Physical Examination and Health Assessment,
9th Ed., by Carolyn Jarvis & Ann L. Eckhardt.
Rationales are provided to reinforce key
concepts.
Questions 1-20: Evidence-Based Assessment & The Nursing Process
1. After completing an initial assessment of a patient, the nurse charts that his respirations are
eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Reflective
b. Subjective
c. Objective
d. Introspective
Answer: c. Objective
Rationale: Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data are what the person says
about himself or herself. (Jarvis & Eckhardt, 2023, Chapter 1)
2. A patient tells the nurse, "I am very nervous, nauseated, and feel hot." These types of data would
be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
Answer: c. Subjective
Rationale: Subjective data are what the person says about himself or herself during history taking. Only
the patient can perceive and report these feelings. (Jarvis & Eckhardt, 2023, Chapter 1)
,3. The patient's record, laboratory studies, objective data, and subjective data combine to form the:
a. Discharge summary
b. Admitting data
c. Financial statement
d. Database
Answer: d. Database
Rationale: Together with the patient's record and laboratory studies, the objective and subjective data
form the database. The nurse uses this information to make clinical judgments. (Jarvis & Eckhardt, 2023,
Chapter 1)
4. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
Answer: b. Clustering related cues
Rationale: Clustering related cues helps the nurse see relationships among pieces of data. For example,
clustering fever, cough, and crackles suggests a respiratory infection. (Jarvis & Eckhardt, 2023, Chapter
1)
5. A patient is admitted with shortness of breath and respiratory distress. Which priority problem
should the nurse address first?
a. Lack of knowledge about disease process
b. Acute pain
c. Respiratory distress
d. Need for patient education
Answer: c. Respiratory distress
Rationale: First-level priority problems are emergent, life-threatening, and immediate. Airway,
breathing, and circulation (ABCs) always take precedence. Respiratory distress threatens the
airway/breathing. (Jarvis & Eckhardt, 2023, Chapter 1)
, 6. A nurse is preparing to perform a physical assessment on a patient. Which statement is true
regarding the inspection phase?
a. Inspection requires a quick glance at the patient's body systems.
b. Inspection usually yields little information.
c. Inspection takes time and reveals significant information.
d. Inspection may be uncomfortable for the expert practitioner.
Answer: c. Inspection takes time and reveals significant information.
Rationale: Inspection is the most important assessment technique. It requires good lighting, adequate
exposure, and occasional use of instruments. It is performed first in each body system assessment.
(Jarvis & Eckhardt, 2023, Chapter 8)
7. When performing a physical assessment, which technique does the nurse always perform first?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation
Answer: c. Inspection
Rationale: Inspection always comes first. It is the systematic, deliberate visual examination of the
patient. Palpation, percussion, and auscultation follow, except during abdominal assessment where
auscultation precedes palpation. (Jarvis & Eckhardt, 2023, Chapter 8)
8. The nurse is unable to palpate a patient's right radial pulse. What is the best action?
a. Auscultate over the area with a stethoscope.
b. Use a Doppler device to check for pulsations.
c. Document the finding as "absent radial pulse."
d. Palpate the left radial pulse for comparison.
Answer: b. Use a Doppler device to check for pulsations.
Rationale: A Doppler (ultrasonic stethoscope) amplifies blood flow sounds and can detect pulses that
are not palpable. If the pulse is absent bilaterally, further vascular assessment is needed. (Jarvis &
Eckhardt, 2023, Chapter 8)
9th Ed., by Carolyn Jarvis & Ann L. Eckhardt.
Rationales are provided to reinforce key
concepts.
Questions 1-20: Evidence-Based Assessment & The Nursing Process
1. After completing an initial assessment of a patient, the nurse charts that his respirations are
eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Reflective
b. Subjective
c. Objective
d. Introspective
Answer: c. Objective
Rationale: Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data are what the person says
about himself or herself. (Jarvis & Eckhardt, 2023, Chapter 1)
2. A patient tells the nurse, "I am very nervous, nauseated, and feel hot." These types of data would
be:
a. Objective
b. Reflective
c. Subjective
d. Introspective
Answer: c. Subjective
Rationale: Subjective data are what the person says about himself or herself during history taking. Only
the patient can perceive and report these feelings. (Jarvis & Eckhardt, 2023, Chapter 1)
,3. The patient's record, laboratory studies, objective data, and subjective data combine to form the:
a. Discharge summary
b. Admitting data
c. Financial statement
d. Database
Answer: d. Database
Rationale: Together with the patient's record and laboratory studies, the objective and subjective data
form the database. The nurse uses this information to make clinical judgments. (Jarvis & Eckhardt, 2023,
Chapter 1)
4. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
Answer: b. Clustering related cues
Rationale: Clustering related cues helps the nurse see relationships among pieces of data. For example,
clustering fever, cough, and crackles suggests a respiratory infection. (Jarvis & Eckhardt, 2023, Chapter
1)
5. A patient is admitted with shortness of breath and respiratory distress. Which priority problem
should the nurse address first?
a. Lack of knowledge about disease process
b. Acute pain
c. Respiratory distress
d. Need for patient education
Answer: c. Respiratory distress
Rationale: First-level priority problems are emergent, life-threatening, and immediate. Airway,
breathing, and circulation (ABCs) always take precedence. Respiratory distress threatens the
airway/breathing. (Jarvis & Eckhardt, 2023, Chapter 1)
, 6. A nurse is preparing to perform a physical assessment on a patient. Which statement is true
regarding the inspection phase?
a. Inspection requires a quick glance at the patient's body systems.
b. Inspection usually yields little information.
c. Inspection takes time and reveals significant information.
d. Inspection may be uncomfortable for the expert practitioner.
Answer: c. Inspection takes time and reveals significant information.
Rationale: Inspection is the most important assessment technique. It requires good lighting, adequate
exposure, and occasional use of instruments. It is performed first in each body system assessment.
(Jarvis & Eckhardt, 2023, Chapter 8)
7. When performing a physical assessment, which technique does the nurse always perform first?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation
Answer: c. Inspection
Rationale: Inspection always comes first. It is the systematic, deliberate visual examination of the
patient. Palpation, percussion, and auscultation follow, except during abdominal assessment where
auscultation precedes palpation. (Jarvis & Eckhardt, 2023, Chapter 8)
8. The nurse is unable to palpate a patient's right radial pulse. What is the best action?
a. Auscultate over the area with a stethoscope.
b. Use a Doppler device to check for pulsations.
c. Document the finding as "absent radial pulse."
d. Palpate the left radial pulse for comparison.
Answer: b. Use a Doppler device to check for pulsations.
Rationale: A Doppler (ultrasonic stethoscope) amplifies blood flow sounds and can detect pulses that
are not palpable. If the pulse is absent bilaterally, further vascular assessment is needed. (Jarvis &
Eckhardt, 2023, Chapter 8)
