lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 1
Table of Contents u u
Table of u 1
Content
u
s
Chapter 01: Evidence-Based Assessment u u u 2
Chapter 02: Cultural Competence
u u 15
Chapter 03: The Interview
u u u u 31
Chapter 04: The Complete Health History u u u u u 49
Chapter 05: Mental Status Assessment
u u u u u 64
Chapter 06: Substance Use Assessment
u u u u u
81
Chapter 07: Domestic and Family Violence Assessments
u u u u u u
87
Chapter 08: Assessment Techniques and Safety in the Clinical
u u u u u u u u u
93
Setting Chapter 09: General Survey, Measurement, Vital Signs
u u u u u u u u
112
Chapter 10: Pain Assessment: The Fifth Vital
u u u u u u u
134
Sign Chapter 11: Nutritional Assessment
u u u u
142
Chapter 12: Skin, Hair, and Nails
u u u u u u
156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics Chapter
u u u u u u u u u
177
14: Eyes
u u
195
Chapter 15: Ears
212
u u
Chapter 16: Nose, Mouth, and Throat
229
u u
Chapter 17: Breasts and Regional
247
u u u u u
Lymphatics Chapter 18: Thorax and Lungs
267
u u u u u u
Chapter 19: Heart and Neck Vessels
u u u u u u
285
Chapter 20: Peripheral Vascular System and Lymphatic System
u u u u u u u
304
Chapter 21: Abdomen
u u u
321
Chapter 22: Musculoskeletal System u u u
338
Chapter 23: Neurologic
u u System
359
Chapter 24: Male Genitourinary
u u u u
384
System Chapter 25: Anus, Rectum,
u u u u u
402
and Prostate u
416
Chapter 26: Female Genitourinary System u u u u
438
Chapter 27: The Complete Health Assessment: Adult
u u u u u u
451
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
u u u u u u u u u
454
Chapter 29: Bedside Assessment of the Hospitalized Patient
u u u u u u u u
460
Chapter 30: The Pregnant Woman u u u u
473
Chapter 31: Functional Assessment of the Older Adult
u u u u u u u
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 2
Chapter 01: Evidence-Based Assessment u u u
MULTIPLE CHOICE u
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
u u u u u u u u u u u u u u u
eupneic and his pulse is 58 beats per minute. These types of data would be:
u u u u u u u u u u u u u u u u
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A u
Objective data are what the health professional observes by inspecting, percussing, palpating, and
u u u u u u u u u u u u
auscultating during the physical examination. Subjective data is what the person says about him or herself
u u u u u u u u u u u u u u u u
during history taking.
u The terms
u reflective and introspective
u are not used to describe u u u u u u u u u u u u u u u u u
data.
u
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
u u u u u u u u u u u u u u u u u
data would be:
u u u
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C u
Subjective data are what the person says about him or herself during history taking. Objective data are
u u u u u u u u u u u u u u u u
what the health professional observes by inspecting, percussing, palpating, and
u u u u u u u u u u u u u u u u u u
auscultating during the physical examination. The terms reflective and introspective are
u u u u u u u u u u u u u u u u u
u not used to describe
u u u u u u
data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
u u u u u u u u u u u u u
a. Data base. u
b. Admitting data. u
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 3
c. Financial statement. u
d. Discharge summary. u
ANS: A u
Together with the patients record and laboratory studies, the objective and subjective data form the data
u u u u u u u u u u u u u u u
base. The other items are not part of the patients record, laboratory studies, or
u u u u u u u u u u u u u u u u
udata.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
u u u u u u u u u u u u u u u u u
nurses next action should be to:
u u u u u u
a. Immediately notify the patients physician. u u u u
b. Document the sound exactly as it was heard. u u u u u u u
c. Validate the data by asking a coworker to listen to the breath sounds.
u u u u u u u u u u u u
d. Assess again in 20 minutes to note whether the sound is still present.
u u u u u u u u u u u u
ANS: C u
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
u u u u u u u u u u u u u u u u
data to ensure accuracy. If the nurse has less experience in an area, then he or she
u u u u u u u u u u u u u u u u u
asks an expert to listen.
u u u u u
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
u u u u u u u u u u u u u u
u nurse should keep in mind that novice nurses, without a background of skills and experience
u u u u u u u u u u u u u u
ufrom which to draw, are more likely to make their decisions using:
u u u u u u u u u u u
a. Intuition.
b. A set of rules.
u u u
c. Articles in journals. u u
d. Advice from supervisors. u u
ANS: B u
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
u u u u u u u u u u u u u u
u links. DIF: u u u Cognitive u u Level: u u Understanding u u (Comprehension) u u REF: u u p. u u 3
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 4
MSC: Client Needs: General
u u u
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
u u u u u u u u u u u u u u
labeling it. These responses are referred to as:
u u u u u u u u
a. Intuition.
b. The nursing process. u u
c. Clinical knowledge. u
d. Diagnostic reasoning. u
ANS: A u
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
u u u u u u u u u u u u u u
udata and act without consciously labeling it. The other options are not correct.
u u u u u u u u u u u u u u u u u u u u
DIF: Cognitive Level: Understanding (Comprehension) REF: p.
u u u u u u
u 4 MSC: Client Needs: General
u u u u
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best
u u u u u u u u u u u
ureflects EBP? u
a. EBP relies on tradition for support of best practices.
u u u u u u u u
b. EBP is simply the use of best practice techniques for the treatment of patients.
u u u u u u u u u u u u u
c. EBP emphasizes the use of best evidence with the clinicians experience.
u u u u u u u u u u
d. The patients own preferences are not important with EBP.
u u u u u u u u
ANS: C u
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination
u u u u u u u u u u u u u u u
with the clinicians experience, as well as patient preferences and values, when
u u u u u u u u u u u u u
umaking decisions about care and treatment. EBP is more than simply using the best
u u u u u u u u u u u u u u
upractice techniques to treat patients, and questioning tradition is important when no
u u u u u u u u u u u u u u u u
ucompelling and supportive research evidence exists. u u u u u u u
DIF: Cognitive Level: Applying (Application) REF: p. 5
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which
u u u u u u u u u u u u u u u u
is an example of a first-level priority problem?
u u u u u u u u
a. Patient with postoperative pain u u u
b. Newly diagnosed patient with diabetes who needs diabetic teaching
u u u u u u u u
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 1
Table of Contents u u
Table of u 1
Content
u
s
Chapter 01: Evidence-Based Assessment u u u 2
Chapter 02: Cultural Competence
u u 15
Chapter 03: The Interview
u u u u 31
Chapter 04: The Complete Health History u u u u u 49
Chapter 05: Mental Status Assessment
u u u u u 64
Chapter 06: Substance Use Assessment
u u u u u
81
Chapter 07: Domestic and Family Violence Assessments
u u u u u u
87
Chapter 08: Assessment Techniques and Safety in the Clinical
u u u u u u u u u
93
Setting Chapter 09: General Survey, Measurement, Vital Signs
u u u u u u u u
112
Chapter 10: Pain Assessment: The Fifth Vital
u u u u u u u
134
Sign Chapter 11: Nutritional Assessment
u u u u
142
Chapter 12: Skin, Hair, and Nails
u u u u u u
156
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics Chapter
u u u u u u u u u
177
14: Eyes
u u
195
Chapter 15: Ears
212
u u
Chapter 16: Nose, Mouth, and Throat
229
u u
Chapter 17: Breasts and Regional
247
u u u u u
Lymphatics Chapter 18: Thorax and Lungs
267
u u u u u u
Chapter 19: Heart and Neck Vessels
u u u u u u
285
Chapter 20: Peripheral Vascular System and Lymphatic System
u u u u u u u
304
Chapter 21: Abdomen
u u u
321
Chapter 22: Musculoskeletal System u u u
338
Chapter 23: Neurologic
u u System
359
Chapter 24: Male Genitourinary
u u u u
384
System Chapter 25: Anus, Rectum,
u u u u u
402
and Prostate u
416
Chapter 26: Female Genitourinary System u u u u
438
Chapter 27: The Complete Health Assessment: Adult
u u u u u u
451
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
u u u u u u u u u
454
Chapter 29: Bedside Assessment of the Hospitalized Patient
u u u u u u u u
460
Chapter 30: The Pregnant Woman u u u u
473
Chapter 31: Functional Assessment of the Older Adult
u u u u u u u
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 2
Chapter 01: Evidence-Based Assessment u u u
MULTIPLE CHOICE u
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are
u u u u u u u u u u u u u u u
eupneic and his pulse is 58 beats per minute. These types of data would be:
u u u u u u u u u u u u u u u u
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A u
Objective data are what the health professional observes by inspecting, percussing, palpating, and
u u u u u u u u u u u u
auscultating during the physical examination. Subjective data is what the person says about him or herself
u u u u u u u u u u u u u u u u
during history taking.
u The terms
u reflective and introspective
u are not used to describe u u u u u u u u u u u u u u u u u
data.
u
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
u u u u u u u u u u u u u u u u u
data would be:
u u u
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C u
Subjective data are what the person says about him or herself during history taking. Objective data are
u u u u u u u u u u u u u u u u
what the health professional observes by inspecting, percussing, palpating, and
u u u u u u u u u u u u u u u u u u
auscultating during the physical examination. The terms reflective and introspective are
u u u u u u u u u u u u u u u u u
u not used to describe
u u u u u u
data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
u u u u u u u u u u u u u
a. Data base. u
b. Admitting data. u
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 3
c. Financial statement. u
d. Discharge summary. u
ANS: A u
Together with the patients record and laboratory studies, the objective and subjective data form the data
u u u u u u u u u u u u u u u
base. The other items are not part of the patients record, laboratory studies, or
u u u u u u u u u u u u u u u u
udata.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
u u u u u u u u u u u u u u u u u
nurses next action should be to:
u u u u u u
a. Immediately notify the patients physician. u u u u
b. Document the sound exactly as it was heard. u u u u u u u
c. Validate the data by asking a coworker to listen to the breath sounds.
u u u u u u u u u u u u
d. Assess again in 20 minutes to note whether the sound is still present.
u u u u u u u u u u u u
ANS: C u
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the
u u u u u u u u u u u u u u u u
data to ensure accuracy. If the nurse has less experience in an area, then he or she
u u u u u u u u u u u u u u u u u
asks an expert to listen.
u u u u u
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 2
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
u u u u u u u u u u u u u u
u nurse should keep in mind that novice nurses, without a background of skills and experience
u u u u u u u u u u u u u u
ufrom which to draw, are more likely to make their decisions using:
u u u u u u u u u u u
a. Intuition.
b. A set of rules.
u u u
c. Articles in journals. u u
d. Advice from supervisors. u u
ANS: B u
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive
u u u u u u u u u u u u u u
u links. DIF: u u u Cognitive u u Level: u u Understanding u u (Comprehension) u u REF: u u p. u u 3
, lOMoARcPSD|
u
th
Test Bank: Physical Examination & Health Assessment 7 Edition
u u u u u u u u 4
MSC: Client Needs: General
u u u
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
u u u u u u u u u u u u u u
labeling it. These responses are referred to as:
u u u u u u u u
a. Intuition.
b. The nursing process. u u
c. Clinical knowledge. u
d. Diagnostic reasoning. u
ANS: A u
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment
u u u u u u u u u u u u u u
udata and act without consciously labeling it. The other options are not correct.
u u u u u u u u u u u u u u u u u u u u
DIF: Cognitive Level: Understanding (Comprehension) REF: p.
u u u u u u
u 4 MSC: Client Needs: General
u u u u
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best
u u u u u u u u u u u
ureflects EBP? u
a. EBP relies on tradition for support of best practices.
u u u u u u u u
b. EBP is simply the use of best practice techniques for the treatment of patients.
u u u u u u u u u u u u u
c. EBP emphasizes the use of best evidence with the clinicians experience.
u u u u u u u u u u
d. The patients own preferences are not important with EBP.
u u u u u u u u
ANS: C u
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination
u u u u u u u u u u u u u u u
with the clinicians experience, as well as patient preferences and values, when
u u u u u u u u u u u u u
umaking decisions about care and treatment. EBP is more than simply using the best
u u u u u u u u u u u u u u
upractice techniques to treat patients, and questioning tradition is important when no
u u u u u u u u u u u u u u u u
ucompelling and supportive research evidence exists. u u u u u u u
DIF: Cognitive Level: Applying (Application) REF: p. 5
u u u u u u u
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
u u u u u u u u u u
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which
u u u u u u u u u u u u u u u u
is an example of a first-level priority problem?
u u u u u u u u
a. Patient with postoperative pain u u u
b. Newly diagnosed patient with diabetes who needs diabetic teaching
u u u u u u u u
