EXAMINATIONdSTUDYdGUIDEd2022
Table of Contents
d d
Tabled ofd Contents 1
Chapterd01:dEvidence- 2
BaseddAssessmentdChapterd02:d Culturald 15
CompetencedChapterd03:dThedInterview 31
Chapterd04:dThedCompletedHealthdHistoryd 49
Chapterd05:dMentaldStatusdAssessmentdCh 64
apterd06:dSubstancedUsedAssessment 81
Chapterd 07:d Domesticd andd Familyd Violenced Assessments 87
Chapterd08:dAssessmentdTechniquesdanddSafetydindthedClinicaldSettingd 93
Chapterd09:dGeneraldSurvey,dMeasurement,dVitaldSigns 112
Chapterd10:dPaindAssessment:dThedFifthdVitaldSigndChapte 134
rd11:dNutritionaldAssessment 142
Chapterd12:dSkin,d Hair,d andd Nails 156
Chapterd13:dHead,dFace,danddNeck,dIncludingdRegionaldLymphaticsdCha 177
pterd14:dEyes 195
Chapterd15:d Ears 212
Chapterd16:dNose,d Mouth,d andd Throatd Chapte 229
rd17:dBreastsdanddRegionaldLymphaticsdChapte 247
rd18:dThoraxdanddLungs 267
Chapterd 19:d Heartd andd Neckd Vessels 285
Chapterd20:dPeripheraldVasculardSystemdanddLymphaticdSystemdChapte 304
rd21:dAbdomen 321
Chapterd22:dMusculoskeletaldSystemdCh 338
apterd23:d Neurologicd Systemd Chapterd2 359
4:dMaledGenitourinarydSystemdChapterd2 384
5:dAnus,dRectum,danddProstate 402
Chapterd 26:d Femaled Genitourinaryd System 416
Chapterd 27:d Thed Completed Healthd Assessment:d Adult 438
Chapterd28:dThedCompletedPhysicaldAssessment:dInfant,dChild,danddAdolescentdC 451
hapterd29:dBedsidedAssessmentdofdthedHospitalizeddPatient 454
Chapterd 30:d Thed PregnantdWoman 460
Chapterd31:d Functionald Assessmentd ofd thed Olderd Adult 473
,PHYSICALdEXAMINATIONdTESTdBANKdJARVISdd
EXAMINATIONdSTUDYdGUIDEd2022
Chapter 01: Evidence-Based Assessment
d d d
MULTIPLEd CHOICE
1. Afterdcompletingdandinitialdassessmentdofdadpatient,dthednursedhasdcharteddthatdhisdrespirationsdaredeupneicdanddhi
sdpulsedisd58dbeatsdperdminute.dThesedtypesdofddatadwoulddbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:d A
Objectiveddatadaredwhatdthedhealthdprofessionaldobservesdbydinspecting,dpercussing,dpalpating,danddauscultatingddu
ringdthedphysicaldexamination.dSubjectiveddatadisdwhatdthedpersondsaysdaboutdhimdordherselfdduringdhistorydta
king.dThedtermsdreflectivedanddintrospectivedarednotduseddtoddescribeddata.
DIF:d Cognitived Level:d Understandingd (Comprehension)d REF:d p.d 2
MSC:dClientd Needs:d Safed andd Effectived Cared Environment:d Managementd ofd Care
2. Adpatientd tellsd thed nursed thatdhed isd veryd nervous,d isd nauseated,d andd feelsd hot.d Thesed typesd ofd datad wouldd be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:d C
Subjectiveddatadaredwhatdthedpersondsaysdaboutdhimdordherselfdduringdhistorydtaking.dObjectiveddatadaredwhatdthedheal
thdprofessionaldobservesdbydinspecting,dpercussing,dpalpating,danddauscultatingdduringdthedphysicaldexaminatio
n.dThedtermsdreflectivedanddintrospectivedarednotduseddtoddescribeddata.
DIF:d Cognitived Level:d Understandingd (Comprehension)d REF:d p.d 2
MSC:dClientd Needs:d Safed andd Effectived Cared Environment:d Managementd ofd Care
3. Thed patientsd record,dlaboratoryd studies,d objectived data,d andd subjectived datad combined tod formd the:
a. Datadbase.
b. Admittingd data.
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EXAMINATIONdSTUDYdGUIDEd2022
c. Financiald statement.
d. Discharged summary.
ANS:d A
Togetherdwithdthedpatientsdrecorddanddlaboratorydstudies,dthedobjectivedanddsubjectiveddatadformdtheddatadbase.dT
hedotherditemsdarednotdpartdofdthedpatientsdrecord,dlaboratorydstudies,dorddata.
DIF:d Cognitived Level:d Rememberingd (Knowledge)d REF:d p.d 2
MSC:dClientd Needs:d Safed andd Effectived Cared Environment:d Managementd ofd Care
4. Whendlisteningdtodadpatientsdbreathdsounds,dthednursedisdunsuredofdadsounddthatdisdheard.dThednursesdnextdac
tiondshoulddbedto:
a. Immediatelyd notifyd thed patientsd physician.
b. Documentd thed soundd exactlyd asd itd wasd heard.
c. Validatedtheddatad byd askingdadcoworkerdtod listendtodthed breathdsounds.
d. Assessd againdind20d minutesdtodnotedwhetherd thed sounddisd stilldpresent.
ANS:d C
Whendunsuredofdadsounddhearddwhiledlisteningdtodadpatientsdbreathdsounds,dthednursedvalidatesdtheddatadtodensuredaccu
racy.dIfdthednursedhasdlessdexperiencedindandarea,dthendhedordshedasksdandexpertdtodlisten.
DIF:d Cognitived Level:d Analyzingd (Analysis)d REF:d p.d 2
MSC:dClientd Needs:d Safed andd Effectived Cared Environment:d Managementd ofd Care
5. Thednursedisdconductingdadclassdfordnewdgraduatednurses.dDuringdthedteachingdsession,dthednursedshoulddkeepd
ind minddthatdnovicednurses,d withoutd adbackgroundd ofdskillsd anddexperienced fromd whichdtoddraw,d ared moredlikelydt
odmakedtheirddecisionsdusing:
a. Intuition.
b. Adsetdofdrules.
c. Articlesdindjournals.
d. Adviced fromd supervisors.
ANS:d B
Novicednursesdoperatedfromdadsetdofddefined,dstructureddrules.dThedexpertdpractitionerdusesdintuitivedlinks.dDIF
:dCognitivedLevel:dUnderstandingd(Comprehension)dREF:dp.d3
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EXAMINATIONdSTUDYdGUIDEd2022
MSC:d Clientd Needs:d General
6. Expertdnursesdlearndtodattenddtodadpatterndofdassessmentddatadanddactdwithoutdconsciouslydlabelingdit.dThesedre
sponsesdaredreferreddtodas:
a. Intuition.
b. Thed nursingd process.
c. Clinicald knowledge.
d. Diagnosticd reasoning.
ANS:d A
Intuitiondisdcharacterizeddbydpatterndrecognitionexpertdnursesdlearndtodattenddtodadpatterndofdassessmentddatadandd
actdwithoutdconsciouslydlabelingdit.dThedotherdoptionsdarednotdcorrect.
DIF:dCognitivedLevel:dUnderstandingd(Comprehension)dREF:dp.d4d
MSC:dClientdNeeds:dGeneral
7. Thednursedisdreviewingdinformationdaboutdevidence-
baseddpracticed(EBP).dWhichdstatementdbestdreflectsdEBP?
a. EBPd reliesdond traditiond ford supportd ofd bestd practices.
b. EBPd isd simplyd thed used ofdbestdpracticedtechniquesd fordthedtreatmentdofd patients.
c. EBPdemphasizesd thedusedofdbestd evidenced withd thed cliniciansd experience.
d. Thedpatientsd ownd preferencesd ared notd importantd withdEBP.
ANS:dC
EBPdisdadsystematicdapproachdtodpracticedthatdemphasizesdthedusedofdbestdevidencedindcombinationdwithdthedclinician
sdexperience,dasdwelldasdpatientdpreferencesdanddvalues,dwhendmakingddecisionsdaboutdcaredanddtreatment.dEBPd
isdmoredthandsimplydusingdthedbestdpracticedtechniquesdtodtreatdpatients,danddquestioningdtraditiondisdimportantd
whendnodcompellingdanddsupportivedresearchdevidencedexists.
DIF:d Cognitived Level:d Applyingd (Application)d REF:d p.d 5
MSC:dClientd Needs:d Safed andd Effectived Cared Environment:d Managementd ofd Care
8. Thednursedisdconductingd adclassdondprioritydsettingdfordadgroupdofdnewdgraduatednurses.dWhichdisdandexampled o
fdadfirst-leveldprioritydproblem?
a. Patientd withd postoperatived pain
b. Newlyd diagnosedd patientd withd diabetesd whod needsd diabeticd teaching