Authors: Carolyn Jarvis, Ann L . Eckhardt Testbank
Table of Contents 1
Chapter 01: Evidence-Based 2
Assessment Chapter 02: Cultural 15
Assessment Chapter 03: The 31
Interview 49
Chapter 04: The Complete Health 80
86
History Chapter 05: Mental Status
nical Setting 92
Assessment Chapter 06: Substance
111
Use Assessment
118
Chapter 07: Domestic and Family Violence Assessment 133
Chapter 08: Assessment Techniques and Safety in the 141
Cli Chapter 09: General Survey and Measurement
Chapter 10: Vital Signs
Chapter 11: Pain Assessment 155
Chapter 12: Nutrition 176
Assessment Chapter 13: Skin, 194
Hair, and Nails 211
Chapter 14: Head, Face, Neck, and Regional 228
Lymphatics Chapter 15: Eyes 246
Chapter 16: Ears 266
Chapter 17: Nose, Mouth, and Throat 284
Chapter 18: Breasts, Axillae, and Regional Lymphatics 303
Chapter 19: Thorax and Lungs 320
Chapter 20: Heart and Neck Vessels 337
Chapter 21: Peripheral Vascular System and Lymphatic System 358
Chapter 22: Abdomen 382
Chapter 23: Musculoskeletal System 400
Chapter 24: Neurologic System 414
Chapter 25: Male Genitourinary System 436
Chapter 26: 449
Anus, Rectum, and Prostate 452
Chapter 27: Female Genitourinary System 458
Chapter 28: The Complete Health Assessment: Adult 471
Chapter 29: The Complete Physical Assessment: Infant, Child, and
AdolescentChapter 30: Bedside Assessment and Electronic Documentation
Chapter 31: The Pregnant Woman
Chapter 32: Functional Assessment of the Older Adult
FLYINGHIGHER725@GMAIL .COM
,Chapter 01: Evidence-Based Assessment
MULTIPLE CHOICE
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 wouldbe:
a. Objective .
b. Reflective .
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 is what the person says about him or
herself 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. A patient tells the nurse that he is very nervous, is nauseated, and feels hot . These types of data
would be:
a. Objective .
b. Reflective .
c. Subjective .
d. Introspective .
ANS: C
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 .
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
,a. Data base .
b. Admitting data .
, c. Financial statement .
d. Discharge summary .
ANS: A
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 .
DIF: Cognitive Level: Remembering (Knowledge)
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 action should be to:
a. Immediately notify the patients physician .
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 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
.
DIF: Cognitive Level: Analyzing (Analysis)
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 in mind that novice nurses, without a background of skills and experience from which to
draw, are more likely to make their decisions using:
a. Intuition .
b. A set of rules .
c. Articles in journals .
d. Advice from supervisors .
ANS: B
Novice nurses operate from a set of defined, structured rules . The expert practitioner uses