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Table of Contents a w a w
Table of Contents a w a w 1
Chapter 01: Evidence-Based a w a w 2
aAssessmentChapter 02: Cultural
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aCompetence Chapter 03: The Interview
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Chapter 04: The Complete Health History
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Chapter 05: Mental Status Assessment
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Chapter 06: Substance Use Assessment
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Chapter 07: Domestic and Family Violence Assessments
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Chapter 08: Assessment Techniques and Safety in the Clinical Setting
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Chapter 09: General Survey, Measurement, Vital Signs
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Chapter 10: Pain Assessment: The Fifth Vital SignChapter
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a 134
11: Nutritional Assessment
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Chapter 12: Skin, Hair, and Nails
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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics
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Chapter 14: Eyes
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Chapter 15: Ears a w a w 212
Chapter 16: Nose, Mouth, and Throat
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Chapter 17: Breasts and Regional
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LymphaticsChapter 18: Thorax and Lungs
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Chapter 19: Heart and Neck Vessels
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Chapter 20: Peripheral Vascular System and Lymphatic System
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Chapter 21: Abdomen
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Chapter 22: Musculoskeletal System
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Chapter 23: Neurologic System
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Chapter 24: Male Genitourinary
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System
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Chapter 25: Anus, Rectum, and Prostate
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Chapter 26: Female Genitourinary System
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Chapter 27: The Complete Health Assessment: Adult
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Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
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Chapter 29: Bedside Assessment of the Hospitalized Patient
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Chapter 30: The Pregnant Woman
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Chapter 31: Functional Assessment of the Older Adult
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,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
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Chapter 01: Evidence-Based Assessment a w a w a w
MULTIPLE CHOICE a w
1. Aftercompletinganinitialassessmentofapatient,thenursehaschartedthathisrespirationsareeupneicandhis
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pulse is 58 beats per minute. These types of data would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A aw
Objectivedataarewhatthehealthprofessionalobservesbyinspecting,percussing,palpating,andauscultating
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during the physical examination. Subjective data is what the person says about him or herself during history
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taking. The termsreflective andintrospective are not used to describe data.
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DIF:CognitiveLevel:Understanding(Comprehension)REF: p.2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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2. Apatienttellsthenursethatheisverynervous,isnauseated,andfeelshot.Thesetypesofdatawouldbe:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C aw
Subjectivedataarewhatthepersonsaysabouthimorherselfduringhistorytaking.Objectivedataarewhatthehealth
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professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The
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termsreflective andintrospective are not used to describe data.
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DIF:CognitiveLevel:Understanding(Comprehension)REF: p.2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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3. Thepatientsrecord,laboratorystudies,objectivedata,andsubjectivedatacombinetoformthe:
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a. Database. aw
b. Admittingdata. aw
,Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
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a aw aw aw 3
c. Financial statement. a w
d. Dischargesummary. aw
ANS: A aw
Togetherwiththepatientsrecordandlaboratorystudies,theobjectiveandsubjectivedataformthedatabase.The
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other items are not part of the patients record, laboratory studies, or data.
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DIF:CognitiveLevel:Remembering(Knowledge)REF:p.2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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4. Whenlisteningtoapatientsbreathsounds,thenurseisunsureofasoundthatisheard.Thenursesnextaction
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should be to:
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a. Immediatelynotifythepatientsphysician. aw aw aw aw
b. Documentthesoundexactlyasitwasheard. aw aw aw aw aw aw aw
c. Validatethedatabyaskingacoworkertolistentothebreathsounds. aw aw aw aw aw aw aw aw aw aw aw aw
d. Assessagainin20minutestonotewhetherthesoundisstillpresent. aw aw aw aw aw aw aw aw aw aw aw aw
ANS: C aw
Whenunsureofasoundheardwhilelisteningtoapatientsbreathsounds,thenursevalidatesthedatatoensureaccuracy.
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If the nurse has less experience in an area, then he or she asks an expert to listen.
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DIF:CognitiveLevel:Analyzing(Analysis)REF:p.2
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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5. Thenurse isconducting a class for new graduate nurses.Duringthe teaching session, thenurse shouldkeepinmind
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that novice nurses, without a background of skills and experience from which to draw, are more likely to make their
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decisions using:
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a. Intuition.
b. A set of rules.
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c. Articlesinjournals. aw aw
d. Advicefromsupervisors. aw aw
ANS: B aw
Novicenursesoperatefromasetofdefined,structuredrules.Theexpertpractitionerusesintuitivelinks.DIF:
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aw Cognitive Level: Understanding (Comprehension) REF: p. 3 aw aw aw aw aw aw
, Test Bank: Physical Examination & HealthAssessment 7e (Jarvis 2015)
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MSC:ClientNeeds:General aw aw aw
6. Expertnurseslearntoattendtoapatternofassessmentdataandactwithoutconsciouslylabelingit.These
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responses are referred to as:
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a. Intuition.
b. Thenursingprocess. aw aw
c. Clinicalknowledge. aw
d. Diagnosticreasoning. aw
ANS: A aw
Intuitionischaracterizedbypatternrecognitionexpertnurseslearntoattendtoapatternofassessmentdataandact
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without consciously labeling it. The other options are not correct.
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DIF:CognitiveLevel:Understanding(Comprehension)REF: p.4
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MSC: Client Needs: General
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7. Thenurseisreviewinginformationaboutevidence-basedpractice(EBP).WhichstatementbestreflectsEBP?
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a. EBPreliesontraditionforsupportofbestpractices. aw aw aw aw aw aw aw aw
b. EBPissimplytheuseofbestpracticetechniquesforthetreatmentofpatients.
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c. EBPemphasizestheuseofbestevidencewiththecliniciansexperience.
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d. ThepatientsownpreferencesarenotimportantwithEBP.
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ANS: C
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EBPisasystematicapproachtopracticethatemphasizestheuseofbestevidenceincombinationwiththeclinicians
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experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is
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more than simply using the best practice techniques to treat patients, and questioning tradition is important when no
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compelling andsupportive research evidence exists.
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DIF:CognitiveLevel:Applying(Application)REF:p.5
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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare
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8. Thenurseisconductingaclassonprioritysettingforagroupofnewgraduatenurses.Whichisanexampleof a first-
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level priority problem?
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a. Patientwithpostoperativepain aw aw aw
b. Newlydiagnosedpatientwithdiabeteswhoneedsdiabeticteaching aw aw aw aw aw aw aw aw