Edit
Tho 24
,TableofContents
f f
Chapterf01fUnderstandingfHealthfAssessment _______________________________________________________ 1
Chapterf02fInterviewingfthefPatientvforfthefHealthfHistoryf f f f f f f f f f f f f f f f f f f f f f f f f f f f f11f Chapterf03fTakin
gfthefHealthfHistory _________________________________________________________________________ 40
Chapterf04fAssessingfNutritionfandfAfnthropometricfMeasurementsf f f f f f f f f f f f f f f f f f f f f f f f61f Chapterf05fAss
essmentvTechniques ________________________________________________________________________ 88
Chapterf06fGeneralfSurveyfafndfAssessingfVitalfSignsf f 99fC
hapterf07fAssessingvPain ____________________________________________________________________ 128
Chapterf08fAssessingvthefSkin,fHair,fandfNails _____________________________________________________ 149
Chapterf09fAssessingfthefHead,fFace,fMouth,fandfNeckf f f f f f f f f f f f f f f f f f f f f f f f f f f f f f188fChapterf10vAssess
ingfthefEars ______________________________________________________________________________ 229
Chapterf11fAssessingvthefEyes ________________________________________________________________ 250
Chapterf12fAssessingfthefRespiratoryfSystem 281
Chapterf 13fAssessingf thefCardiovascularfSystem 308
Chapterf14fAssessingvthefAbdomen 335
Chapterf15fAssessingf thefPeripheralfVascularfSystemfandfRegionalfLymphaticfSystem 363
Chapterf 16fAssessingf thefMusculoskeletalfSystem 391
Chapterf17fAssessingvthefNeurologicalfSystem 417
Chapterf18fAssessingf thefFemalefBreasts,fAxillae,fandfReproductivefSystem 451
Chapterf19fAssessingfthefMalefBreastsfandfReproductivevSystem 477
Chapterf20vAssessingfthefAnusfandfRectum 501
Chapterf21fAssessingvthefNewborn 517
Chapterf22fAssessingfthefChildfandfAdolescent 555
Chapterf23fAssessingfthefPregnantfWoman 583
Chapterf24fAssessingvthefOlderfAdult 612
, TestfBankv-
Chapterf1:fUnderstandingfHealthfAssessment
1. ThefWorldfHealthfOrganizationv(WHO)festablishedfavglobalfstrategyfcalledf“HealthfforfAll.”f Thefgofalff
orfthisfstrategyfis:
1. Allfindividualsftofgetvthefsamefhealthfcarefthroughoutftheirflifefspans.
2. Thefgovernmentftofsupplyfmoneyftofcarevforfallfthefpeoplefinfthefworld.
3. Resourcesfforfhealthfcarevtofbefevenlyfdistributedfandfaccessible.
4. Health-carevprovidersfcanfneverfdenyfpatientsfhealthfcare.
ANS:f3
Page:f1
Feedback
1. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthatfallfindividualsfgetfthefsamef healtfhfcar
efthroughoutvtheirflifefspans.
2. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthefgovernmentfwillfsupplyfmoneyf tofcafrevforfa
llfthefpeoplefinfthefworld.
3. Thisfisfcorrect.f“HealthfforfAll”fmeansfthatvresourcesfforfhealthfcarefarefevenlyf distrfibu
tedfandfaccessibleftofeveryone.
4. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthatfhealth-
fcarefprovidersfcanvdenyf patientsfhealthfcare.
2. Healthfassessmentfisfaffoundationalfandfpriorityfnursingfskill.fThisfessentialvskillfrequiresf registeredfnfurs
esf(RNs)fto:
1. Diagnosefandftreatfpatients.
2. Identifyfnormalfandfabnormalffindings.
3. Referfpatientsfwithfabnormalffindings.
4. Counselfpatientsvwithfpsychosocialfneeds.
ANS:f2
Page:f5-6
Feedback
1. Thisfisfincorrect.fThefrolefoffthevRNfisfnotftofdiagnosefandftreatfpatients.
2. Thisfisfcorrect.fAssessingfpatientsfandfbeingfableftofidentifyfnormalffromfabnormalf findifngsfi
sfanfessentialfrolefoffthefRN.
3. Thisfisfincorrect.fRNsfinfcollaborationfwithfthefhealth-
carefprovidersvdofreferf patients.fThisfisfnotfthefessentialfandffoundationalfrolefin
4. Thisfisfincorrect.fRNsfdofcounselfpatients,fbutfitfisfnotvthefessentialfandffoundationalf rolefinfhe
althfassessment.
3f|fPfafgfe
, TestfBankv-
3. Youfarefassessingvafpatientfwithffivefgunshotfwoundsfonfaftraumafunit.fTherefisfafpolicefpresencefoutfsidef
hisfdoorfbecausefthefpatientvisfafknownfdrugfdealerfinfthefcommunity.fYoufknowfthatfnursesfmustvtfreatfallfpa
tientsfasfpersons.fThisfisfcalled:
1. Caring.
2. Holisticfprocess.
3. Person-centeredfcaref(PCC).
4. Standardsfoffcare.
ANS:f3
Page:f2
Feedback
1. Thisfisfincorrect.fCaringvisfdisplayingvafconcernfforfpatients.
2. Thisfisfincorrect.fThefholisticfcaringfprocessfisfafrelationalfprocess;fthefnursef collafboratesf
withfthefindividualftofpursuefgoalsfforfhealthfandfwell-being.
3. Thisfisfcorrect.fThefnewfmovementvinfhealthfcarevisfperson-
centeredfcaref(PCC),f whichfemphasizesfthefintrinsicfvaluefofftreatingvallfpatientsfasfp
4. Thisfisfincorrect.fStandardsfoffcarefidentifyfstandardsfoffprofessionalfnursingf pracftic
e.
4.fThefscience-
basedfframeworkvupdatedfeveryf10fyearsfbyfthefU.S.fDepartmentvoffHealthfandf HumanfServicesfthatvhafsfsetf
nationalfgoalsfandfobjectivesfforvhealthfpromotionfandfdiseasef preventionfis:
1. HealthyvPeople.
2. HealthyvPeoplev2020.
3. U.S.fPreventivefTaskfForce.
4. WorldvHealthfOrganization.
ANS:f2
Page:f2
Feedback
1. Thisfisfincorrect.fHealthyfPeoplevisvthefgeneralftitlefforfthefnation’sffederalfinitiative.
2. Thisfisfcorrect.fHealthyvPeoplev2020fspecificallyfidentifiesfscience-
fbased,fnationalf goals fandfobjectivesfwithf10-
yearftargetsfdesignedftofguidefnationalfhealthfpromotionf andfdiseasefpreventionfeffortsftofim
provefthefhealthfoffallfpeoplefinfthefUnited States.
3. Thisfisfincorrect.fThefU.S.fPreventivefServicesfTaskfForce’sfgoalfisftofusefevidence-
fbasedfmedicineftofimprovefthefhealthfoffallfAmericansfbyfmakingvevidence-
basedf recommendationsfaboutvclinicalfpreventivevservicesfsuchfasfscreenings,fcounselingfservi
ces,fandfpreventivefmedications.
4. Thisfisfincorrect.fThevWorldfHealthfOrganizationfisfafspecializedfagencyfoffthevf Unitfedf
Nationsfworkingftofimprovefthefhealthfoffthefworld’sfpeople.
4f|fPfafgfe
Tho 24
,TableofContents
f f
Chapterf01fUnderstandingfHealthfAssessment _______________________________________________________ 1
Chapterf02fInterviewingfthefPatientvforfthefHealthfHistoryf f f f f f f f f f f f f f f f f f f f f f f f f f f f f11f Chapterf03fTakin
gfthefHealthfHistory _________________________________________________________________________ 40
Chapterf04fAssessingfNutritionfandfAfnthropometricfMeasurementsf f f f f f f f f f f f f f f f f f f f f f f f61f Chapterf05fAss
essmentvTechniques ________________________________________________________________________ 88
Chapterf06fGeneralfSurveyfafndfAssessingfVitalfSignsf f 99fC
hapterf07fAssessingvPain ____________________________________________________________________ 128
Chapterf08fAssessingvthefSkin,fHair,fandfNails _____________________________________________________ 149
Chapterf09fAssessingfthefHead,fFace,fMouth,fandfNeckf f f f f f f f f f f f f f f f f f f f f f f f f f f f f f188fChapterf10vAssess
ingfthefEars ______________________________________________________________________________ 229
Chapterf11fAssessingvthefEyes ________________________________________________________________ 250
Chapterf12fAssessingfthefRespiratoryfSystem 281
Chapterf 13fAssessingf thefCardiovascularfSystem 308
Chapterf14fAssessingvthefAbdomen 335
Chapterf15fAssessingf thefPeripheralfVascularfSystemfandfRegionalfLymphaticfSystem 363
Chapterf 16fAssessingf thefMusculoskeletalfSystem 391
Chapterf17fAssessingvthefNeurologicalfSystem 417
Chapterf18fAssessingf thefFemalefBreasts,fAxillae,fandfReproductivefSystem 451
Chapterf19fAssessingfthefMalefBreastsfandfReproductivevSystem 477
Chapterf20vAssessingfthefAnusfandfRectum 501
Chapterf21fAssessingvthefNewborn 517
Chapterf22fAssessingfthefChildfandfAdolescent 555
Chapterf23fAssessingfthefPregnantfWoman 583
Chapterf24fAssessingvthefOlderfAdult 612
, TestfBankv-
Chapterf1:fUnderstandingfHealthfAssessment
1. ThefWorldfHealthfOrganizationv(WHO)festablishedfavglobalfstrategyfcalledf“HealthfforfAll.”f Thefgofalff
orfthisfstrategyfis:
1. Allfindividualsftofgetvthefsamefhealthfcarefthroughoutftheirflifefspans.
2. Thefgovernmentftofsupplyfmoneyftofcarevforfallfthefpeoplefinfthefworld.
3. Resourcesfforfhealthfcarevtofbefevenlyfdistributedfandfaccessible.
4. Health-carevprovidersfcanfneverfdenyfpatientsfhealthfcare.
ANS:f3
Page:f1
Feedback
1. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthatfallfindividualsfgetfthefsamef healtfhfcar
efthroughoutvtheirflifefspans.
2. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthefgovernmentfwillfsupplyfmoneyf tofcafrevforfa
llfthefpeoplefinfthefworld.
3. Thisfisfcorrect.f“HealthfforfAll”fmeansfthatvresourcesfforfhealthfcarefarefevenlyf distrfibu
tedfandfaccessibleftofeveryone.
4. Thisfisfincorrect.f“HealthfforfAll”fdoesfnotfmeanfthatfhealth-
fcarefprovidersfcanvdenyf patientsfhealthfcare.
2. Healthfassessmentfisfaffoundationalfandfpriorityfnursingfskill.fThisfessentialvskillfrequiresf registeredfnfurs
esf(RNs)fto:
1. Diagnosefandftreatfpatients.
2. Identifyfnormalfandfabnormalffindings.
3. Referfpatientsfwithfabnormalffindings.
4. Counselfpatientsvwithfpsychosocialfneeds.
ANS:f2
Page:f5-6
Feedback
1. Thisfisfincorrect.fThefrolefoffthevRNfisfnotftofdiagnosefandftreatfpatients.
2. Thisfisfcorrect.fAssessingfpatientsfandfbeingfableftofidentifyfnormalffromfabnormalf findifngsfi
sfanfessentialfrolefoffthefRN.
3. Thisfisfincorrect.fRNsfinfcollaborationfwithfthefhealth-
carefprovidersvdofreferf patients.fThisfisfnotfthefessentialfandffoundationalfrolefin
4. Thisfisfincorrect.fRNsfdofcounselfpatients,fbutfitfisfnotvthefessentialfandffoundationalf rolefinfhe
althfassessment.
3f|fPfafgfe
, TestfBankv-
3. Youfarefassessingvafpatientfwithffivefgunshotfwoundsfonfaftraumafunit.fTherefisfafpolicefpresencefoutfsidef
hisfdoorfbecausefthefpatientvisfafknownfdrugfdealerfinfthefcommunity.fYoufknowfthatfnursesfmustvtfreatfallfpa
tientsfasfpersons.fThisfisfcalled:
1. Caring.
2. Holisticfprocess.
3. Person-centeredfcaref(PCC).
4. Standardsfoffcare.
ANS:f3
Page:f2
Feedback
1. Thisfisfincorrect.fCaringvisfdisplayingvafconcernfforfpatients.
2. Thisfisfincorrect.fThefholisticfcaringfprocessfisfafrelationalfprocess;fthefnursef collafboratesf
withfthefindividualftofpursuefgoalsfforfhealthfandfwell-being.
3. Thisfisfcorrect.fThefnewfmovementvinfhealthfcarevisfperson-
centeredfcaref(PCC),f whichfemphasizesfthefintrinsicfvaluefofftreatingvallfpatientsfasfp
4. Thisfisfincorrect.fStandardsfoffcarefidentifyfstandardsfoffprofessionalfnursingf pracftic
e.
4.fThefscience-
basedfframeworkvupdatedfeveryf10fyearsfbyfthefU.S.fDepartmentvoffHealthfandf HumanfServicesfthatvhafsfsetf
nationalfgoalsfandfobjectivesfforvhealthfpromotionfandfdiseasef preventionfis:
1. HealthyvPeople.
2. HealthyvPeoplev2020.
3. U.S.fPreventivefTaskfForce.
4. WorldvHealthfOrganization.
ANS:f2
Page:f2
Feedback
1. Thisfisfincorrect.fHealthyfPeoplevisvthefgeneralftitlefforfthefnation’sffederalfinitiative.
2. Thisfisfcorrect.fHealthyvPeoplev2020fspecificallyfidentifiesfscience-
fbased,fnationalf goals fandfobjectivesfwithf10-
yearftargetsfdesignedftofguidefnationalfhealthfpromotionf andfdiseasefpreventionfeffortsftofim
provefthefhealthfoffallfpeoplefinfthefUnited States.
3. Thisfisfincorrect.fThefU.S.fPreventivefServicesfTaskfForce’sfgoalfisftofusefevidence-
fbasedfmedicineftofimprovefthefhealthfoffallfAmericansfbyfmakingvevidence-
basedf recommendationsfaboutvclinicalfpreventivevservicesfsuchfasfscreenings,fcounselingfservi
ces,fandfpreventivefmedications.
4. Thisfisfincorrect.fThevWorldfHealthfOrganizationfisfafspecializedfagencyfoffthevf Unitfedf
Nationsfworkingftofimprovefthefhealthfoffthefworld’sfpeople.
4f|fPfafgfe