93
Physical
Chapter 09: General Survey, Measurement, Vital Signs 112
Chapter 10: Pain Assessment: The Fifth Vital Sign 134
Chapter 11: Nutritional Assessment 142
Chapter 12: Skin, Hair, and Nails 156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics 177
Chapter 14: Eyes 195
Examination
Chapter 15: Ears 212
Chapter 16: Nose, Mouth, and Throat 229
Chapter 17: Breasts and Regional Lymphatics 247
Chapter 18: Thorax and Lungs 267
Chapter 19: Heart and Neck Vessels 285
Chapter 20: Peripheral Vascular System and Lymphatic System 304
& Health
Chapter 21: Abdomen 321
Chapter 22: Musculoskeletal System 338
Chapter 23: Neurologic System 359
Chapter 24: Male Genitourinary System 384
Chapter 25: Anus, Rectum, and Prostate 402
Chapter 26: Female Genitourinary System 416
Chapter 27: The Complete Health Assessment: Adult 438
Assessment
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent 451
Chapter 29: Bedside Assessment of the Hospitalized Patient 454
Chapter 30: The Pregnant Woman 460
Chapter 31: Functional Assessment of the Older Adult 473
th
7 Edition
(Jarvis )
CHAPTERS 1-31 COMPLETE
TESTBANK
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th th
Test Bank: Physical Examination & Health Assessment 7 Edition 2 Test Bank: Physical Examination & Health Assessment 7 Edition 3
(Jarvis 2015) (Jarvis 2015)
Chapter 01: Evidence-Based Assessment c. Financial statement.
MULTIPLE CHOICE
d. Discharge summary.
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
his pulse is 58 beats per minute. These types of data would be:
ANS: A
a. Objective.
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
The other items are not part of the patients record, laboratory studies, or data.
b. Reflective.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
c. Subjective. MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
d. Introspective. action should be to:
ANS: A a. Immediately notify the patients physician.
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
b. Document the sound exactly as it was heard.
during the physical examination. Subjective data is what the person says about him or herself during history
taking. The terms reflective and introspective are not used to describe data.
c. Validate the data by asking a coworker to listen to the breath sounds.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Assess again in 20 minutes to note whether the sound is still present.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
ANS: C
a. Objective.
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure
accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
b. Reflective.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2
c. Subjective. MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep
d. Introspective. in mind that novice nurses, without a background of skills and experience from which to draw, are more likely
to make their decisions using:
ANS: C
a. Intuition.
Subjective data are what the person says about him or herself 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. b. A set of rules.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
c. Articles in journals.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. Advice from supervisors.
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base. ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
b. Admitting data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
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Test Bank: Physical Examination & Health Assessment 7 Edition 4 Test Bank: Physical Examination & Health Assessment 7 Edition 5
(Jarvis 2015) (Jarvis 2015)
MSC: Client Needs: General c. Individual with a small laceration on the sole of the foot
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These
responses are referred to as: d. Individual with shortness of breath and respiratory distress
a. Intuition. ANS: D
First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an
b. The nursing process. airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
c. Clinical knowledge.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. Diagnostic reasoning.
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems
include which of these aspects?
ANS: A
a. Low self-esteem
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and
act without consciously labeling it. The other options are not correct.
b. Lack of knowledge
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: General c. Abnormal laboratory values
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects
EBP? d. Severely abnormal vital signs
a. EBP relies on tradition for support of best practices. ANS: C
Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g.,
b. EBP is simply the use of best practice techniques for the treatment of patients. mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
c. EBP emphasizes the use of best evidence with the clinicians experience.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. The patients own preferences are not important with EBP. 10. Which critical thinking skill helps the nurse see relationships among the data?
ANS: C a. Validation
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the
clinicians experience, as well as patient preferences and values, when making decisions about care and b. Clustering related cues
treatment. EBP 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.
c. Identifying gaps in data
DIF: Cognitive Level: Applying (Application) REF: p. 5
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Distinguishing relevant from irrelevant
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example
of a first-level priority problem? ANS: B
Clustering related cues helps the nurse see relationships among the data.
a. Patient with postoperative pain
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
b. Newly diagnosed patient with diabetes who needs diabetic teaching MSC: Client Needs: Safe and Effective Care Environment: Management of Care
, lOMoARcPSD|578 852 3 lOMoARcPSD|578 852 3
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Test Bank: Physical Examination & Health Assessment 7 Edition 6 Test Bank: Physical Examination & Health Assessment 7 Edition 7
(Jarvis 2015) (Jarvis 2015)
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the d. Sleep, pain, and breathing
appropriateness of the diagnosis.
ANS: A
a. Nursing
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and
circulation), followed by second-level problems, and then third-level problems.
b. Medical
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 4
c. Admission
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. Which of these would be formulated by a nurse using diagnostic reasoning?
d. Collaborative
a. Nursing diagnosis
ANS: A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes b. Medical diagnosis
for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing
interventions.
c. Diagnostic hypothesis
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Diagnostic assessment
12. The nursing process is a sequential method of problem solving that nurses use and includes which steps?
ANS: C
a. Assessment, treatment, planning, evaluation, discharge, and follow-up Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a
nursing diagnosis.
b. Admission, assessment, diagnosis, treatment, and discharge planning DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: General
c. Admission, diagnosis, treatment, evaluation, and discharge planning
15. Barriers to incorporating EBP include:
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
a. Nurses lack of research skills in evaluating the quality of research studies.
ANS: D
b. Lack of significant research studies.
The nursing process is a method of problem solving that includes assessment, diagnosis, outcome
identification, planning, implementation, and evaluation.
c. Insufficient clinical skills of nurses.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care d. Inadequate physical assessment skills.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty
breathing. How should the nurse prioritize these problems? ANS: A
As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other
a. Breathing, pain, and sleep colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The
other responses are not considered barriers.
b. Breathing, sleep, and pain DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: General
c. Sleep, breathing, and pain
16. What step of the nursing process includes data collection by health history, physical examination, and
interview?
