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 0323510809

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 0323510809

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 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, nauseous, and “feels hot.” What type of

assessment 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 introspective 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 combine

to 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 0323510809

 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 the 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 of 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 included 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 simply 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 0323510809

EBP is a systematic approach to practice that emphasizes the use of research evidence in

combination with the clinician’s expertise and clinical knowledge (physical assessment), as

well as patient values and preferences, when making decisions about care and treatment. EBP

is more than simply using the best practice techniques to treat patients, and questioning

tradition is important when no compelling and supportive research evidence exists.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

 7. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which

is an example of a first-level priority problem?

a. Patient with postoperative pain

b. Newly diagnosed patient with diabetes who needs diabetic teaching

c. Individual with a small laceration on the sole of the foot

d. Individual with shortness of breath and respiratory distress

ANS: D

First-level priority problems are those that are emergent, life-threatening, and immediate (e.g.,

establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal

vital signs). Postoperative pain, diabetic teaching for a patient newly diagnosed with diabetes,

and a small laceration on sole of the foot are not considered first-level priority problems.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

 8. When considering priority setting of problems, the nurse keeps in mind that second-level

priority problems include which of these aspects?

a. Low self-esteem

b. Lack of knowledge

c. Abnormal laboratory values

d. Severely abnormal vital signs

ANS: C

Abnormal laboratory values are a second-level priority problem. Second-level priority

problems are those that require prompt intervention to forestall further deterioration (e.g.,

mental status change, acute pain, abnormal laboratory values, risks to safety or security). Low

self-esteem and lack of knowledge are considered third-level priority as although they are

important to a patient’s health, they can be addressed after more urgent health problems are

addressed. Severely abnormal vital signs would be considered a first-level priority problem.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

 9. Which critical-thinking skill helps the nurse see relationships among the data?

a. Validation

b. Clustering related cues

c. Identifying gaps in data

d. Distinguishing relevant from irrelevant

ANS: B

Chapter 1 - Evidence-Based Assessment 5

Physical Examination and Health Assessment 8th Edition 0323510809