Chapter 1 - Evidence-Based Assessment 3
Chapter 2 - Cultural Assessment 13
Chapter 3 - The Interview 26
Chapter 4 - The Complete Health History 43
Chapter 5 - Mental Status Assessment 55
Chapter 6 - Substance Use Assessment 70
Chapter 7 - Domestic and Family Violence Assessment 76
Chapter 8 - Assessment Techniques and Safety in the Clinical Setting 82
Chapter 9 - General Survey and Measurement 97
Chapter 10 - Vital Signs 102
Chapter 11 - Pain Assessment 116
Chapter 12 - Nutrition Assessment 123
Chapter 13 - Skin Hair and Nails 134
Chapter 14 - Head Face Neck and Regional Lymphatics 152
Chapter 15 - Eyes 166
Chapter 16 - Ears 180
Chapter 17 - Nose Mouth and Throat 195
Chapter 18 - Breasts Axillae and Regional Lymphatics 210
Chapter 19 - Thorax and Lungs 226
Chapter 20 - Heart and Neck Vessels 241
Chapter 21 - Peripheral Vascular System and Lymphatic System 255
Chapter 22 - Abdomen 269
Chapter 23 - Musculoskeletal System 282
Chapter 24 - Neurologic System 299
Chapter 25 - Male Genitourinary System 320
Chapter 26 - Anus Rectum and Prostate 334
Chapter 27 - Female Genitourinary System 344
Chapter 28 - The Complete Health Assessment Adult 362
Chapter 29 - The Complete Physical Assessment Infant Young Child and
Adolescent 367
Physical Examination and Health Assessment 8th Edition 0323510809by GeekBano Chapter 30 - Bedside Assessment and Electronic Documentation 369
Chapter 31 - The Pregnant Woman 374
Chapter 32 - Functional Assessment of the Older Adult 385
Physical Examination and Health Assessment 8th Edition 0323510809by GeekBano Chapter 01: Evidence-Based Assessment Jarvis: Physical Examination and Health Assessment, 8th Edition
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. What type of assessment data is this?
a.Objective
b.Reflective
c.Subjective
d.Introspective
ANS: A Objective data is 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 int rospective 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, nauseous, and “feels hot.” What type ofassessment data is this?
a.Objective
b.Reflective
c.Subjective
d.Introspective
ANS: C Subjective data is what the person says about him or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and int rospective are not used to describe data.
DIF
: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3.What do the patient’s record, laboratory studies, objective data, and subjective data combineto form?
a.Database
b.Admitting data
c.Financial statement
d.Discharge summary
ANS: A Together with the patient’s record and laboratory studies, the objective and subjective data form the database. The other items are not part of the patient’s record, laboratory studies, or data.
DIF
: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Safe and Effective Care Environment: Management of Care Chapter 1 - Evidence-Based Assessment 3
Physical Examination and Health Assessment 8th Edition 0323510809by GeekBano 4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. Which action should the nurse take next ? a. Notify the patient’s physician. b. Document t he sound exactly as it was heard. c. Validate the data by asking another nurse 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 patient’s breath sounds, the nurse validates the data to ensure accuracy by either repeating the assessment themselves or asking another nurse to assess the breath sounds. If the nurse has less experience analyzing breath sounds, then he or she should ask an expert to listen. When unsure of a sound heard while listening to a patient’s breath sounds, the nurse should validate the data before documenting to ensure accuracy and before notifying the patient’s physician. To validate that data, the nurse either repeats the assessment himself or herself or asks another nurse to assess the breath sounds. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management o f Care 5. The nurse is conducting a class for new graduate nurses. While teaching the class, what should the nurse keep in mind regarding what novice nurses, without a background of skills and experience from which to draw upon, are more likely to base their decisions on? 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 to make decisions. It takes time, perhaps a few years, in similar clinical situations to achieve competency and it is functioning at the level of an expert practitioner when intuition is include d in making clinical decisions. Intuition is included in decision making when functioning at the level of an expert practitioner. While information in journal articles and advice from supervisors may assist in making decisions, novice nurses do not typically base their decisions on them. It would also be important that if information from journal articles and advice from supervisors were used, that they were evidence based. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General 6. 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 s imply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinician’s experience. d. EBP does not consider the patient’s own preferences as important. ANS: C Chapter 1 - Evidence-Based Assessment 4
Physical Examination and Health Assessment 8th Edition 0323510809by GeekBano
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