TEST BANK hV
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 9TH
hV hV hV hV hV
EDITION
hV
Authors: h V Carolyn Jarvis And Ann L. Eckhardt
hV hV hV hV hV
TEST BANK hV
,TABLE OF CONTENT
hV hV
Chapter hV01: hVEvidence-Based hVAssessment ................................................................................................ 3
Chapter hV02: hVCultural hVAssessment ........................................................................................................... 12
Chapter hV03: hVThe hVInterview ..................................................................................................................... 23
Chapter hV04: hVThe hVComplete hVHealth hVHistory.......................................................................................... 39
Chapter hV05: hVMental hVStatus hVAssessment ................................................................................................ 51
Chapter hV06: hVSubstance hVUse hVAssessment ............................................................................................... 66
Chapter hV07: hVFamily hVViolence hVand hVHuman hVTrafficking ...................................................................... 72
Chapter hV08: hVAssessment hVTechniques hVand hVSafety hVin hVthe hVClinical hVSetting ....................................... 78
Chapter hV09: hVGeneral hVSurvey hVand hVMeasurement................................................................................... 93
Chapter hV10: hVVital hVSigns .......................................................................................................................... 98
Chapter hV11: hVPain hVAssessment ............................................................................................................... 112
Chapter hV12: hVNutrition hVAssessment ....................................................................................................... 119
Chapter hV13: hVSkin, hVHair, hVand hVNails ..................................................................................................... 131
Chapter hV14: hVHead, hVFace, hVand hVNeck, hVand hVRegional hVLymphatics..................................................... 149
Chapter hV15: hVEyes.................................................................................................................................... 163
Chapter hV16: hVEars .................................................................................................................................... 177
Chapter hV17: hVNose, hVMouth, hVand hVThroat............................................................................................... 192
Chapter hV18: hVBreasts, hVAxillae, hVand hVRegional hVLymphatics ................................................................. 207
Chapter hV19: hVThorax hVand hVLungs ........................................................................................................... 223
Chapter hV20: hVHeart hVand hVNeck hVVessels ................................................................................................. 239
Chapter hV21: hVPeripheral hVVascular hVSystem hVand hVLymphatic hVSystem .................................................. 254
Chapter hV22: hVAbdomen ........................................................................................................................... 268
Chapter hV23: hVMusculoskeletal hVSystem ................................................................................................... 280
Chapter hV24: hVNeurologic hVSystem ........................................................................................................... 297
Chapter hV25: hVMale hVGenitourinary hVSystem ............................................................................................ 318
Chapter hV26: hVAnus, hVRectum, hVand hVProstate .......................................................................................... 332
Chapter hV27: hVFemale hVGenitourinary hVSystem ........................................................................................ 343
Chapter hV28: hVThe hVComplete hVHealth hVAssessment: hVAdult .................................................................... 361
Chapter hV29: hVThe hVComplete hVPhysical hVAssessment: hVInfant, hVYoung hVChild, hVand hVAdolescent.......... 366
Chapter hV30: hVBedside hVAssessment hVand hVElectronic hVDocumentation ................................................... 368
Chapter hV31: hVPregnancy .......................................................................................................................... 373
Chapter hV32: hVFunctional hVAssessment hVof hVthe hVOlder hVAdult ................................................................. 384
,Chapter 01: Evidence-Based Assessment
hV hV hV
Jarvis: Physical Examination and Health Assessment, 9th Edition
hV hV hV hV hV hV hV
MULTIPLE hVCHOICE
1. After hVcompleting hVan hVinitial hVassessment hVof hVa hVpatient, hVthe hVnurse hVhas hVcharted hVthat hVhis
respirations hVare hVeupneic hVand hVhis hVpulse hVis hV58 hVbeats hVper hVminute. hVWhat hVtype hVof
hV
hVassessment hVdata hVis hVthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: h V A
Objective hVdata hVis hVwhat hVthe hVhealth hVprofessional hVobserves hVby hVinspecting, hVpercussing,
hVpalpating, hVand hVauscultating hVduring hVthe hVphysical hVexamination. hVSubjective hVdata hVis
hVwhat hVthe hVperson hVsays hVabout hVhim hVor hVherself hVduring hVhistory hVtaking. hVThe hVterms
hVreflective hVand hVintrospective hVare hVnot hVused hVto hVdescribe hVdata.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
2. A hVpatient hVtells hVthe hVnurse hVthat hVhe hVis hVvery hVnervous, hVnauseous, hVand hV―feels hVhot.‖
hV What hVtypehVof hVassessment hVdata hVis hVthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: hVC
Subjective hVdata hVis hVwhat hVthe hVperson hVsays hVabout hVhim hVor hVherself hVduring hVhistory hVtaking.
hVObjective hVdata hVis hVwhat hVthe hVhealth hVprofessional hVobserves hVby hVinspecting, hVpercussing,
hVpalpating, hVand hVauscultating hVduring hVthe hVphysical hVexamination. hVThe hVterms hVreflective
hVand hVintrospective hVare hVnot hVused hVto hVdescribe hVdata.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
3. What hVdo hVthe hVpatient‘s hVrecord, hVlaboratory hVstudies, hVobjective hVdata, hVand hVsubjective
datacombine hVto hVform?
hV
a. Database
b. Admitting hVdata
c. Financial hVstatement
d. Discharge hVsummary
ANS: hVA
The hVobjective hVand hVsubjective hVdata hVtogether hVwith hVthe hVpatient‘s hVrecord hVand hVlaboratory
hVstudies, hVform hVthe hVdatabase. hVThe hVother hVitems hVare hVnot hVpart hVof hVthe hVpatient‘s hVrecord,
hVlaboratory hVstudies, hVor hVdata.
DIF: Cognitive hVLevel: hVRemembering hV(Knowledge)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
, 4. When hVlistening hVto hVa hVpatient‘s hVbreath hVsounds, hVthe hVnurse hVis hVunsure hVof hVa hVsound
hV that hVisheard. hVWhich hVaction hVwould hVthe hVnurse hVtake hVnext?
a. Notify hVthe hVpatient‘s hVphysician.
b. Document hVthe hVsound hVexactly hVas hVit hVwas hVheard.
c. Validate hVthe hVdata hVby hVasking hVanother hVnurse hVto hVlisten hVto hVthe hVbreath hVsounds.
d. Assess hVagain hVin hV20 hVminutes hVto hVnote hVwhether hVthe hVsound hVis hVstill hVpresent.
ANS: hVC
When hVunsure hVof hVa hVsound hVheard hVwhile hVlistening hVto hVa hVpatient‘s hVbreath hVsounds, hVthe
hVnurse hVvalidates hVthe hVdata hVto hVensure hVaccuracy hVby hVeither hVrepeating hVthe hVassessment
hVthemselves hVor hVasking hVanother hVnurse hVto hVassess hVthe hVbreath hVsounds. hVIf hVthe hVnurse hVhas
hVless hVexperience hVanalyzing hVbreath hVsounds, hVthen hVhe hVor hVshe hVshould hVask hVan hVexpert hVto
hVlisten. hVWhen hVunsure hVof hVa hVsound hVheard hVwhile hVlistening hVto hVa hVpatient‘s hVbreath hVsounds,
hVthe hVnurse hVshould hVvalidate hVthe hVdata hVbefore hVdocumenting hVto hVensure hVaccuracy hVand
hVbefore hVnotifying hVthe hVpatient‘s hVphysician. hVTo hVvalidate hVthat hVdata, hVthe hVnurse hVeither
hVrepeats hVthe hVassessment hVhimself hVor hVherself hVor hVasks hVanother hVnurse hVto hVassess hVthe
hVbreath hVsounds.
DIF: Cognitive hVLevel: hVApplying hV(Application)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
5. The hVnurse hVis hVconducting hVa hVclass hVfor hVnew hVgraduate hVnurses. hVWhile hVteaching hVthe hVclass,
hVwhathVwould hVthe hVnurse hVkeep hVin hVmind hVregarding hVwhat hVnovice hVnurses, hVwithout hVa
hVbackground hVof hVskills hVand hVexperience hVfrom hVwhich hVto hVdraw hVupon, hVare hVmore hVlikely
hVto hVbase hVtheir hVdecisions hVon?
a. Intuition
b. A hVset hVof hVrules
c. Articles hVin hVjournals
d. Advice hVfromhVsupervisors
ANS: hVB
Novice hVnurses hVoperate hVfrom hVa hVset hVof hVdefined, hVstructured hVrules hVto hVmake hVdecisions. hVIt
hVtakes hVtime, hVperhaps hVa hVfew hVyears, hVin hVsimilar hVclinical hVsituations hVto hVachieve
hVcompetency hVand hVit hVis hVfunctioning hVat hVthe hVlevel hVof hVan hVexpert hVpractitioner hVwhen
hVintuition hVis hVincluded hVin hVmaking hVclinical hVdecisions. hVWhile hVinformation hVin hVjournal
hVarticles hVand hVadvice hVfrom hVsupervisors hVmay hVassist hVin hVmaking hVdecisions, hVnovice hVnurses
hVdo hVnot hVtypically hVbase hVtheir hVdecisions hVon hVthem. hVIt hVwould hValso hVbe hVimportant hVthat hVif
hVinformation hVfrom hVjournal hVarticles hVand hVadvice hVfrom hVsupervisors hVwere hVused, hVthat hVthey
hVwere hVevidence hVbased.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension) MSC: hVClient hVNeeds: hVGeneral
6. The hVnurse hVis hVreviewing hVinformation hVabout hVevidence-based hVpractice hV(EBP). hVWhich
statement hVbest hVreflects hVEBP?
hV
a. EBP hVrelies hVon hVtradition hVfor hVsupport hVof hVbest hVpractices.
b. EBP hVis hVsimply hVthe hVuse hVof hVbest hVpractice hVtechniques hVfor hVthe hVtreatment hVof hVpatients.
c. EBP hVemphasizes hVthe hVuse hVof hVbest hVevidence hVwith hVthe hVclinician‘s hVexperience.
d. EBP hVdoes hVnot hVconsider hVthe hVpatient‘s hVown hVpreferences hVas hVimportant.
ANS: hVC
PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 9TH
hV hV hV hV hV
EDITION
hV
Authors: h V Carolyn Jarvis And Ann L. Eckhardt
hV hV hV hV hV
TEST BANK hV
,TABLE OF CONTENT
hV hV
Chapter hV01: hVEvidence-Based hVAssessment ................................................................................................ 3
Chapter hV02: hVCultural hVAssessment ........................................................................................................... 12
Chapter hV03: hVThe hVInterview ..................................................................................................................... 23
Chapter hV04: hVThe hVComplete hVHealth hVHistory.......................................................................................... 39
Chapter hV05: hVMental hVStatus hVAssessment ................................................................................................ 51
Chapter hV06: hVSubstance hVUse hVAssessment ............................................................................................... 66
Chapter hV07: hVFamily hVViolence hVand hVHuman hVTrafficking ...................................................................... 72
Chapter hV08: hVAssessment hVTechniques hVand hVSafety hVin hVthe hVClinical hVSetting ....................................... 78
Chapter hV09: hVGeneral hVSurvey hVand hVMeasurement................................................................................... 93
Chapter hV10: hVVital hVSigns .......................................................................................................................... 98
Chapter hV11: hVPain hVAssessment ............................................................................................................... 112
Chapter hV12: hVNutrition hVAssessment ....................................................................................................... 119
Chapter hV13: hVSkin, hVHair, hVand hVNails ..................................................................................................... 131
Chapter hV14: hVHead, hVFace, hVand hVNeck, hVand hVRegional hVLymphatics..................................................... 149
Chapter hV15: hVEyes.................................................................................................................................... 163
Chapter hV16: hVEars .................................................................................................................................... 177
Chapter hV17: hVNose, hVMouth, hVand hVThroat............................................................................................... 192
Chapter hV18: hVBreasts, hVAxillae, hVand hVRegional hVLymphatics ................................................................. 207
Chapter hV19: hVThorax hVand hVLungs ........................................................................................................... 223
Chapter hV20: hVHeart hVand hVNeck hVVessels ................................................................................................. 239
Chapter hV21: hVPeripheral hVVascular hVSystem hVand hVLymphatic hVSystem .................................................. 254
Chapter hV22: hVAbdomen ........................................................................................................................... 268
Chapter hV23: hVMusculoskeletal hVSystem ................................................................................................... 280
Chapter hV24: hVNeurologic hVSystem ........................................................................................................... 297
Chapter hV25: hVMale hVGenitourinary hVSystem ............................................................................................ 318
Chapter hV26: hVAnus, hVRectum, hVand hVProstate .......................................................................................... 332
Chapter hV27: hVFemale hVGenitourinary hVSystem ........................................................................................ 343
Chapter hV28: hVThe hVComplete hVHealth hVAssessment: hVAdult .................................................................... 361
Chapter hV29: hVThe hVComplete hVPhysical hVAssessment: hVInfant, hVYoung hVChild, hVand hVAdolescent.......... 366
Chapter hV30: hVBedside hVAssessment hVand hVElectronic hVDocumentation ................................................... 368
Chapter hV31: hVPregnancy .......................................................................................................................... 373
Chapter hV32: hVFunctional hVAssessment hVof hVthe hVOlder hVAdult ................................................................. 384
,Chapter 01: Evidence-Based Assessment
hV hV hV
Jarvis: Physical Examination and Health Assessment, 9th Edition
hV hV hV hV hV hV hV
MULTIPLE hVCHOICE
1. After hVcompleting hVan hVinitial hVassessment hVof hVa hVpatient, hVthe hVnurse hVhas hVcharted hVthat hVhis
respirations hVare hVeupneic hVand hVhis hVpulse hVis hV58 hVbeats hVper hVminute. hVWhat hVtype hVof
hV
hVassessment hVdata hVis hVthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: h V A
Objective hVdata hVis hVwhat hVthe hVhealth hVprofessional hVobserves hVby hVinspecting, hVpercussing,
hVpalpating, hVand hVauscultating hVduring hVthe hVphysical hVexamination. hVSubjective hVdata hVis
hVwhat hVthe hVperson hVsays hVabout hVhim hVor hVherself hVduring hVhistory hVtaking. hVThe hVterms
hVreflective hVand hVintrospective hVare hVnot hVused hVto hVdescribe hVdata.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
2. A hVpatient hVtells hVthe hVnurse hVthat hVhe hVis hVvery hVnervous, hVnauseous, hVand hV―feels hVhot.‖
hV What hVtypehVof hVassessment hVdata hVis hVthis?
a. Objective
b. Reflective
c. Subjective
d. Introspective
ANS: hVC
Subjective hVdata hVis hVwhat hVthe hVperson hVsays hVabout hVhim hVor hVherself hVduring hVhistory hVtaking.
hVObjective hVdata hVis hVwhat hVthe hVhealth hVprofessional hVobserves hVby hVinspecting, hVpercussing,
hVpalpating, hVand hVauscultating hVduring hVthe hVphysical hVexamination. hVThe hVterms hVreflective
hVand hVintrospective hVare hVnot hVused hVto hVdescribe hVdata.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
3. What hVdo hVthe hVpatient‘s hVrecord, hVlaboratory hVstudies, hVobjective hVdata, hVand hVsubjective
datacombine hVto hVform?
hV
a. Database
b. Admitting hVdata
c. Financial hVstatement
d. Discharge hVsummary
ANS: hVA
The hVobjective hVand hVsubjective hVdata hVtogether hVwith hVthe hVpatient‘s hVrecord hVand hVlaboratory
hVstudies, hVform hVthe hVdatabase. hVThe hVother hVitems hVare hVnot hVpart hVof hVthe hVpatient‘s hVrecord,
hVlaboratory hVstudies, hVor hVdata.
DIF: Cognitive hVLevel: hVRemembering hV(Knowledge)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
, 4. When hVlistening hVto hVa hVpatient‘s hVbreath hVsounds, hVthe hVnurse hVis hVunsure hVof hVa hVsound
hV that hVisheard. hVWhich hVaction hVwould hVthe hVnurse hVtake hVnext?
a. Notify hVthe hVpatient‘s hVphysician.
b. Document hVthe hVsound hVexactly hVas hVit hVwas hVheard.
c. Validate hVthe hVdata hVby hVasking hVanother hVnurse hVto hVlisten hVto hVthe hVbreath hVsounds.
d. Assess hVagain hVin hV20 hVminutes hVto hVnote hVwhether hVthe hVsound hVis hVstill hVpresent.
ANS: hVC
When hVunsure hVof hVa hVsound hVheard hVwhile hVlistening hVto hVa hVpatient‘s hVbreath hVsounds, hVthe
hVnurse hVvalidates hVthe hVdata hVto hVensure hVaccuracy hVby hVeither hVrepeating hVthe hVassessment
hVthemselves hVor hVasking hVanother hVnurse hVto hVassess hVthe hVbreath hVsounds. hVIf hVthe hVnurse hVhas
hVless hVexperience hVanalyzing hVbreath hVsounds, hVthen hVhe hVor hVshe hVshould hVask hVan hVexpert hVto
hVlisten. hVWhen hVunsure hVof hVa hVsound hVheard hVwhile hVlistening hVto hVa hVpatient‘s hVbreath hVsounds,
hVthe hVnurse hVshould hVvalidate hVthe hVdata hVbefore hVdocumenting hVto hVensure hVaccuracy hVand
hVbefore hVnotifying hVthe hVpatient‘s hVphysician. hVTo hVvalidate hVthat hVdata, hVthe hVnurse hVeither
hVrepeats hVthe hVassessment hVhimself hVor hVherself hVor hVasks hVanother hVnurse hVto hVassess hVthe
hVbreath hVsounds.
DIF: Cognitive hVLevel: hVApplying hV(Application)
MSC: hVClient hVNeeds: hVSafe hVand hVEffective hVCare hVEnvironment: hVManagement hVof hVCare
5. The hVnurse hVis hVconducting hVa hVclass hVfor hVnew hVgraduate hVnurses. hVWhile hVteaching hVthe hVclass,
hVwhathVwould hVthe hVnurse hVkeep hVin hVmind hVregarding hVwhat hVnovice hVnurses, hVwithout hVa
hVbackground hVof hVskills hVand hVexperience hVfrom hVwhich hVto hVdraw hVupon, hVare hVmore hVlikely
hVto hVbase hVtheir hVdecisions hVon?
a. Intuition
b. A hVset hVof hVrules
c. Articles hVin hVjournals
d. Advice hVfromhVsupervisors
ANS: hVB
Novice hVnurses hVoperate hVfrom hVa hVset hVof hVdefined, hVstructured hVrules hVto hVmake hVdecisions. hVIt
hVtakes hVtime, hVperhaps hVa hVfew hVyears, hVin hVsimilar hVclinical hVsituations hVto hVachieve
hVcompetency hVand hVit hVis hVfunctioning hVat hVthe hVlevel hVof hVan hVexpert hVpractitioner hVwhen
hVintuition hVis hVincluded hVin hVmaking hVclinical hVdecisions. hVWhile hVinformation hVin hVjournal
hVarticles hVand hVadvice hVfrom hVsupervisors hVmay hVassist hVin hVmaking hVdecisions, hVnovice hVnurses
hVdo hVnot hVtypically hVbase hVtheir hVdecisions hVon hVthem. hVIt hVwould hValso hVbe hVimportant hVthat hVif
hVinformation hVfrom hVjournal hVarticles hVand hVadvice hVfrom hVsupervisors hVwere hVused, hVthat hVthey
hVwere hVevidence hVbased.
DIF: Cognitive hVLevel: hVUnderstanding hV(Comprehension) MSC: hVClient hVNeeds: hVGeneral
6. The hVnurse hVis hVreviewing hVinformation hVabout hVevidence-based hVpractice hV(EBP). hVWhich
statement hVbest hVreflects hVEBP?
hV
a. EBP hVrelies hVon hVtradition hVfor hVsupport hVof hVbest hVpractices.
b. EBP hVis hVsimply hVthe hVuse hVof hVbest hVpractice hVtechniques hVfor hVthe hVtreatment hVof hVpatients.
c. EBP hVemphasizes hVthe hVuse hVof hVbest hVevidence hVwith hVthe hVclinician‘s hVexperience.
d. EBP hVdoes hVnot hVconsider hVthe hVpatient‘s hVown hVpreferences hVas hVimportant.
ANS: hVC
