Physical Examination and Health Assessment 8e 1
Table of Contents
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 141
Chapter 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 246
Chapter 19: Thorax and Lungs 266
Chapter 20: Heart and Neck Vessels 284
Chapter 21: Peripheral Vascular System and Lymphatic System 303
Chapter 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
,Physical Examination and Health Assessment 8e 2
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 would be:
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.
,Physical Examination and Health Assessment 8e 3
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)
, Physical Examination and Health Assessment 8e 4
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These
responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and
act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects
EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with EBP.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the
clinicians experience, as well as patient preferences and values, when making decisions about care and
treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning
tradition is important when no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example
of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
Table of Contents
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 141
Chapter 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 246
Chapter 19: Thorax and Lungs 266
Chapter 20: Heart and Neck Vessels 284
Chapter 21: Peripheral Vascular System and Lymphatic System 303
Chapter 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
,Physical Examination and Health Assessment 8e 2
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 would be:
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.
,Physical Examination and Health Assessment 8e 3
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)
, Physical Examination and Health Assessment 8e 4
MSC: Client Needs: General
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These
responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and
act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects
EBP?
a. EBP relies on tradition for support of best practices.
b. EBP is simply the use of best practice techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence with the clinicians experience.
d. The patients own preferences are not important with EBP.
ANS: C
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the
clinicians experience, as well as patient preferences and values, when making decisions about care and
treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning
tradition is important when no compelling and supportive research evidence exists.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example
of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
