1
Table of Contents
Tablem of 1
Contents
Chapterm 01:m Evidence-Based 2
AssessmentjChapterm 02:m Cultural 15
Assessment 31
Chapterm 03:m Them Interview 49
Chapterm 04:m Them Completem Health 64
HistoryChapterm 05:m Mentalm StatusmAsse 80
ssmentm Chapterm 06:m SubstancemUsem A 86
ssessment 92
Chapterm 07:m Domestic m andm Family m Violencem Assessmen 111
t
Chapterm 08:m Assessmentm Techniquesm andm Safety m inm th Clinical 118
e
SettingChapterm 09:m Generalm Survey m andm Measurement 133
Chapterm 10:m Vitalm Signs 141
Chapterm 11:m Pain 155
Assessment 176
Chapterm 12:m Nutrition 194
AssessmentChapterm 13:m Skin, 211
Hair,m andm Nails 228
Chapterm 14:m Head, m Face, m Neck, m and m Regional 246
LymphaticsChapterm 15:m Eyes 266
Chapter 16: Ears 284
Chapterm 17:m Nose,m Mouth,m andm ThroatmChapt 303
erm 18:m Breasts,m Axillae,m andm RegionalmLymph 320
aticsChapterm 19:m Thorax m andm LungsmChapter 337
m 20:m Heartm andm Neck m Vessels 358
Chapterm 21:m Peripheralm Vascularm System m andm Lymphatic m System mChap 382
term 22:m Abdomen 400
Chapterm 23:m Musculoskeletalm System 414
mChapterm 24: Neurologic 436
System mChapterm 25:m 449
Malem Genitourinary mSystem 452
Chapterm 26:m Anus,m Rectum,m andm ProstatemC 458
hapterm 27:m Femalem Genitourinary m System 471
Chapterm 28:m Them Completem Healthm Assessment:m Adult
Chapterm 29:m Them Completem Physicalm Assessment:m Infant,m Child,m andmAdol
escentChapterm 30:m Bedsidem Assessmentm andm Electronic m Docum entationmCha
pterm 31:m Them Pregnantm Wom an
Chapterm 32:m Functionalm Assessmentm of m them Olderm Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEm CHOICE
1. After m completingm anm initialm assessmentm ofm am patient, m the m nurse m has m charted m thatm his m respirations
m aremeupneicm andhis m pulsem is m 58m beatsm per m minute. m Thesem typesm of m data m wouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m A
Objectivem datam arem whatm them healthm professionalm observesm bym inspecting, m percussing, m palpating, m andm
auscultatingduring m them physicalm examination. m Subjectivem datam ism what m them personm saysm aboutm himm o
rm herselfm duringm historytaking. m Them termsm reflectivem andm introspectivem are m notm used m tom describem da
ta.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
2. Am patientm tells m the m nursem that m he m is m verym nervous, m is m nauseated, m and m feelsm hot. m These m types m of
m datamwouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivem data m arem whatm them personm saysm aboutm himm or m herselfm duringm historym taking. m Objectivem datam
aremwhatm thehealth m professional m observesm bym inspecting, m percussing, m palpating, m andm auscultatingm duringm
themphysicalm examination. m Them termsm reflectivem andm introspectivem are m notm used m tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
3. Them patientsm record, m laboratorym studies, m objectivem data, m andm subjectivem datam combinem to m form m the:
a. Datam base.
b. Admittingm data.
, 3
c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togetherm withm them patients m recordm andm laboratorym studies, m them objective m andm subjective m data m form m th
emdatam base.Them otherm itemsm arem notm part m ofm them patientsm record, m laboratorym studies, m orm data.
DIF:m Cognitivem Level:m Rememberingm (Knowledge)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
4. Whenm listening m tom a m patientsm breath m sounds, m the m nurse m is m unsure m of m a m sound m that m is m heard.
m Themnursesm nextactionm should m be m to:
a. Immediatelym notifym the m patients m physician.
b. Documentm them sound m exactly m asm it m wasm heard.
c. Validatem them data m bym askingm am coworker m tom listen m to m them breath m sounds.
d. Assessm again m in m 20m minutesm tom notem whether m the m soundm is m stillm present.
ANS:m C
Whenm unsure m of m a m sound m heard m whilem listening m to m a m patientsm breath m sounds, m the m nursem validatesm the
m datamtom ensureaccuracy. m If m the m nursem hasm lessm experiencem inm anm area, m thenm hem or m shem asksm anm exp
ertm tom listen.
DIF:m Cognitivem Level:m Analyzingm (Analysis)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
5. Them nursem ism conductingm am classm form new m graduatem nurses. m Duringm them teachingm session, m them nurs
em should m keep minm mind m thatm novicem nurses, m withoutm am backgroundm of m skillsm and m experiencem fromm w
hichm tomdraw, m arem morem likelytom makem theirm decisions m using:
a. Intuition.
b. Am setm ofm rules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicem nurses m operate m from m a m setm ofm defined, m structured m rules. m The m expertm practitioner m usesm intuitive mlin
ks.DIF:m Cognitivem Level:m Understandingm (Comprehension)
, 4
MSC:m Clientm Needs: m General
6. Expertm nursesm learn m to m attendm to m am pattern m ofm assessmentm datam and m actm without m consciously m lab
elingmit. m Theseresponsesm arem referredm tom as:
a. Intuition.
b. Them nursingm process.
c. Clinicalm knowledge.
d. Diagnosticm reasoning.
ANS:m A
Intuitionm ism characterizedm bym patternm recognitionexpert m nurses m learnm tom attend m to m a m pattern m of m assess
mentmdatam andactm withoutm consciously m labelingm it. m Them otherm optionsm arem notm correct.
DIF:m Cognitivem Level:m Understandingm(Comprehens
ion)MSC:m Clientm Needs:m General
7. Them nursem ism reviewingm informationm aboutm evidence-
basedm practicem (E BP). m Whichm statementm bestmreflectsE BP?
a. EBPm reliesm onm tradition m form support m of m best m practices.
b. EBPm ism simply m them usem ofm bestm practicem techniques m for m the m treatmentm of m patients.
c. EBPm emphasizesm the m use m ofm bestm evidencem with m them clinicians m experience.
d. Them patientsm own m preferences m arem notm important m with
EBP.ANS:m C
EBPm ism am systematicm approach m to m practice m that m emphasizes m them use m ofm best m evidencem inm combinationm
withmthecliniciansm experience, m asm well m asm patientm preferencesm andm values, m whenm making m decisions
m aboutmcarem and m treatment. m EBP m ism more m thanm simplym usingm them bestm practicem techniquesm tom tre
atm patients, mandm questioningm traditionm ism importantm whenm nom compellingm andm supportive m researchm evi
dencem exists.
DIF:m Cognitivem Level:m Applyingm (Application)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
8. Them nursem is m conducting m a m classm on m priority m setting m for m am groupm ofm newm graduate m nurses. m Whi
chm ismanm exampleof m am first-levelm prioritym problem?
a. Patientm withm postoperativem pain
b. Newlym diagnosedm patientm with m diabetesm whom needsm diabeticm teaching
Table of Contents
Tablem of 1
Contents
Chapterm 01:m Evidence-Based 2
AssessmentjChapterm 02:m Cultural 15
Assessment 31
Chapterm 03:m Them Interview 49
Chapterm 04:m Them Completem Health 64
HistoryChapterm 05:m Mentalm StatusmAsse 80
ssmentm Chapterm 06:m SubstancemUsem A 86
ssessment 92
Chapterm 07:m Domestic m andm Family m Violencem Assessmen 111
t
Chapterm 08:m Assessmentm Techniquesm andm Safety m inm th Clinical 118
e
SettingChapterm 09:m Generalm Survey m andm Measurement 133
Chapterm 10:m Vitalm Signs 141
Chapterm 11:m Pain 155
Assessment 176
Chapterm 12:m Nutrition 194
AssessmentChapterm 13:m Skin, 211
Hair,m andm Nails 228
Chapterm 14:m Head, m Face, m Neck, m and m Regional 246
LymphaticsChapterm 15:m Eyes 266
Chapter 16: Ears 284
Chapterm 17:m Nose,m Mouth,m andm ThroatmChapt 303
erm 18:m Breasts,m Axillae,m andm RegionalmLymph 320
aticsChapterm 19:m Thorax m andm LungsmChapter 337
m 20:m Heartm andm Neck m Vessels 358
Chapterm 21:m Peripheralm Vascularm System m andm Lymphatic m System mChap 382
term 22:m Abdomen 400
Chapterm 23:m Musculoskeletalm System 414
mChapterm 24: Neurologic 436
System mChapterm 25:m 449
Malem Genitourinary mSystem 452
Chapterm 26:m Anus,m Rectum,m andm ProstatemC 458
hapterm 27:m Femalem Genitourinary m System 471
Chapterm 28:m Them Completem Healthm Assessment:m Adult
Chapterm 29:m Them Completem Physicalm Assessment:m Infant,m Child,m andmAdol
escentChapterm 30:m Bedsidem Assessmentm andm Electronic m Docum entationmCha
pterm 31:m Them Pregnantm Wom an
Chapterm 32:m Functionalm Assessmentm of m them Olderm Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEm CHOICE
1. After m completingm anm initialm assessmentm ofm am patient, m the m nurse m has m charted m thatm his m respirations
m aremeupneicm andhis m pulsem is m 58m beatsm per m minute. m Thesem typesm of m data m wouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m A
Objectivem datam arem whatm them healthm professionalm observesm bym inspecting, m percussing, m palpating, m andm
auscultatingduring m them physicalm examination. m Subjectivem datam ism what m them personm saysm aboutm himm o
rm herselfm duringm historytaking. m Them termsm reflectivem andm introspectivem are m notm used m tom describem da
ta.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
2. Am patientm tells m the m nursem that m he m is m verym nervous, m is m nauseated, m and m feelsm hot. m These m types m of
m datamwouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivem data m arem whatm them personm saysm aboutm himm or m herselfm duringm historym taking. m Objectivem datam
aremwhatm thehealth m professional m observesm bym inspecting, m percussing, m palpating, m andm auscultatingm duringm
themphysicalm examination. m Them termsm reflectivem andm introspectivem are m notm used m tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
3. Them patientsm record, m laboratorym studies, m objectivem data, m andm subjectivem datam combinem to m form m the:
a. Datam base.
b. Admittingm data.
, 3
c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togetherm withm them patients m recordm andm laboratorym studies, m them objective m andm subjective m data m form m th
emdatam base.Them otherm itemsm arem notm part m ofm them patientsm record, m laboratorym studies, m orm data.
DIF:m Cognitivem Level:m Rememberingm (Knowledge)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
4. Whenm listening m tom a m patientsm breath m sounds, m the m nurse m is m unsure m of m a m sound m that m is m heard.
m Themnursesm nextactionm should m be m to:
a. Immediatelym notifym the m patients m physician.
b. Documentm them sound m exactly m asm it m wasm heard.
c. Validatem them data m bym askingm am coworker m tom listen m to m them breath m sounds.
d. Assessm again m in m 20m minutesm tom notem whether m the m soundm is m stillm present.
ANS:m C
Whenm unsure m of m a m sound m heard m whilem listening m to m a m patientsm breath m sounds, m the m nursem validatesm the
m datamtom ensureaccuracy. m If m the m nursem hasm lessm experiencem inm anm area, m thenm hem or m shem asksm anm exp
ertm tom listen.
DIF:m Cognitivem Level:m Analyzingm (Analysis)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
5. Them nursem ism conductingm am classm form new m graduatem nurses. m Duringm them teachingm session, m them nurs
em should m keep minm mind m thatm novicem nurses, m withoutm am backgroundm of m skillsm and m experiencem fromm w
hichm tomdraw, m arem morem likelytom makem theirm decisions m using:
a. Intuition.
b. Am setm ofm rules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicem nurses m operate m from m a m setm ofm defined, m structured m rules. m The m expertm practitioner m usesm intuitive mlin
ks.DIF:m Cognitivem Level:m Understandingm (Comprehension)
, 4
MSC:m Clientm Needs: m General
6. Expertm nursesm learn m to m attendm to m am pattern m ofm assessmentm datam and m actm without m consciously m lab
elingmit. m Theseresponsesm arem referredm tom as:
a. Intuition.
b. Them nursingm process.
c. Clinicalm knowledge.
d. Diagnosticm reasoning.
ANS:m A
Intuitionm ism characterizedm bym patternm recognitionexpert m nurses m learnm tom attend m to m a m pattern m of m assess
mentmdatam andactm withoutm consciously m labelingm it. m Them otherm optionsm arem notm correct.
DIF:m Cognitivem Level:m Understandingm(Comprehens
ion)MSC:m Clientm Needs:m General
7. Them nursem ism reviewingm informationm aboutm evidence-
basedm practicem (E BP). m Whichm statementm bestmreflectsE BP?
a. EBPm reliesm onm tradition m form support m of m best m practices.
b. EBPm ism simply m them usem ofm bestm practicem techniques m for m the m treatmentm of m patients.
c. EBPm emphasizesm the m use m ofm bestm evidencem with m them clinicians m experience.
d. Them patientsm own m preferences m arem notm important m with
EBP.ANS:m C
EBPm ism am systematicm approach m to m practice m that m emphasizes m them use m ofm best m evidencem inm combinationm
withmthecliniciansm experience, m asm well m asm patientm preferencesm andm values, m whenm making m decisions
m aboutmcarem and m treatment. m EBP m ism more m thanm simplym usingm them bestm practicem techniquesm tom tre
atm patients, mandm questioningm traditionm ism importantm whenm nom compellingm andm supportive m researchm evi
dencem exists.
DIF:m Cognitivem Level:m Applyingm (Application)
MSC:m Clientm Needs:m Safem andm Effectivem Carem E nvironment: m Management m ofm Care
8. Them nursem is m conducting m a m classm on m priority m setting m for m am groupm ofm newm graduate m nurses. m Whi
chm ismanm exampleof m am first-levelm prioritym problem?
a. Patientm withm postoperativem pain
b. Newlym diagnosedm patientm with m diabetesm whom needsm diabeticm teaching
