TEST BANK
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,Table !!of !!Contents 1
Chapter !!01: !!Evidence-Based !!Assessment 2
!!Chapter !!02: !!Cultural !!Assessment 15
Chapter !!03: !!The !!Interview 31
Chapter !!04: !!The !!Complete !!Health !!History 49
!!Chapter !!05: !!Mental !!Status !!Assessment 64
!!Chapter !!06: !!Substance !!Use !!Assessment 80
Chapter !!07: !!Domestic !!and !!Family !!Violence !!Assessment 86
Chapter !!08: !!Assessment !!Techniques !!and !!Safety !!in !!the !!Clinical 92
!!Setting !!Chapter !!09: !!General !!Survey !!and !!Measurement 111
Chapter !!10: !!Vital !!Signs 118
!!Chapter !!11: !Pain !Assessment 133
Chapter !12: !!Nutrition !!Assessment 141
!!Chapter !!13: !!Skin, !!Hair, !!and !!Nails 155
Chapter !!14: !!Head, !!Face, !!Neck, !!and !!Regional !!Lymphatics 176
!!Chapter !!15: !!Eyes 194
Chapter !!16: !!Ears 211
Chapter !!17: !!Nose, !!Mouth, !!and !!Throat 228
Chapter !!18: !!Breasts, !!Axillae, !!and !!Regional !!Lymphatics 246
!!Chapter !!19: !!Thorax !!and !!Lungs 266
Chapter !!20: !!Heart !!and !!Neck !!Vessels 284
Chapter !!21: !!Peripheral !!Vascular !!System !!and !!Lymphatic !!System 303
!!Chapter !!22: !!Abdomen 320
Chapter !!23: !!Musculoskeletal !!System 337
!!Chapter ! ! 24: !!Neurologic ! ! System 358
! ! Chapter !!25: !!Male !!Genitourinary 382
!!System !!Chapter !26: !!Anus, !!Rectum, 400
!!and !!Prostate 414
Chapter !!27: !!Female !!Genitourinary !!System 436
Chapter !!28: !!The !!Complete !!Health !!Assessment: !!Adult 449
Chapter !!29: !!The !!Complete !!Physical !!Assessment: !!Infant, !!Child, !!and 452
!!Adolescent !!Chapter !!30: !!Bedside !!Assessment !!and !!Electronic 458
!!Documentation 471
Chapter !!31: !!The !!Pregnant !!Woman
Chapter !!32: !!Functional !!Assessment !!of !!the !!Older !!Adult
,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
!! intuitive !!links. !!DIF: !!Cognitive !!Level: !!Understanding !!(Comprehension)
!!
,Table !!of !!Contents 1
Chapter !!01: !!Evidence-Based !!Assessment 2
!!Chapter !!02: !!Cultural !!Assessment 15
Chapter !!03: !!The !!Interview 31
Chapter !!04: !!The !!Complete !!Health !!History 49
!!Chapter !!05: !!Mental !!Status !!Assessment 64
!!Chapter !!06: !!Substance !!Use !!Assessment 80
Chapter !!07: !!Domestic !!and !!Family !!Violence !!Assessment 86
Chapter !!08: !!Assessment !!Techniques !!and !!Safety !!in !!the !!Clinical 92
!!Setting !!Chapter !!09: !!General !!Survey !!and !!Measurement 111
Chapter !!10: !!Vital !!Signs 118
!!Chapter !!11: !Pain !Assessment 133
Chapter !12: !!Nutrition !!Assessment 141
!!Chapter !!13: !!Skin, !!Hair, !!and !!Nails 155
Chapter !!14: !!Head, !!Face, !!Neck, !!and !!Regional !!Lymphatics 176
!!Chapter !!15: !!Eyes 194
Chapter !!16: !!Ears 211
Chapter !!17: !!Nose, !!Mouth, !!and !!Throat 228
Chapter !!18: !!Breasts, !!Axillae, !!and !!Regional !!Lymphatics 246
!!Chapter !!19: !!Thorax !!and !!Lungs 266
Chapter !!20: !!Heart !!and !!Neck !!Vessels 284
Chapter !!21: !!Peripheral !!Vascular !!System !!and !!Lymphatic !!System 303
!!Chapter !!22: !!Abdomen 320
Chapter !!23: !!Musculoskeletal !!System 337
!!Chapter ! ! 24: !!Neurologic ! ! System 358
! ! Chapter !!25: !!Male !!Genitourinary 382
!!System !!Chapter !26: !!Anus, !!Rectum, 400
!!and !!Prostate 414
Chapter !!27: !!Female !!Genitourinary !!System 436
Chapter !!28: !!The !!Complete !!Health !!Assessment: !!Adult 449
Chapter !!29: !!The !!Complete !!Physical !!Assessment: !!Infant, !!Child, !!and 452
!!Adolescent !!Chapter !!30: !!Bedside !!Assessment !!and !!Electronic 458
!!Documentation 471
Chapter !!31: !!The !!Pregnant !!Woman
Chapter !!32: !!Functional !!Assessment !!of !!the !!Older !!Adult
,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
!! intuitive !!links. !!DIF: !!Cognitive !!Level: !!Understanding !!(Comprehension)
