1
Test Bank for Physical Examination and Health Asse
m m m m m m mm
ssment Latest Update 2024
m m m
Table of Contents
Tablem of 1
Contents
Chapterm 01:m Evidence-Based 2
AssessmentmChapterm 02:m Cultural 15
Assessment 31
Chapterm 03:m Them Interview 49
Chapterm 04:m Them Completem Health 64
HistoryChapterm 05:m Mentalm StatusmAss 80
essmentm Chapterm 06:m SubstancemUsem 86
Assessment 92
Chapterm 07:m Domestic m andm Fam ily m Violencem Assessmen 111
t
Chapterm 08:m Assessm entm 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 andm Regional 246
m LymphaticsChapter m 15:m Eyes 266
Chapter 16: Ears 284
Chapterm 17:m Nose,m Mouth,m andm Throat 303
Chapterm 18:m Breasts,m Axillae,m andm Regional 320
LymphaticsChapterm 19:m Thorax m andm Lungs 337
Chapterm 20:m Heartm andm Neck m Vessels 358
Chapterm 21:m Peripheralm Vascularm System m andm Lymphati System 382
c
Chapterm 22:m Abdomen 400
Chapterm 23:m Musculoskeletalm System 414
Chapterm 24: Neurologic System 436
Chapterm 25:m Malem Genitourinary 449
System 452
Chapterm 26:m Anus,m Rectum,m andm Prostate 458
Chapterm 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 andm Adolescent
Chapterm 30:m Bedsidem Assessm entm andm Electronic m Docum entationmChapterm 31:m Th
em Pregnantm Woman
Chapterm 32:m Functionalm Assessmentm of m them Olderm Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEm CHOICE
1. After m completingm an m initial m assessment m ofm am patient, m them nurse m has m chartedm that m hism 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 and
mauscultatingduringm the m physical m examination. m Subjectivem data m is m what m them personm saysm about m him m
ormherselfm duringm historytaking. m Them termsm reflectivem andm introspectivem arem notm usedm tom describem d
ata.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
2. Am patientm tellsm the m nurse m that m he m is m very m nervous, m is m nauseated, m andm feels m hot. m These m types m of
m datamwouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivem data m are m what m the m personm says m aboutm himm orm herself m duringm history m taking. m Objective m datam a
remwhatm thehealthm professionalm observesm bym inspecting, m percussing, m palpating, m and m auscultatingm duringm t
hemphysicalm examination. m The m termsm reflectivem andm introspectivem arem notm usedm tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
3. Them patients m record, m laboratorym studies, m objectivem data, m and m subjectivem data m combinem to m formm the:
a. Datam base.
b. Admittingm data.
, 3
c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togetherm withm the m patients m recordm andm laboratorym studies, m them objectivem andm subjective m datam formm 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 Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
4. Whenm listening m to m am patients m breath m sounds, m the m nursem is m unsurem ofm am soundm that m ism heard.
m Themnursesm nextactionm shouldm bem to:
a. Immediatelym notify m them patients m physician.
b. Documentm them soundm exactly m asm itm wasm heard.
c. Validatem them datam bym askingm a m coworker m tom listen m tom them breath m sounds.
d. Assessm again m inm 20m minutesm tom notem whether m them soundm ism stillm present.
ANS:m C
Whenm unsurem ofm am sound m heard m whilem listeningm tom am patientsm breath m sounds, m them nursem validatesm the
m datamtom ensureaccuracy. m If m them nursem hasm lessm experiencem inm anm area, m thenm hem or m shem asksm anm exp
ertm tomlisten.
DIF:m Cognitivem Level: m Analyzing m (Analysis)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
5. Them nursem ism conductingm am classm form new m graduatem nurses. m Duringm them teachingm session, m them nurs
em should mkeep min m mind m that m novice m nurses, m without m a m background m of m skills m and m experience m fromm wh
ichm tomdraw, m arem morem likelytom makem theirm decisionsm using:
a. Intuition.
b. Am setm ofm rules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicem nurses m operatem fromm a m setm ofm defined, m structured m rules. m Them expertm practitioner m usesm intuitive mlink
s.DIF:m Cognitivem Level:m Understandingm (Comprehension)
, 4
MSC:m Client m Needs:m General
6. Expertm nursesm learnm tom attendm to m am pattern m ofm assessment m data m andm actm without m consciously m lab
elingmit. m Theseresponsesm arem referredm tom as:
a. Intuition.
b. Them nursing m process.
c. Clinicalm knowledge.
d. Diagnosticmreasoning.
ANS:m A
Intuitionm ism characterized m bym pattern m recognitionexpert m nurses m learnm tom attendm tom am patternm ofm assess
mentmdatam andactm withoutm consciously m labelingm it. m Them otherm optionsm arem notm correct.
DIF:m Cognitivem Level:m Understandingm(Comprehen
sion)MSC:m Clientm Needs:m General
7. Themnursemis mreviewingminformationmaboutm evidence-
basedmpractice m(E BP). m Whichm statementm bestm reflectsEBP?
a. EBPm reliesm onm traditionm form supportm ofm best m practices.
b. EBPm ism simplym them use m ofm bestm practicem techniquesm form the m treatment m ofm patients.
c. EBPm emphasizesm them use m of m best m evidencem with m them clinicians m experience.
d. Them patients m ownm preferencesm arem not m importantm with
EBP.ANS:m C
EBPm ism am systematic m approach m to m practicem thatm emphasizesm them usem ofm best m evidencem inm combinationm
withmtheclinicians m experience, m asm well m asm patient m preferencesm and m values, m when m makingm decision
sm aboutmcarem and m treatment. m E BP m is m morem than m simply m using m them best m practicem techniques m to m tr
eatm patients, mand m questioning m tradition m ism importantm whenm no m compellingm andm supportivem researchm e
videncem exists.
DIF:m Cognitivem Level: m Applyingm (Application)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
8. Them nursem ism conducting m am classm on m priority m setting m form am groupm ofm newm graduate m nurses. m Whi
chm ismanm exampleof m a m first-levelm prioritym problem?
a. Patientm withm postoperative m pain
b. Newlym diagnosed m patient m with m diabetes m who m needsm diabetic m teaching
Test Bank for Physical Examination and Health Asse
m m m m m m mm
ssment Latest Update 2024
m m m
Table of Contents
Tablem of 1
Contents
Chapterm 01:m Evidence-Based 2
AssessmentmChapterm 02:m Cultural 15
Assessment 31
Chapterm 03:m Them Interview 49
Chapterm 04:m Them Completem Health 64
HistoryChapterm 05:m Mentalm StatusmAss 80
essmentm Chapterm 06:m SubstancemUsem 86
Assessment 92
Chapterm 07:m Domestic m andm Fam ily m Violencem Assessmen 111
t
Chapterm 08:m Assessm entm 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 andm Regional 246
m LymphaticsChapter m 15:m Eyes 266
Chapter 16: Ears 284
Chapterm 17:m Nose,m Mouth,m andm Throat 303
Chapterm 18:m Breasts,m Axillae,m andm Regional 320
LymphaticsChapterm 19:m Thorax m andm Lungs 337
Chapterm 20:m Heartm andm Neck m Vessels 358
Chapterm 21:m Peripheralm Vascularm System m andm Lymphati System 382
c
Chapterm 22:m Abdomen 400
Chapterm 23:m Musculoskeletalm System 414
Chapterm 24: Neurologic System 436
Chapterm 25:m Malem Genitourinary 449
System 452
Chapterm 26:m Anus,m Rectum,m andm Prostate 458
Chapterm 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 andm Adolescent
Chapterm 30:m Bedsidem Assessm entm andm Electronic m Docum entationmChapterm 31:m Th
em Pregnantm Woman
Chapterm 32:m Functionalm Assessmentm of m them Olderm Adult
, 2
Chapter 01: Evidence-Based Assessment
MULTIPLEm CHOICE
1. After m completingm an m initial m assessment m ofm am patient, m them nurse m has m chartedm that m hism 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 and
mauscultatingduringm the m physical m examination. m Subjectivem data m is m what m them personm saysm about m him m
ormherselfm duringm historytaking. m Them termsm reflectivem andm introspectivem arem notm usedm tom describem d
ata.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
2. Am patientm tellsm the m nurse m that m he m is m very m nervous, m is m nauseated, m andm feels m hot. m These m types m of
m datamwouldm be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS:m C
Subjectivem data m are m what m the m personm says m aboutm himm orm herself m duringm history m taking. m Objective m datam a
remwhatm thehealthm professionalm observesm bym inspecting, m percussing, m palpating, m and m auscultatingm duringm t
hemphysicalm examination. m The m termsm reflectivem andm introspectivem arem notm usedm tom describem data.
DIF:m Cognitivem Level:m Understandingm (Comprehension)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
3. Them patients m record, m laboratorym studies, m objectivem data, m and m subjectivem data m combinem to m formm the:
a. Datam base.
b. Admittingm data.
, 3
c. Financialm statement.
d. Dischargem summary.
ANS:m A
Togetherm withm the m patients m recordm andm laboratorym studies, m them objectivem andm subjective m datam formm 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 Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
4. Whenm listening m to m am patients m breath m sounds, m the m nursem is m unsurem ofm am soundm that m ism heard.
m Themnursesm nextactionm shouldm bem to:
a. Immediatelym notify m them patients m physician.
b. Documentm them soundm exactly m asm itm wasm heard.
c. Validatem them datam bym askingm a m coworker m tom listen m tom them breath m sounds.
d. Assessm again m inm 20m minutesm tom notem whether m them soundm ism stillm present.
ANS:m C
Whenm unsurem ofm am sound m heard m whilem listeningm tom am patientsm breath m sounds, m them nursem validatesm the
m datamtom ensureaccuracy. m If m them nursem hasm lessm experiencem inm anm area, m thenm hem or m shem asksm anm exp
ertm tomlisten.
DIF:m Cognitivem Level: m Analyzing m (Analysis)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
5. Them nursem ism conductingm am classm form new m graduatem nurses. m Duringm them teachingm session, m them nurs
em should mkeep min m mind m that m novice m nurses, m without m a m background m of m skills m and m experience m fromm wh
ichm tomdraw, m arem morem likelytom makem theirm decisionsm using:
a. Intuition.
b. Am setm ofm rules.
c. Articlesm inm journals.
d. Advicem fromm supervisors.
ANS:m B
Novicem nurses m operatem fromm a m setm ofm defined, m structured m rules. m Them expertm practitioner m usesm intuitive mlink
s.DIF:m Cognitivem Level:m Understandingm (Comprehension)
, 4
MSC:m Client m Needs:m General
6. Expertm nursesm learnm tom attendm to m am pattern m ofm assessment m data m andm actm without m consciously m lab
elingmit. m Theseresponsesm arem referredm tom as:
a. Intuition.
b. Them nursing m process.
c. Clinicalm knowledge.
d. Diagnosticmreasoning.
ANS:m A
Intuitionm ism characterized m bym pattern m recognitionexpert m nurses m learnm tom attendm tom am patternm ofm assess
mentmdatam andactm withoutm consciously m labelingm it. m Them otherm optionsm arem notm correct.
DIF:m Cognitivem Level:m Understandingm(Comprehen
sion)MSC:m Clientm Needs:m General
7. Themnursemis mreviewingminformationmaboutm evidence-
basedmpractice m(E BP). m Whichm statementm bestm reflectsEBP?
a. EBPm reliesm onm traditionm form supportm ofm best m practices.
b. EBPm ism simplym them use m ofm bestm practicem techniquesm form the m treatment m ofm patients.
c. EBPm emphasizesm them use m of m best m evidencem with m them clinicians m experience.
d. Them patients m ownm preferencesm arem not m importantm with
EBP.ANS:m C
EBPm ism am systematic m approach m to m practicem thatm emphasizesm them usem ofm best m evidencem inm combinationm
withmtheclinicians m experience, m asm well m asm patient m preferencesm and m values, m when m makingm decision
sm aboutmcarem and m treatment. m E BP m is m morem than m simply m using m them best m practicem techniques m to m tr
eatm patients, mand m questioning m tradition m ism importantm whenm no m compellingm andm supportivem researchm e
videncem exists.
DIF:m Cognitivem Level: m Applyingm (Application)
MSC:m Client m Needs: m Safe m and m Effective m Carem E nvironment:m Managementm ofm Care
8. Them nursem ism conducting m am classm on m priority m setting m form am groupm ofm newm graduate m nurses. m Whi
chm ismanm exampleof m a m first-levelm prioritym problem?
a. Patientm withm postoperative m pain
b. Newlym diagnosed m patient m with m diabetes m who m needsm diabetic m teaching
