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1
2
Chapter 01: Evidence-Based Assessment
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15
Chapter 02: Cultural Assessment
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Chapter 03: The Interview
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31
Chapter 04: The Complete Health History
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49
Chapter 05: Mental Status Assessment
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64
Chapter 06: Substance Use Assessment
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80
Chapter 07: Domestic and Family Violence Assessment
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86
Chapter 08: Assessment Techniques and Safety in the Clinical Setting
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92
Chapter 09: General Survey and Measurement
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111
Chapter 10: Vital Signs
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118
133
Chapter 11: Pain Assessment
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Chapter 12: Nutrition Assessment
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141
Chapter 13: Skin, Hair, and Nails
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155
Chapter 14: Head, Face, Neck, and Regional Lymphatics
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176
Chapter 15: Eyes
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194
Chapter 16: Ears
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211
Chapter 17: Nose, Mouth, and Throat
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228
Chapter 18: Breasts, Axillae, and Regional Lymphatics Chapter
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246
19: Thorax and Lungs
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266
Chapter 20: Heart and Neck Vessels
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284
Chapter 21: Peripheral Vascular System and Lymphatic System Chapter
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303
22: Abdomen
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320
Chapter 23: Musculoskeletal System
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337
Chapter 24: Neurologic System
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358
LChapter 25: Male Genitourinary System
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382
Chapter 26: Anus, Rectum, and Prostate
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400
Chapter 27: Female Genitourinary System
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414
Chapter 28: The Complete Health Assessment: Adult
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436
Chapter 29: The Complete Physical Assessment: Infant, Child, and Adolescent
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449
Chapter 30: Bedside Assessment and Electronic Documentation
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452
Chapter 31: The Pregnant Woman
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458
Chapter 32: Functional Assessment of the Older Adult
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471
,Chapter 01: Evidence-Based Assessment L L L
MULTIPLE CHOICE L
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and
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his pulse is 58 beats per minute. These types of data wouldbe:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A L
Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating
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during the physical examination. Subjective data is what the person says about him or herself during history
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taking. The terms reflective and introspective are not used to describe data.
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DIF: Cognitive Level: Understanding (Comprehension)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:
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a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C L
Subjective data are what the person says about him or herself during history taking. Objective data are what the
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health professional observes by inspecting, percussing, palpating, and auscultating during the physical
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examination. The terms reflective and introspective are not used to describe data.
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DIF: Cognitive Level: Understanding (Comprehension)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
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a. Data base. L
b. Admitting data. L
, c. Financial statement. L
d. Discharge summary. L
ANS: A L
Together with the patients record and laboratory studies, the objective and subjective data form the data base.
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The other items are not part of the patients record, laboratory studies, or data.
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DIF: Cognitive Level: Remembering (Knowledge)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
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action should be to:
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a. Immediately notify the patients physician. L L L L
b. Document the sound exactly as it was heard. L L L L L L L
c. Validate the data by asking a coworker to listen to the breath sounds.
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d. Assess again in 20 minutes to note whether the sound is still present.
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ANS: C L
When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure
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accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
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DIF: Cognitive Level: Analyzing (Analysis)
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MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep
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Lin mind that novice nurses, without a background of skills and experience from which to draw, are more
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likely to make their decisions using:
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a. Intuition.
b. A set of rules.
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c. Articles in journals. L L
d. Advice from supervisors. L L
ANS: B L
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
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DIF: Cognitive Level: Understanding (Comprehension)
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