TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 1
TestBank l
,TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 2
Table of Contents
l l
1
Chapterl 01:l Evidence- 2
Basedl AssessmentlChapterl02:l CulturallAs 15
sessment 31
Chapterl 03:l Thel Interview 49
Chapterl 04:l Thel Completel Healthl HistorylC 64
hapterl 05:l Mentall Statusl AssessmentlChap 80
terl 06:l Substancel Usel Assessment 86
Chapterl 07:l Domesticl andl Familyl Violencel Assessment 92
Chapterl 08:l Assessmentl Techniquesl andl Safetyl inl thel Clinicall SettinglCh 111
apterl09:lGenerallSurveylandlMeasurement 118
Chapterl10:lVitallSignslChapter 133
l 11:l Painl Assessment 141
Chapterl 12:l Nutritionl AssessmentlChapter 155
l 13:l Skin,l Hair,l andl Nails 176
Chapterl 14:l Head,l Face,l Neck,l andl Regionall LymphaticslCh 194
apterl15:lEyes 211
Chapterl 16:l Ears 228
Chapterl 17:l Nose,l Mouth,l andl Throat 246
Chapterl 18:l Breasts,l Axillae,l andl Regionall LymphaticslC 266
hapterl19:lThoraxlandlLungs 284
Chapterl 20:l Heartl andl Neckl Vessels 303
Chapterl 21:l Peripherall Vascularl Systeml andl Lymphaticl SystemlCh 320
apterl22:lAbdomen 337
Chapterl 23:l Musculoskeletall SystemlCha 358
pterl 24:l Neurologicl SystemlChapterl 25:l 382
Malel Genitourinaryl SystemlChapterl 26:l A 400
nus,l Rectum,l andl Prostate 414
Chapterl 27:l Femalel Genitourinaryl System 436
Chapterl 28:l Thel Completel Healthl Assessment:l Adult 449
Chapterl 29:l Thel Completel Physicall Assessment:l Infant,l Child,l andl AdolescentlCh 452
apterl30:l BedsidelAssessmentl andlElectronicl Documentation 458
Chapterl 31:l Thel Pregnantl Woman 471
Chapterl 32:l Functionall Assessmentl ofl thel Olderl Adult
,TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 3
Chapter 01: Evidence-Based Assessment
l l l
MULTIPLEl CHOICE
1. Afterl completingl anl initiall assessmentl ofl al patient,l thel nursel hasl chartedl thatl hisl respirationsl arel eupneicl andlhislp
ulselisl58lbeatslperlminute.lTheseltypeslofldatalwouldlbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.l
ANS:lA
Objectiveldatalarelwhatlthelhealthlprofessionallobserveslbylinspecting,lpercussing,lpalpating,landlauscultatingldurin
glthelphysicallexamination.lSubjectiveldatalislwhatlthelpersonl sayslaboutlhimlorlherselflduringlhistoryltaking.lTh
eltermslreflectivelandlintrospectivelarelnotlusedltoldescribeldata.
DIF:l Cognitivel Level:l Understandingl (Comprehension)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
2. Al patientl tellsl thel nursel thatl hel isl veryl nervous,l isl nauseated,l andl feelsl hot.lThesel typesl ofl datal wouldl be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.l
ANS:lC
Subjectivel datal arel whatl thel personl saysl aboutl himl orl herselfl duringl historyl taking.l Objectivel datal arel whatl thelhealt
hlprofessionallobserveslbylinspecting,lpercussing,lpalpating,landlauscultatinglduringlthelphysicallexamination.l
Theltermslreflectivelandlintrospectivelarelnotlusedltoldescribeldata.
DIF:l Cognitivel Level:l Understandingl (Comprehension)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
3. Thel patientsl record,l laboratoryl studies,l objectivel data,l andl subjectivel datal combinel tol forml the:
a. Datalbase.
b. Admittingldata.
, TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 4
c. Financiall statement.
d. Dischargel summary.
ANS:lA
Togetherl withl thel patientsl recordl andl laboratoryl studies,l thel objectivel andl subjectivel datal forml thel datal base.lThelot
herlitemslarelnotlpartloflthelpatientslrecord,llaboratorylstudies,lorldata.
DIF:l Cognitivel Level:l Rememberingl (Knowledge)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
4. Whenl listeningl tolal patientsl breathl sounds,l thel nursel isl unsurel ofl al soundl thatl isl heard.l Thel nursesl nextlactio
nlshouldlbelto:
a. Immediatelyl notifyl thel patientsl physician.
b. Documentl thel soundl exactlyl asl itl wasl heard.
c. Validatel thel datal byl askingl alcoworkerl tol listenl tol thel breathl sounds.
d. Assessl againl inl 20l minutesl tolnotel whetherl thel soundl isl stilll present.
ANS:lC
Whenl unsurel ofl al soundl heardl whilel listeningl tol al patientsl breathl sounds,l thelnursel validatesl thel datal tol ensurelaccur
acy.lIflthelnurselhasllesslexperiencelinlanlarea,lthenlhelorlshelaskslanlexpertltollisten.
DIF:l Cognitivel Level:l Analyzingl (Analysis)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
5. Thelnurselislconductingl alclasslforlnewl graduatelnurses.l Duringlthelteachinglsession,lthelnurselshouldlkeeplinl mi
ndl thatl novicel nurses,l withoutl al backgroundl ofl skillsl andl experiencel froml whichl tol draw,l arel morel likelyltolmakelth
eirldecisionslusing:
a. Intuition.
b. Alsetloflrules.
c. Articlesl inl journals.
d. Advicel froml supervisors.
ANS:lB
Novicel nursesl operatel froml al setl ofl defined,l structuredl rules.l Thel expertl practitionerl usesl intuitivel links.lDIF:lCo
gnitivelLevel:lUnderstandingl(Comprehension)
TestBank l
,TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 2
Table of Contents
l l
1
Chapterl 01:l Evidence- 2
Basedl AssessmentlChapterl02:l CulturallAs 15
sessment 31
Chapterl 03:l Thel Interview 49
Chapterl 04:l Thel Completel Healthl HistorylC 64
hapterl 05:l Mentall Statusl AssessmentlChap 80
terl 06:l Substancel Usel Assessment 86
Chapterl 07:l Domesticl andl Familyl Violencel Assessment 92
Chapterl 08:l Assessmentl Techniquesl andl Safetyl inl thel Clinicall SettinglCh 111
apterl09:lGenerallSurveylandlMeasurement 118
Chapterl10:lVitallSignslChapter 133
l 11:l Painl Assessment 141
Chapterl 12:l Nutritionl AssessmentlChapter 155
l 13:l Skin,l Hair,l andl Nails 176
Chapterl 14:l Head,l Face,l Neck,l andl Regionall LymphaticslCh 194
apterl15:lEyes 211
Chapterl 16:l Ears 228
Chapterl 17:l Nose,l Mouth,l andl Throat 246
Chapterl 18:l Breasts,l Axillae,l andl Regionall LymphaticslC 266
hapterl19:lThoraxlandlLungs 284
Chapterl 20:l Heartl andl Neckl Vessels 303
Chapterl 21:l Peripherall Vascularl Systeml andl Lymphaticl SystemlCh 320
apterl22:lAbdomen 337
Chapterl 23:l Musculoskeletall SystemlCha 358
pterl 24:l Neurologicl SystemlChapterl 25:l 382
Malel Genitourinaryl SystemlChapterl 26:l A 400
nus,l Rectum,l andl Prostate 414
Chapterl 27:l Femalel Genitourinaryl System 436
Chapterl 28:l Thel Completel Healthl Assessment:l Adult 449
Chapterl 29:l Thel Completel Physicall Assessment:l Infant,l Child,l andl AdolescentlCh 452
apterl30:l BedsidelAssessmentl andlElectronicl Documentation 458
Chapterl 31:l Thel Pregnantl Woman 471
Chapterl 32:l Functionall Assessmentl ofl thel Olderl Adult
,TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 3
Chapter 01: Evidence-Based Assessment
l l l
MULTIPLEl CHOICE
1. Afterl completingl anl initiall assessmentl ofl al patient,l thel nursel hasl chartedl thatl hisl respirationsl arel eupneicl andlhislp
ulselisl58lbeatslperlminute.lTheseltypeslofldatalwouldlbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.l
ANS:lA
Objectiveldatalarelwhatlthelhealthlprofessionallobserveslbylinspecting,lpercussing,lpalpating,landlauscultatingldurin
glthelphysicallexamination.lSubjectiveldatalislwhatlthelpersonl sayslaboutlhimlorlherselflduringlhistoryltaking.lTh
eltermslreflectivelandlintrospectivelarelnotlusedltoldescribeldata.
DIF:l Cognitivel Level:l Understandingl (Comprehension)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
2. Al patientl tellsl thel nursel thatl hel isl veryl nervous,l isl nauseated,l andl feelsl hot.lThesel typesl ofl datal wouldl be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.l
ANS:lC
Subjectivel datal arel whatl thel personl saysl aboutl himl orl herselfl duringl historyl taking.l Objectivel datal arel whatl thelhealt
hlprofessionallobserveslbylinspecting,lpercussing,lpalpating,landlauscultatinglduringlthelphysicallexamination.l
Theltermslreflectivelandlintrospectivelarelnotlusedltoldescribeldata.
DIF:l Cognitivel Level:l Understandingl (Comprehension)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
3. Thel patientsl record,l laboratoryl studies,l objectivel data,l andl subjectivel datal combinel tol forml the:
a. Datalbase.
b. Admittingldata.
, TestlBankl-lPhysicallExaminationlandlHealthlAssessmentl8el(bylJarvis) 4
c. Financiall statement.
d. Dischargel summary.
ANS:lA
Togetherl withl thel patientsl recordl andl laboratoryl studies,l thel objectivel andl subjectivel datal forml thel datal base.lThelot
herlitemslarelnotlpartloflthelpatientslrecord,llaboratorylstudies,lorldata.
DIF:l Cognitivel Level:l Rememberingl (Knowledge)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
4. Whenl listeningl tolal patientsl breathl sounds,l thel nursel isl unsurel ofl al soundl thatl isl heard.l Thel nursesl nextlactio
nlshouldlbelto:
a. Immediatelyl notifyl thel patientsl physician.
b. Documentl thel soundl exactlyl asl itl wasl heard.
c. Validatel thel datal byl askingl alcoworkerl tol listenl tol thel breathl sounds.
d. Assessl againl inl 20l minutesl tolnotel whetherl thel soundl isl stilll present.
ANS:lC
Whenl unsurel ofl al soundl heardl whilel listeningl tol al patientsl breathl sounds,l thelnursel validatesl thel datal tol ensurelaccur
acy.lIflthelnurselhasllesslexperiencelinlanlarea,lthenlhelorlshelaskslanlexpertltollisten.
DIF:l Cognitivel Level:l Analyzingl (Analysis)
MSC:l Clientl Needs:l Safel andl Effectivel Carel Environment:l Managementl ofl Care
5. Thelnurselislconductingl alclasslforlnewl graduatelnurses.l Duringlthelteachinglsession,lthelnurselshouldlkeeplinl mi
ndl thatl novicel nurses,l withoutl al backgroundl ofl skillsl andl experiencel froml whichl tol draw,l arel morel likelyltolmakelth
eirldecisionslusing:
a. Intuition.
b. Alsetloflrules.
c. Articlesl inl journals.
d. Advicel froml supervisors.
ANS:lB
Novicel nursesl operatel froml al setl ofl defined,l structuredl rules.l Thel expertl practitionerl usesl intuitivel links.lDIF:lCo
gnitivelLevel:lUnderstandingl(Comprehension)
