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 |Setting 92
|Chapter |09: |General |Survey |and |Measurement 111
Chapter |10: |Vital |Signs 118
|Chapter |11: |Pain |Assessment 133
Chapter |12: |Nutrition |Assessment |Chapter 141
|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 |Chapter 246
|19: |Thorax |and |Lungs 266
Chapter |20: |Heart |and |Neck |Vessels 284
Chapter |21: |Peripheral |Vascular |System |and |Lymphatic |System |Chapter 303
|22: |Abdomen 320
Chapter |23: |Musculoskeletal |System 337
|Chapter | 24: |Neurologic | System 358
| Chapter |25: |Male |Genitourinary |System 382
|Chapter |26: |Anus, |Rectum, |and |Prostate 400
Chapter |27: |Female |Genitourinary |System 414
Chapter |28: |The |Complete |Health |Assessment: |Adult 436
Chapter |29: |The |Complete |Physical |Assessment: |Infant, |Child, |and |Adolescent 449
|Chapter |30: |Bedside |Assessment |and |Electronic |Documentation 452
Chapter |31: |The |Pregnant |Woman 458
Chapter |32: |Functional |Assessment |of |the |Older |Adult 471
,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 |Setting 92
|Chapter |09: |General |Survey |and |Measurement 111
Chapter |10: |Vital |Signs 118
|Chapter |11: |Pain |Assessment 133
Chapter |12: |Nutrition |Assessment |Chapter 141
|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 |Chapter 246
|19: |Thorax |and |Lungs 266
Chapter |20: |Heart |and |Neck |Vessels 284
Chapter |21: |Peripheral |Vascular |System |and |Lymphatic |System |Chapter 303
|22: |Abdomen 320
Chapter |23: |Musculoskeletal |System 337
|Chapter | 24: |Neurologic | System 358
| Chapter |25: |Male |Genitourinary |System 382
|Chapter |26: |Anus, |Rectum, |and |Prostate 400
Chapter |27: |Female |Genitourinary |System 414
Chapter |28: |The |Complete |Health |Assessment: |Adult 436
Chapter |29: |The |Complete |Physical |Assessment: |Infant, |Child, |and |Adolescent 449
|Chapter |30: |Bedside |Assessment |and |Electronic |Documentation 452
Chapter |31: |The |Pregnant |Woman 458
Chapter |32: |Functional |Assessment |of |the |Older |Adult 471
,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)
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