1
Table of Contents
Table of 1
Contents
Chapter 01: Evidence-Based 2
AssessmentjChapter 02: Cultural 15
Assessment 31
Chapter 03: The Interview 49
Chapter 04: The Complete Health 64
HistoryChapter 05: Mental Status 80
Assessment Chapter 06: Substance 86
Use Assessment 92
Chapter 07: Domestic and Family Violence Assessment 111
Chapter 08: Assessment Techniques and Safety in the Clinical 118
SettingChapter 09: General Survey and Measurement 133
Chapter 10: Vital Signs 141
Chapter 11: Pain 155
Assessment 176
Chapter 12: Nutrition 194
AssessmentChapter 13: Skin, 211
Hair, and Nails 228
Chapter 14: Head, Face, Neck, and Regional 246
LymphaticsChapter 15: Eyes 266
Chapter 16: Ears 284
Chapter 17: Nose, Mouth, and Throat 303
Chapter 18: Breasts, Axillae, and Regional 320
LymphaticsChapter 19: Thorax and Lungs 337
Chapter 20: Heart and Neck Vessels 358
Chapter 21: Peripheral Vascular System and Lymphatic System 382
Chapter 22: Abdomen 400
Chapter 23: Musculoskeletal System 414
Chapter 24: Neurologic System 436
Chapter 25: Male Genitourinary 449
System 452
Chapter 26: Anus, Rectum, and Prostate 458
Chapter 27: Female Genitourinary System 471
Chapter 28: The Complete Health Assessment: Adult
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
, 2
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 andhis pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating, and
auscultatingduring the physical examination. Subjective data is what the person says about him or
herself during historytaking. 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 thehealth 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.
, 3
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 nextaction 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 ensureaccuracy. 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 likelyto 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 intuitive
links.DIF: Cognitive Level: Understanding (Comprehension)
, 4
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling
it. Theseresponses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
data andact without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding
(Comprehension)MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best
reflectsEBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with
EBP.ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with
theclinicians experience, as well as patient preferences and values, when making decisions about
care and 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is
an exampleof a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
Table of Contents
Table of 1
Contents
Chapter 01: Evidence-Based 2
AssessmentjChapter 02: Cultural 15
Assessment 31
Chapter 03: The Interview 49
Chapter 04: The Complete Health 64
HistoryChapter 05: Mental Status 80
Assessment Chapter 06: Substance 86
Use Assessment 92
Chapter 07: Domestic and Family Violence Assessment 111
Chapter 08: Assessment Techniques and Safety in the Clinical 118
SettingChapter 09: General Survey and Measurement 133
Chapter 10: Vital Signs 141
Chapter 11: Pain 155
Assessment 176
Chapter 12: Nutrition 194
AssessmentChapter 13: Skin, 211
Hair, and Nails 228
Chapter 14: Head, Face, Neck, and Regional 246
LymphaticsChapter 15: Eyes 266
Chapter 16: Ears 284
Chapter 17: Nose, Mouth, and Throat 303
Chapter 18: Breasts, Axillae, and Regional 320
LymphaticsChapter 19: Thorax and Lungs 337
Chapter 20: Heart and Neck Vessels 358
Chapter 21: Peripheral Vascular System and Lymphatic System 382
Chapter 22: Abdomen 400
Chapter 23: Musculoskeletal System 414
Chapter 24: Neurologic System 436
Chapter 25: Male Genitourinary 449
System 452
Chapter 26: Anus, Rectum, and Prostate 458
Chapter 27: Female Genitourinary System 471
Chapter 28: The Complete Health Assessment: Adult
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
, 2
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 andhis pulse is 58 beats per minute. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A
Objective data are what the health professional observes by inspecting, percussing, palpating, and
auscultatingduring the physical examination. Subjective data is what the person says about him or
herself during historytaking. 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 thehealth 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.
, 3
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 nextaction 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 ensureaccuracy. 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 likelyto 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 intuitive
links.DIF: Cognitive Level: Understanding (Comprehension)
, 4
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling
it. Theseresponses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
data andact without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding
(Comprehension)MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best
reflectsEBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with
EBP.ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with
theclinicians experience, as well as patient preferences and values, when making decisions about
care and 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is
an exampleof a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
