,Test hyBank: hyPhysical hyExamination hy& hyHealth hyAssessment hy7e hy(Jarvis 1
2015)
Table of Contents
hy hy
Table hy of 1
hy Contents
Chapter hy01: hyEvidence-Based 2
hyAssessment hyChapter hy02: hyCultural 15
hyCompetence h y Chapter hy03: hyThe 31
hyInterview 49
Chapter hy04: hyThe hyComplete hyHealth hyHistory 64
hyChapter hy05: hyMental hyStatus hyAssessment 81
hyChapter hy06: hySubstance hyUse hyAssessment 87
Chapter h y 07: h y Domestic hy and h y Family hy Violence hy Assessments 93
Chapter hy08: hyAssessment hyTechniques hyand hySafety hyin hythe hyClinical 112
hySetting hyChapter hy09: hyGeneral hySurvey, hyMeasurement, hyVital hySigns 134
Chapter hy10: hyPain hyAssessment: hyThe hyFifth hyVital hySign 142
hyChapter hy11: hyNutritional hyAssessment 156
Chapter hy 12: hy Skin, hy Hair, hy and hy Nails 177
Chapter hy13: hyHead, hyFace, hyand hyNeck, hyIncluding hyRegional 195
hyLymphatics hyChapter hy14: hyEyes 212
Chapter hy 15: hy Ears 229
Chapter h y 16: h y Nose, h y Mouth, h y and h y Throat 247
hyChapter hy17: hyBreasts hyand hyRegional 267
hyLymphatics hyChapter hy18: hyThorax hyand 285
hyLungs 304
Chapter hy 19: hy Heart hy and hy Neck hy Vessels 321
Chapter hy20: hyPeripheral hyVascular hySystem hyand hyLymphatic hySystem 338
hyChapter hy21: hyAbdomen 359
Chapter hy22: hyMusculoskeletal hySystem 384
hyChapter h y 23: h y Neurologic h y System 402
hyChapter hy24: hyMale hyGenitourinary 416
hySystem 438
Chapter hy25: hyAnus, hyRectum, hyand hyProstate 451
hyChapter hy26: hyFemale hyGenitourinary hySystem 454
Chapter h y 27: h y The h y Complete h y Health h y Assessment: h y Adult 460
Chapter hy28: hyThe hyComplete hyPhysical hyAssessment: hyInfant, hyChild, hyand 473
hyAdolescent hyChapter hy29: hyBedside hyAssessment hyof hythe hyHospitalized hyPatient
Chapter hy 30: hy The h y Pregnant hy Woman
Chapter h y 31: h y Functional h y Assessment h y of h y the h y Older hy Adult
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,Test hyBank: hyPhysical hyExamination hy& hyHealth hyAssessment hy7e hy(Jarvis 2
2015)
Chapter 01: Evidence-Based Assessment
hy hy hy
MULTIPLE h y CHOICE
1. After hycompleting hyan hyinitial hyassessment hyof hya hypatient, hythe hynurse hyhas hycharted hythat hyhis hyrespirations hyare
hyeupneic hyand h y his hypulse hyis hy58 hybeats hyper hyminute. hyThese hytypes hyof hydata hywould hybe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: h yA
Objective hydata hyare hywhat hythe hyhealth hyprofessional hyobserves hyby hyinspecting, hypercussing, hypalpating, hyand
hyauscultating h y during hythe hyphysical hyexamination. hySubjective hydata hyis hywhat hythe hyperson hysays hyabout hyhim
hyor hyherself hyduring hyhistory h y taking. hyThe hyterms hyreflective hyand hyintrospective hyare hynot hyused hyto hydescribe
hydata.
DIF: h y Cognitive h y Level: h y Understanding h y (Comprehension) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
2. A hypatient hytells hythe hynurse hythat hyhe hyis hyvery h ynervous, hyis hynauseated, hyand hyfeels hyhot. hyThese hytypes hyof hydata
hywould hybe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: h yC
Subjective hydata hyare hywhat hythe hyperson hysays hyabout hyhim hyor hyherself hyduring hyhistory hytaking. hyObjective hydata
hyare hywhat hythe h y health hyprofessional hyobserves hyby hyinspecting, hypercussing, hypalpating, hyand hyauscultating
hyduring hythe hyphysical hyexamination. hyThe hyterms hyreflective hyand hyintrospective hyare hynot hyused hyto hydescribe
hydata.
DIF: h y Cognitive h y Level: h y Understanding h y (Comprehension) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
3. The h ypatients h yrecord, h ylaboratory h ystudies, h yobjective h ydata, h yand h ysubjective h ydata h ycombine h yto h yform h ythe:
a. Data hybase.
b. Admitting h y data.
Downloaded hyby hyJazmin hyOrtega
, Test hyBank: hyPhysical hyExamination hy& hyHealth hyAssessment hy7e hy(Jarvis 3
2015)
c. Financial h y statement.
d. Discharge h y summary.
ANS: h yA
Together hywith hythe hypatients hyrecord hyand hylaboratory hystudies, hythe hyobjective hyand hysubjective hydata hyform hythe
hydata hybase. hyThe hyother hyitems hyare hynot hypart hyof hythe hypatients hyrecord, hylaboratory hystudies, hyor hydata.
DIF: h y Cognitive h y Level: h y Remembering h y (Knowledge) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
4. When hylistening hyto hya hypatients hybreath hysounds, hythe hynurse hyis hyunsure hyof hya hysound hythat hyis hyheard. hyThe
hynurses hynext hyaction hyshould hybe hyto:
a. Immediately h ynotify h ythe h ypatients h yphysician.
b. Document hythe hysound hyexactly hyas h yit hywas h yheard.
c. Validate hythe hydata hyby hyasking hya hycoworker hyto hylisten hyto hythe hybreath hysounds.
d. Assess hyagain hyin hy20 hyminutes hyto hynote hywhether hythe hysound hyis hystill hypresent.
ANS: h yC
When hyunsure hyof hya hysound hyheard hywhile hylistening hyto hya hypatients hybreath hysounds, hythe hynurse hyvalidates hythe
hydata hyto hyensure h y accuracy. hyIf hythe hynurse hyhas hyless hyexperience hyin hyan hyarea, hythen hyhe hyor hyshe hyasks hyan
hyexpert hyto hylisten.
DIF: h yCognitive h y Level: h yAnalyzing h y (Analysis) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
5. The h y nurse h y is h y conducting h y a h y class h y for h y new h y graduate h y nurses. h y During h y the h y teaching h y session, h y the
h y nurse h y should h y keep hyin hymind hythat hynovice hynurses, hywithout hya hybackground hyof hyskills hyand hyexperience hyfrom
hywhich hyto hydraw, hyare hymore hylikely h y to hymake hytheir hydecisions hyusing:
a. Intuition.
b. A hyset hyof hyrules.
c. Articles hyin hyjournals.
d. Advice h yfrom h ysupervisors.
ANS: h yB
Novice hynurses hyoperate hyfrom hya hyset hyof hydefined, hystructured hyrules. hyThe hyexpert hypractitioner hyuses
intuitive hylinks. hyDIF: hyCognitive hyLevel: hyUnderstanding hy(Comprehension) hyREF: hyp. hy3
hy
Downloaded hyby hyJazmin hyOrtega
2015)
Table of Contents
hy hy
Table hy of 1
hy Contents
Chapter hy01: hyEvidence-Based 2
hyAssessment hyChapter hy02: hyCultural 15
hyCompetence h y Chapter hy03: hyThe 31
hyInterview 49
Chapter hy04: hyThe hyComplete hyHealth hyHistory 64
hyChapter hy05: hyMental hyStatus hyAssessment 81
hyChapter hy06: hySubstance hyUse hyAssessment 87
Chapter h y 07: h y Domestic hy and h y Family hy Violence hy Assessments 93
Chapter hy08: hyAssessment hyTechniques hyand hySafety hyin hythe hyClinical 112
hySetting hyChapter hy09: hyGeneral hySurvey, hyMeasurement, hyVital hySigns 134
Chapter hy10: hyPain hyAssessment: hyThe hyFifth hyVital hySign 142
hyChapter hy11: hyNutritional hyAssessment 156
Chapter hy 12: hy Skin, hy Hair, hy and hy Nails 177
Chapter hy13: hyHead, hyFace, hyand hyNeck, hyIncluding hyRegional 195
hyLymphatics hyChapter hy14: hyEyes 212
Chapter hy 15: hy Ears 229
Chapter h y 16: h y Nose, h y Mouth, h y and h y Throat 247
hyChapter hy17: hyBreasts hyand hyRegional 267
hyLymphatics hyChapter hy18: hyThorax hyand 285
hyLungs 304
Chapter hy 19: hy Heart hy and hy Neck hy Vessels 321
Chapter hy20: hyPeripheral hyVascular hySystem hyand hyLymphatic hySystem 338
hyChapter hy21: hyAbdomen 359
Chapter hy22: hyMusculoskeletal hySystem 384
hyChapter h y 23: h y Neurologic h y System 402
hyChapter hy24: hyMale hyGenitourinary 416
hySystem 438
Chapter hy25: hyAnus, hyRectum, hyand hyProstate 451
hyChapter hy26: hyFemale hyGenitourinary hySystem 454
Chapter h y 27: h y The h y Complete h y Health h y Assessment: h y Adult 460
Chapter hy28: hyThe hyComplete hyPhysical hyAssessment: hyInfant, hyChild, hyand 473
hyAdolescent hyChapter hy29: hyBedside hyAssessment hyof hythe hyHospitalized hyPatient
Chapter hy 30: hy The h y Pregnant hy Woman
Chapter h y 31: h y Functional h y Assessment h y of h y the h y Older hy Adult
Downloaded hyby hyJazmin hyOrtega
,Test hyBank: hyPhysical hyExamination hy& hyHealth hyAssessment hy7e hy(Jarvis 2
2015)
Chapter 01: Evidence-Based Assessment
hy hy hy
MULTIPLE h y CHOICE
1. After hycompleting hyan hyinitial hyassessment hyof hya hypatient, hythe hynurse hyhas hycharted hythat hyhis hyrespirations hyare
hyeupneic hyand h y his hypulse hyis hy58 hybeats hyper hyminute. hyThese hytypes hyof hydata hywould hybe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: h yA
Objective hydata hyare hywhat hythe hyhealth hyprofessional hyobserves hyby hyinspecting, hypercussing, hypalpating, hyand
hyauscultating h y during hythe hyphysical hyexamination. hySubjective hydata hyis hywhat hythe hyperson hysays hyabout hyhim
hyor hyherself hyduring hyhistory h y taking. hyThe hyterms hyreflective hyand hyintrospective hyare hynot hyused hyto hydescribe
hydata.
DIF: h y Cognitive h y Level: h y Understanding h y (Comprehension) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
2. A hypatient hytells hythe hynurse hythat hyhe hyis hyvery h ynervous, hyis hynauseated, hyand hyfeels hyhot. hyThese hytypes hyof hydata
hywould hybe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: h yC
Subjective hydata hyare hywhat hythe hyperson hysays hyabout hyhim hyor hyherself hyduring hyhistory hytaking. hyObjective hydata
hyare hywhat hythe h y health hyprofessional hyobserves hyby hyinspecting, hypercussing, hypalpating, hyand hyauscultating
hyduring hythe hyphysical hyexamination. hyThe hyterms hyreflective hyand hyintrospective hyare hynot hyused hyto hydescribe
hydata.
DIF: h y Cognitive h y Level: h y Understanding h y (Comprehension) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
3. The h ypatients h yrecord, h ylaboratory h ystudies, h yobjective h ydata, h yand h ysubjective h ydata h ycombine h yto h yform h ythe:
a. Data hybase.
b. Admitting h y data.
Downloaded hyby hyJazmin hyOrtega
, Test hyBank: hyPhysical hyExamination hy& hyHealth hyAssessment hy7e hy(Jarvis 3
2015)
c. Financial h y statement.
d. Discharge h y summary.
ANS: h yA
Together hywith hythe hypatients hyrecord hyand hylaboratory hystudies, hythe hyobjective hyand hysubjective hydata hyform hythe
hydata hybase. hyThe hyother hyitems hyare hynot hypart hyof hythe hypatients hyrecord, hylaboratory hystudies, hyor hydata.
DIF: h y Cognitive h y Level: h y Remembering h y (Knowledge) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
4. When hylistening hyto hya hypatients hybreath hysounds, hythe hynurse hyis hyunsure hyof hya hysound hythat hyis hyheard. hyThe
hynurses hynext hyaction hyshould hybe hyto:
a. Immediately h ynotify h ythe h ypatients h yphysician.
b. Document hythe hysound hyexactly hyas h yit hywas h yheard.
c. Validate hythe hydata hyby hyasking hya hycoworker hyto hylisten hyto hythe hybreath hysounds.
d. Assess hyagain hyin hy20 hyminutes hyto hynote hywhether hythe hysound hyis hystill hypresent.
ANS: h yC
When hyunsure hyof hya hysound hyheard hywhile hylistening hyto hya hypatients hybreath hysounds, hythe hynurse hyvalidates hythe
hydata hyto hyensure h y accuracy. hyIf hythe hynurse hyhas hyless hyexperience hyin hyan hyarea, hythen hyhe hyor hyshe hyasks hyan
hyexpert hyto hylisten.
DIF: h yCognitive h y Level: h yAnalyzing h y (Analysis) h y REF: h y p. h y 2
MSC: h yClient h yNeeds: h y Safe h yand h y Effective h yCare h y Environment: h yManagement h yof h y Care
5. The h y nurse h y is h y conducting h y a h y class h y for h y new h y graduate h y nurses. h y During h y the h y teaching h y session, h y the
h y nurse h y should h y keep hyin hymind hythat hynovice hynurses, hywithout hya hybackground hyof hyskills hyand hyexperience hyfrom
hywhich hyto hydraw, hyare hymore hylikely h y to hymake hytheir hydecisions hyusing:
a. Intuition.
b. A hyset hyof hyrules.
c. Articles hyin hyjournals.
d. Advice h yfrom h ysupervisors.
ANS: h yB
Novice hynurses hyoperate hyfrom hya hyset hyof hydefined, hystructured hyrules. hyThe hyexpert hypractitioner hyuses
intuitive hylinks. hyDIF: hyCognitive hyLevel: hyUnderstanding hy(Comprehension) hyREF: hyp. hy3
hy
Downloaded hyby hyJazmin hyOrtega
