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Table of Contents
Foundations for Clinical Proficiency ......................................................................................................... 3
Evaluating Clinical Evidence ................................................................................................................... 14
Interviewing and the Health History ........................................................................................................ 28
Beginning the Physical Examination: General Survey, Vital Signs, and Pain ......................................... 38
Behavior and Mental Status ..................................................................................................................... 50
The Skin, Hair, and Nails ......................................................................................................................... 62
The Head and Neck .................................................................................................................................. 74
The Thorax and Lungs ............................................................................................................................. 86
The Cardiovascular System ...................................................................................................................... 98
The Breasts and Axillae ......................................................................................................................... 110
The Abdomen ......................................................................................................................................... 123
The Peripheral Vascular System ............................................................................................................ 134
Male Genitalia and Hernias .................................................................................................................... 145
Female Genitalia .................................................................................................................................... 157
The Anus, Rectum, and Prostate ............................................................................................................ 169
The Musculoskeletal System .................................................................................................................. 181
The Nervous System .............................................................................................................................. 193
Assessing Children: Infancy Through Adolescence............................................................................... 205
The Pregnant Woman ............................................................................................................................. 208
The Older Adult ..................................................................................................................................... 220
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16. What step of the nursing process includes data collection by health history, physical
examination, and interview?
a Planning
.
b Diagnosis
.
c Evaluation
.
d Assessment
.
ANS: D
Data collection, including performing the health history, physical examination, and interview, is
the assessment step of the nursing process (see Figure 1-2).
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
MSC: Client Needs: General
17. During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which suggestion by the
nurse manager would best help these problems?
a Form a committee to conduct research studies.
.
b Post published research studies on the units bulletin boards.
.
c Encourage the nurses to visit the library to review studies.
.
d Teach the nurses how to conduct electronic searches for research studies.
.
ANS: D
Facilitating support for EBP would include teaching the nurses how to conduct electronic
searches; time to visit the library may not be available for many nurses. Actually conducting
research studies may be helpful in the long-run but not an immediate solution to reviewing
existing research.
DIF: Cognitive Level: Applying (Application) REF: p. 6
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a Disease originates from the external environment.
.
b The individual human is a closed system.
.
c Nurses are responsible for a patients health state.
.
d Holistic health views the mind, body, and spirit as interdependent.
.
ANS: D
Consideration of the whole person is the essence of holistic health, which views the mind, body,
and spirit as interdependent. The basis of disease originates from both the external environment
and from within the person. Both the individual human and the external environment are open
systems, continually changing and adapting, and each person is responsible for his or her own
personal health state.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. The nurse recognizes that the concept of prevention in describing health is essential because:
a Disease can be prevented by treating the external environment.
.
b The majority of deaths among Americans under age 65 years are not
. preventable.
c Prevention places the emphasis on the link between health and personal
. behavior.
d The means to prevention is through treatment provided by primary health care
. practitioners.
ANS: C
A natural progression to prevention rounds out the present concept of health. Guidelines to
prevention place the emphasis on the link between health and personal behavior.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: General
20. The nurse is performing a physical assessment on a newly admitted patient. An example of
objective information obtained during the physical assessment includes the:
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Table of Contents
Foundations for Clinical Proficiency ......................................................................................................... 3
Evaluating Clinical Evidence ................................................................................................................... 14
Interviewing and the Health History ........................................................................................................ 28
Beginning the Physical Examination: General Survey, Vital Signs, and Pain ......................................... 38
Behavior and Mental Status ..................................................................................................................... 50
The Skin, Hair, and Nails ......................................................................................................................... 62
The Head and Neck .................................................................................................................................. 74
The Thorax and Lungs ............................................................................................................................. 86
The Cardiovascular System ...................................................................................................................... 98
The Breasts and Axillae ......................................................................................................................... 110
The Abdomen ......................................................................................................................................... 123
The Peripheral Vascular System ............................................................................................................ 134
Male Genitalia and Hernias .................................................................................................................... 145
Female Genitalia .................................................................................................................................... 157
The Anus, Rectum, and Prostate ............................................................................................................ 169
The Musculoskeletal System .................................................................................................................. 181
The Nervous System .............................................................................................................................. 193
Assessing Children: Infancy Through Adolescence............................................................................... 205
The Pregnant Woman ............................................................................................................................. 208
The Older Adult ..................................................................................................................................... 220
, ba g
nk
st in
Te urs
N
16. What step of the nursing process includes data collection by health history, physical
examination, and interview?
a Planning
.
b Diagnosis
.
c Evaluation
.
d Assessment
.
ANS: D
Data collection, including performing the health history, physical examination, and interview, is
the assessment step of the nursing process (see Figure 1-2).
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
MSC: Client Needs: General
17. During a staff meeting, nurses discuss the problems with accessing research studies to
incorporate evidence-based clinical decision making into their practice. Which suggestion by the
nurse manager would best help these problems?
a Form a committee to conduct research studies.
.
b Post published research studies on the units bulletin boards.
.
c Encourage the nurses to visit the library to review studies.
.
d Teach the nurses how to conduct electronic searches for research studies.
.
ANS: D
Facilitating support for EBP would include teaching the nurses how to conduct electronic
searches; time to visit the library may not be available for many nurses. Actually conducting
research studies may be helpful in the long-run but not an immediate solution to reviewing
existing research.
DIF: Cognitive Level: Applying (Application) REF: p. 6
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nk
st in
Te urs
N
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. When reviewing the concepts of health, the nurse recalls that the components of holistic
health include which of these?
a Disease originates from the external environment.
.
b The individual human is a closed system.
.
c Nurses are responsible for a patients health state.
.
d Holistic health views the mind, body, and spirit as interdependent.
.
ANS: D
Consideration of the whole person is the essence of holistic health, which views the mind, body,
and spirit as interdependent. The basis of disease originates from both the external environment
and from within the person. Both the individual human and the external environment are open
systems, continually changing and adapting, and each person is responsible for his or her own
personal health state.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. The nurse recognizes that the concept of prevention in describing health is essential because:
a Disease can be prevented by treating the external environment.
.
b The majority of deaths among Americans under age 65 years are not
. preventable.
c Prevention places the emphasis on the link between health and personal
. behavior.
d The means to prevention is through treatment provided by primary health care
. practitioners.
ANS: C
A natural progression to prevention rounds out the present concept of health. Guidelines to
prevention place the emphasis on the link between health and personal behavior.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: General
20. The nurse is performing a physical assessment on a newly admitted patient. An example of
objective information obtained during the physical assessment includes the:
