,Table of Contents
Chapter 01: Evidence-Based Assessment
Chapter 02: Cultural Assessment Chapter 03:
The Interview
Chapter 04: The Complete Health History
Chapter 05: Mental Status Assessment Chapter
06: Substance Use Assessment
Chapter 07: Domestic and Family Violence Assessment Chapter 08:
Assessment Techniques and Safety in the Clinical Setting
Chapter 09: General Survey and Measurement
Chapter 10: Vital Signs Chapter11:
Pain Assessment
Chapter 12: Nutrition Assessment
Chapter 13: Skin, Hair, and Nails
Chapter 14: Head, Face, Neck, and Regional LymphaticsChapter 15:
Eyes
Chapter 16: Ears
Chapter 17: Nose, Mouth, and Throat
Chapter 18: Breasts, Axillae, and Regional LymphaticsChapter 19:
Thorax and Lungs
Chapter 20: Heart and Neck Vessels
Chapter 21: Peripheral Vascular System and Lymphatic SystemChapter
22: Abdomen
Chapter 23: Musculoskeletal System Chapter 24:
Neurologic System Chapter 25: Male
Genitourinary System Chapter 26:
Anus, Rectum, and Prostate
Chapter 27: Female Genitourinary System
Chapter 28: The Complete Health Assessment: Adult
Chapter 29: The Complete Physical Assessment: Infant, Child, and AdolescentChapter30: Bedside
Assessment and Electronic Documentation
Chapter 31: The Pregnant Woman
Chapter 32: Functional Assessment of the Older Adult
,Chapter 01: Evidence-Based Assessment
MULTIPLE CHOICE
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic andhis
pulse is 58 beats per minute. These types of data wouldbe:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: A
Objective data are 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 introspective 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, is nauseated, and feels hot. These types of data would be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
ANS: C
Subjective data are what the person says about him or herself during history taking. Objective data are what thehealth
professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The
terms reflective and introspective are not used to describe data.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base.
b. Admitting data.
, c. Financial statement.
d. Discharge summary.
ANS: A
Together with the patients record and laboratory studies, the objective and subjective data form the data base.The
other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next
action should be to:
a. Immediately notify the patients physician.
b. Document the sound exactly as it was heard.
c. Validate the data by asking a coworker 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 patients breath sounds, the nurse validates the data to ensureaccuracy. If
the nurse has less experience in an area, then he or she asks an expert to listen.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in
mind that novice nurses, without a background of skills and experience from which to draw, are more likelyto make
their decisions using:
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. The expert practitioner uses intuitive links.DIF:
