TEST BANK
m
,TablemofmContents 1
Chapterm01:mEvidence- 2
BasedmAssessmentmChapterm02:mCulturalmAss 15
essment 31
Chapterm03:mThemInterview 49
Chapterm04:mThemCompletemHealthmHistorymCh 64
apterm05:mMentalmStatusmAssessmentmChapter 80
m06:mSubstancemUsemAssessment 86
Chapterm07:mDomesticmandmFamilymViolencemAssessment 92
Chapterm08:mAssessmentmTechniquesmandmSafetyminmthemClinicalmSetti 111
ngmChapterm09:mGeneralmSurveymandmMeasurement 118
Chapterm10:mVitalmSignsmChap 133
term11:mPainmAssessment 141
Chapterm12:mNutritionmAssessmentmChap 155
term13:mSkin,mHair,mandmNails 176
Chapterm14:mHead,mFace,mNeck,mandmRegionalmLymphaticsmC 194
hapterm15:mEyes 211
Chapterm16:mEars 228
Chapterm17:mNose,mMouth,mandmThroat 246
Chapterm18:mBreasts,mAxillae,mandmRegionalmLymphaticsmCha 266
pterm19:mThoraxmandmLungs 284
Chapterm20:mHeartmandmNeckmVessels 303
Chapterm21:mPeripheralmVascularmSystemmandmLymphaticmSystemmCha 320
pterm22:mAbdomen 337
Chapterm23:mMusculoskeletalmSystemmC 358
hapterm 24:mNeurologicm Systemm Chapte 382
rm25:mMalemGenitourinarymSystemmChap 400
term26:mAnus,mRectum,mandmProstate 414
Chapterm27:mFemalemGenitourinarymSystem 436
Chapterm28:mThemCompletemHealthmAssessment:mAdult 449
Chapterm29:mThemCompletemPhysicalmAssessment:mInfant,mChild,mandmAdolesc 452
entmChapterm30:mBedsidemAssessmentmandmElectronicmDocumentation 458
Chapterm31:mThemPregnantmWoman 471
Chapterm32:mFunctionalmAssessmentmofmthemOldermAdult
,Chapter 01: Evidence-Based Assessment
m m m
MULTIPLEm CHOICE
1. Aftermcompletingmanminitialmassessmentmofmampatient,mthemnursemhasmchartedmthatmhismrespirationsmaremeupne
icmandmhismpulsemism58mbeatsmpermminute.mThesemtypesmofmdatamwouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m A
Objectivemdatamaremwhatmthemhealthmprofessionalmobservesmbyminspecting,mpercussing,mpalpating,mandmauscultat
ingmduringmthemphysicalmexamination.mSubjectivemdatamismwhatmthempersonmsaysmaboutmhimmormherselfmduringm
historymtaking.m Them termsm reflectivem andm introspectivem arem notm usedm tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
2. Ampatientmtellsmthemnursemthatmhemismverymnervous,mismnauseated,mandmfeelsmhot.mThesemtypesmofmdatamwouldm
be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivemdatamaremwhatmthempersonmsaysmaboutmhimmormherselfmduringmhistorymtaking.mObjectivemdatamarem
whatmthemhealthmprofessionalmobservesmbyminspecting,mpercussing,mpalpating,mandmauscultatingmduringmthemph
ysicalmexamination.mThemtermsmreflectivemandmintrospectivemaremnotmusedmtomdescribemdata.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
3. Thempatientsmrecord,m laboratorym studies,m objectivem data,m andmsubjectivem datam combinem tom formmthe:
a. Datambase.
b. Admittingm data.
, c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togethermwithmthempatientsmrecordmandmlaboratorymstudies,mthemobjectivemandmsubjectivemdatamformmthemdata
mbase.mThemothermitemsmaremnotmpartmofmthempatientsmrecord,mlaboratorymstudies,mormdata.
DIF:m Cognitivem Level:m Rememberingm (Knowledge)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
4. Whenmlisteningmtomampatientsmbreathmsounds,mthemnursemismunsuremofmamsoundmthatmismheard.mThemnurs
esmnextmactionmshouldmbemto:
a. Immediatelym notifym them patientsm physician.
b. Documentmthemsoundmexactlymasmitmwasmheard.
c. Validatemthemdatambymaskingmamcoworkermtomlistenmtomthembreathmsounds.
d. Assessmagainminm20mminutesmtomnotemwhethermthemsoundmismstillmpresent.
ANS:m C
Whenmunsuremofmamsoundmheardmwhilemlisteningmtomampatientsmbreathmsounds,mthemnursemvalidatesmthemdatamtomen
suremaccuracy.mIfmthemnursemhasmlessmexperienceminmanmarea,mthenmhemormshemasksmanmexpertmtomlisten.
DIF:m Cognitivem Level:m Analyzingm (Analysis)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
5. Themnursemismconductingm amclassmformnewm graduatemnurses.m Duringmthemteachingmsession,mthemnursemshoul
dmkeepm inm mindm thatm novicem nurses,m withoutm am backgroundm ofm skillsm andm experiencem frommwhichm tom draw,
m arem morem likelymtommakemtheirmdecisionsmusing:
a. Intuition.
b. Amsetmofmrules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicemnursesmoperatemfrommamsetmofmdefined,mstructuredmrules.mThemexpertmpractitionermusesmintuitivemlin
ks.mDIF:mCognitivemLevel:mUnderstandingm(Comprehension)
m
,TablemofmContents 1
Chapterm01:mEvidence- 2
BasedmAssessmentmChapterm02:mCulturalmAss 15
essment 31
Chapterm03:mThemInterview 49
Chapterm04:mThemCompletemHealthmHistorymCh 64
apterm05:mMentalmStatusmAssessmentmChapter 80
m06:mSubstancemUsemAssessment 86
Chapterm07:mDomesticmandmFamilymViolencemAssessment 92
Chapterm08:mAssessmentmTechniquesmandmSafetyminmthemClinicalmSetti 111
ngmChapterm09:mGeneralmSurveymandmMeasurement 118
Chapterm10:mVitalmSignsmChap 133
term11:mPainmAssessment 141
Chapterm12:mNutritionmAssessmentmChap 155
term13:mSkin,mHair,mandmNails 176
Chapterm14:mHead,mFace,mNeck,mandmRegionalmLymphaticsmC 194
hapterm15:mEyes 211
Chapterm16:mEars 228
Chapterm17:mNose,mMouth,mandmThroat 246
Chapterm18:mBreasts,mAxillae,mandmRegionalmLymphaticsmCha 266
pterm19:mThoraxmandmLungs 284
Chapterm20:mHeartmandmNeckmVessels 303
Chapterm21:mPeripheralmVascularmSystemmandmLymphaticmSystemmCha 320
pterm22:mAbdomen 337
Chapterm23:mMusculoskeletalmSystemmC 358
hapterm 24:mNeurologicm Systemm Chapte 382
rm25:mMalemGenitourinarymSystemmChap 400
term26:mAnus,mRectum,mandmProstate 414
Chapterm27:mFemalemGenitourinarymSystem 436
Chapterm28:mThemCompletemHealthmAssessment:mAdult 449
Chapterm29:mThemCompletemPhysicalmAssessment:mInfant,mChild,mandmAdolesc 452
entmChapterm30:mBedsidemAssessmentmandmElectronicmDocumentation 458
Chapterm31:mThemPregnantmWoman 471
Chapterm32:mFunctionalmAssessmentmofmthemOldermAdult
,Chapter 01: Evidence-Based Assessment
m m m
MULTIPLEm CHOICE
1. Aftermcompletingmanminitialmassessmentmofmampatient,mthemnursemhasmchartedmthatmhismrespirationsmaremeupne
icmandmhismpulsemism58mbeatsmpermminute.mThesemtypesmofmdatamwouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m A
Objectivemdatamaremwhatmthemhealthmprofessionalmobservesmbyminspecting,mpercussing,mpalpating,mandmauscultat
ingmduringmthemphysicalmexamination.mSubjectivemdatamismwhatmthempersonmsaysmaboutmhimmormherselfmduringm
historymtaking.m Them termsm reflectivem andm introspectivem arem notm usedm tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
2. Ampatientmtellsmthemnursemthatmhemismverymnervous,mismnauseated,mandmfeelsmhot.mThesemtypesmofmdatamwouldm
be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivemdatamaremwhatmthempersonmsaysmaboutmhimmormherselfmduringmhistorymtaking.mObjectivemdatamarem
whatmthemhealthmprofessionalmobservesmbyminspecting,mpercussing,mpalpating,mandmauscultatingmduringmthemph
ysicalmexamination.mThemtermsmreflectivemandmintrospectivemaremnotmusedmtomdescribemdata.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
3. Thempatientsmrecord,m laboratorym studies,m objectivem data,m andmsubjectivem datam combinem tom formmthe:
a. Datambase.
b. Admittingm data.
, c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togethermwithmthempatientsmrecordmandmlaboratorymstudies,mthemobjectivemandmsubjectivemdatamformmthemdata
mbase.mThemothermitemsmaremnotmpartmofmthempatientsmrecord,mlaboratorymstudies,mormdata.
DIF:m Cognitivem Level:m Rememberingm (Knowledge)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
4. Whenmlisteningmtomampatientsmbreathmsounds,mthemnursemismunsuremofmamsoundmthatmismheard.mThemnurs
esmnextmactionmshouldmbemto:
a. Immediatelym notifym them patientsm physician.
b. Documentmthemsoundmexactlymasmitmwasmheard.
c. Validatemthemdatambymaskingmamcoworkermtomlistenmtomthembreathmsounds.
d. Assessmagainminm20mminutesmtomnotemwhethermthemsoundmismstillmpresent.
ANS:m C
Whenmunsuremofmamsoundmheardmwhilemlisteningmtomampatientsmbreathmsounds,mthemnursemvalidatesmthemdatamtomen
suremaccuracy.mIfmthemnursemhasmlessmexperienceminmanmarea,mthenmhemormshemasksmanmexpertmtomlisten.
DIF:m Cognitivem Level:m Analyzingm (Analysis)
MSC:m Clientm Needs:m Safem andm Effectivem Carem Environment:m Managementm ofm Care
5. Themnursemismconductingm amclassmformnewm graduatemnurses.m Duringmthemteachingmsession,mthemnursemshoul
dmkeepm inm mindm thatm novicem nurses,m withoutm am backgroundm ofm skillsm andm experiencem frommwhichm tom draw,
m arem morem likelymtommakemtheirmdecisionsmusing:
a. Intuition.
b. Amsetmofmrules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicemnursesmoperatemfrommamsetmofmdefined,mstructuredmrules.mThemexpertmpractitionermusesmintuitivemlin
ks.mDIF:mCognitivemLevel:mUnderstandingm(Comprehension)
