,Table of Contents WS WS
1
Chapter 01: Evidence- WS WS 2
Based Assessment Chapter 02: Cultural Asses
WS WS WS WS WS 15
sment 31
Chapter 03: The Interview WS WS WS 49
Chapter 04: The Complete Health History Chapt
WS WS WS WS WS WS 64
er 05: Mental Status Assessment Chapter 06:
WS WS WS WS WS WS WS 80
Substance Use Assessment WS WS 86
Chapter 07: Domestic and Family Violence Assessment
WS WS WS WS WS WS 92
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
WS WS WS WS WS WS WS WS WS WS 111
Chapter 09: General Survey and Measurement
WS WS WS WS WS 118
Chapter 10: Vital Signs Chapt WS WS WS WS 133
er 11: Pain Assessment
WS WS WS 141
Chapter 12: Nutrition AssessmentWS WS WS WS 155
Chapter 13: Skin, Hair, and Nails
WS WS WS WS WS 176
Chapter 14: Head, Face, Neck, and Regional Lymphatics Cha
WS WS WS WS WS WS WS WS 194
pter 15: Eyes WS WS 211
Chapter 16: Ears WS WS 228
Chapter 17: Nose, Mouth, and Throat
WS WS WS WS WS 246
Chapter 18: Breasts, Axillae, and Regional Lymphatics Chapte
WS WS WS WS WS WS WS 266
r 19: Thorax and Lungs
WS WS WS WS 284
Chapter 20: Heart and Neck Vessels
WS WS WS WS WS
303
Chapter 21: Peripheral Vascular System and Lymphatic System Chapte
WS WS WS WS WS WS WS WS 320
r 22: Abdomen
WS WS 337
Chapter 23: Musculoskeletal System Ch
WS WS WS WS
358
apter 24: Neurologic System Chapter
W S WS W S W S WS
382
25: Male Genitourinary System Chapter
WS WS WS WS WS
400
26: Anus, Rectum, and Prostate
WS WS WS WS
414
Chapter 27: Female Genitourinary System
WS WS WS WS
436
Chapter 28: The Complete Health Assessment: Adult
WS WS WS WS WS WS
449
Chapter 29: The Complete Physical Assessment: Infant, Child, and Adolescent
WS WS WS WS WS WS WS WS WS WS
452
Chapter 30: Bedside Assessment and Electronic Documentation
WS WS WS WS WS WS
458
Chapter 31: The Pregnant Woman WS WS WS WS
471
Chapter 32: Functional Assessment of the Older Adult
WS WS WS WS WS WS WS
,Chapter 01: Evidence-Based Assessment WS WS WS
MULTIPLE CHOICE W S
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
his pulse is 58 beats per minute. These types of data wouldbe:
WS WS WS WS WS WS WS WS WS WS WS WS
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A WS
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
WS WS WS WS WS WS WS WS WS WS WS WS WS WS
during the physical examination. Subjective data is what the person says about him or herself during history tak
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
ing. The terms reflective and introspective are not used to describe data.
WS W S W S W S WS W S W S W S W S W S W S
DIF: Cognitive Level: Understanding (Comprehension)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C WS
Subjective data are what the person says about him or herself during history taking. Objective data are what th
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
e health professional observes by inspecting, percussing, palpating, and auscultating during the physical exami
WS WS WS WS WS WS WS WS WS WS WS WS WS
nation. The terms reflective and introspective are not used to describe data.
WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Understanding (Comprehension)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
WS WS WS W S WS W S WS WS WS WS WS WS WS
a. Data base. WS
b. Admitting data. W S
, c. Financial statement. W S
d. Discharge summary. W S
ANS: A WS
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
The other items are not part of the patients record, laboratory studies, or data.
WS WS WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Remembering (Knowledge)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
action should be to:
WS WS WS WS
a. Immediately notify the patients physician. W S W S W S WS
b. Document the sound exactly as it was heard. WS WS WS WS WS WS WS
c. Validate the data by asking a coworker to listen to the breath sounds.
WS WS WS WS WS WS WS WS WS WS WS WS
d. Assess again in 20 minutes to note whether the sound is still present.
WS WS WS WS WS WS WS WS WS WS WS WS
ANS: C WS
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure acc
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
uracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Analyzing (Analysis)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should kee
WS WS WS W S WS WS WS W S WS W S WS WS WS WS WS WS WS
p in mind that novice nurses, without a background of skills and experience from which to draw, are more
W S WS W S WS WS WS WS WS WS WS WS WS WS WS W S WS WS WS W
likely to make their decisions using:
S WS WS WS WS WS
a. Intuition.
b. A set of rules.
WS WS WS
c. Articles in journals. WS WS
d. Advice from supervisors. W S WS
ANS: B WS
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. D
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
IF: Cognitive Level: Understanding (Comprehension)
WS WS WS WS
1
Chapter 01: Evidence- WS WS 2
Based Assessment Chapter 02: Cultural Asses
WS WS WS WS WS 15
sment 31
Chapter 03: The Interview WS WS WS 49
Chapter 04: The Complete Health History Chapt
WS WS WS WS WS WS 64
er 05: Mental Status Assessment Chapter 06:
WS WS WS WS WS WS WS 80
Substance Use Assessment WS WS 86
Chapter 07: Domestic and Family Violence Assessment
WS WS WS WS WS WS 92
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
WS WS WS WS WS WS WS WS WS WS 111
Chapter 09: General Survey and Measurement
WS WS WS WS WS 118
Chapter 10: Vital Signs Chapt WS WS WS WS 133
er 11: Pain Assessment
WS WS WS 141
Chapter 12: Nutrition AssessmentWS WS WS WS 155
Chapter 13: Skin, Hair, and Nails
WS WS WS WS WS 176
Chapter 14: Head, Face, Neck, and Regional Lymphatics Cha
WS WS WS WS WS WS WS WS 194
pter 15: Eyes WS WS 211
Chapter 16: Ears WS WS 228
Chapter 17: Nose, Mouth, and Throat
WS WS WS WS WS 246
Chapter 18: Breasts, Axillae, and Regional Lymphatics Chapte
WS WS WS WS WS WS WS 266
r 19: Thorax and Lungs
WS WS WS WS 284
Chapter 20: Heart and Neck Vessels
WS WS WS WS WS
303
Chapter 21: Peripheral Vascular System and Lymphatic System Chapte
WS WS WS WS WS WS WS WS 320
r 22: Abdomen
WS WS 337
Chapter 23: Musculoskeletal System Ch
WS WS WS WS
358
apter 24: Neurologic System Chapter
W S WS W S W S WS
382
25: Male Genitourinary System Chapter
WS WS WS WS WS
400
26: Anus, Rectum, and Prostate
WS WS WS WS
414
Chapter 27: Female Genitourinary System
WS WS WS WS
436
Chapter 28: The Complete Health Assessment: Adult
WS WS WS WS WS WS
449
Chapter 29: The Complete Physical Assessment: Infant, Child, and Adolescent
WS WS WS WS WS WS WS WS WS WS
452
Chapter 30: Bedside Assessment and Electronic Documentation
WS WS WS WS WS WS
458
Chapter 31: The Pregnant Woman WS WS WS WS
471
Chapter 32: Functional Assessment of the Older Adult
WS WS WS WS WS WS WS
,Chapter 01: Evidence-Based Assessment WS WS WS
MULTIPLE CHOICE W S
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
his pulse is 58 beats per minute. These types of data wouldbe:
WS WS WS WS WS WS WS WS WS WS WS WS
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A WS
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
WS WS WS WS WS WS WS WS WS WS WS WS WS WS
during the physical examination. Subjective data is what the person says about him or herself during history tak
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
ing. The terms reflective and introspective are not used to describe data.
WS W S W S W S WS W S W S W S W S W S W S
DIF: Cognitive Level: Understanding (Comprehension)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C WS
Subjective data are what the person says about him or herself during history taking. Objective data are what th
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
e health professional observes by inspecting, percussing, palpating, and auscultating during the physical exami
WS WS WS WS WS WS WS WS WS WS WS WS WS
nation. The terms reflective and introspective are not used to describe data.
WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Understanding (Comprehension)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
WS WS WS W S WS W S WS WS WS WS WS WS WS
a. Data base. WS
b. Admitting data. W S
, c. Financial statement. W S
d. Discharge summary. W S
ANS: A WS
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
The other items are not part of the patients record, laboratory studies, or data.
WS WS WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Remembering (Knowledge)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
action should be to:
WS WS WS WS
a. Immediately notify the patients physician. W S W S W S WS
b. Document the sound exactly as it was heard. WS WS WS WS WS WS WS
c. Validate the data by asking a coworker to listen to the breath sounds.
WS WS WS WS WS WS WS WS WS WS WS WS
d. Assess again in 20 minutes to note whether the sound is still present.
WS WS WS WS WS WS WS WS WS WS WS WS
ANS: C WS
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure acc
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
uracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
DIF: Cognitive Level: Analyzing (Analysis)
W S W S W S W S
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
WS WS W S W S W S W S W S W S W S W S
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should kee
WS WS WS W S WS WS WS W S WS W S WS WS WS WS WS WS WS
p in mind that novice nurses, without a background of skills and experience from which to draw, are more
W S WS W S WS WS WS WS WS WS WS WS WS WS WS W S WS WS WS W
likely to make their decisions using:
S WS WS WS WS WS
a. Intuition.
b. A set of rules.
WS WS WS
c. Articles in journals. WS WS
d. Advice from supervisors. W S WS
ANS: B WS
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links. D
WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS WS
IF: Cognitive Level: Understanding (Comprehension)
WS WS WS WS
