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Table of Contents
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
Chapter 11: Pain Assessment
Chapter 12: Nutrition Assessment
Chapter 13: Skin, Hair, and Nails
Chapter 14: Head, Face, Neck, and Regional Lymphatics
Chapter 15: Eyes
Chapter 16: Ears
Chapter 17: Nose, Mouth, and Throat
Chapter 18: Breasts, Axillae, and Regional Lymphatics
Chapter 19: Thorax and Lungs
Chapter 20: Heart and Neck Vessels
Chapter 21: Peripheral Vascular System and Lymphatic System
Chapter 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 Adolescent
Chapter 30: 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
- 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. These types of data would be:
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
- 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 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
- The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base. b. Admitting data.
MSC: Client Needs: General
- Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning.
ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
- 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 clinicians experience.
d. The patients own preferences are not important with EBP.
ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, 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
- 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). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 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). DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- 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 Clustering related cues helps the nurse see relationships among the data. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
d. Sleep, pain, and breathing
ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- Which of these would be formulated by a nurse using diagnostic reasoning?
a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment
ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
- Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills.
ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: General
- What step of the nursing process includes data collection by health history, physical examination, and interview?
a. Planning b. Diagnosis c. Evaluation d. Assessment
ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessmen step of the nursing process. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General
- During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?
a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies.
ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?
a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patients health state.
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting?
a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly
ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the persons health care. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms.
ANS: D In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
a. Collect a follow-up data base and then check her blood pressure.
b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.
ANS: A A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
ANS: B The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life- saving measures. The other responses are not appropriate for the situation. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care
- A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual.
a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.
ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how todays nursing actions can apply to the point the nurse wants the patient to reach at a future time. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: General MULTIPLE RESPONSE
- The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute
ANS: A, C, E, F Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to the respiratory cues. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care MATCHING Put the following patient situations in order according to the level of priority.
a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. b. A teenager who was stung by a bee during a soccer match is having trouble breathing. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation.
- a = First-level priority problem
- b = Second-level priority problem
- c = Third-level priority problem
- ANS: B DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patients health but can be addressed after more urgent health problems are addressed.
- ANS: C DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patients health but can be addressed after more urgent health problems are addressed.
- ANS: A DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Safe and Effective Care Environment: Management of Care NOT: First-level priority problems are immediate priorities, such as trouble breathing (remember the airway, breathing, circulation priorities). Second-level priority problems are next in urgency, but not life-threatening. Third-level priorities (e.g., patient education) are important to a patients health but can be addressed after more urgent health problems are addressed.
b. Norms
c. Culture d. Social learning
ANS: C The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: Psychosocial Integrity
- When discussing the use of the term subculture , the nurse recognizes that it is best described as:
a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
ANS: D Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity
- When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is:
a. Hispanic. b. Black. c. Asian. d. American Indian.
ANS: A
Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General
- During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?
a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospitals safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary.
ANS: A The nurse should inquire about the amulets meaning. Amulets, such as charms, are often considered an important means of protection from evil spirits by some cultures. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
- The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver:
a. Is able to speak the patients native language. b. Possesses some basic knowledge of the patients cultural background. c. Applies the proper background knowledge of a patients cultural background to provide the best possible health care. d. Understands and attends to the total context of the patients situation.
ANS: D Culturally competent implies that the caregiver understands and attends to the total context of the individuals situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patients native language. DIF: Cognitive Level: Analyzing (Analysis) MSC: Client Needs: Psychosocial Integrity
- The nurse recognizes that an example of a person who is heritage consistent would be a:
a. Woman who has adapted her clothing to the clothing style of her new country.
ANS: C
Spirituality refers to each persons unique life experiences and his or her personal effort to find purpose and meaning in life. The other responses apply to religion. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
- A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?
a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation
ANS: A Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and acquiring another culture. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity
- The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment?
a. What is your religion? b. Do you mostly participate in the religious traditions of your family? c. Do you smoke? d. Do you have a history of heart disease?
ANS: B Asking questions about participation in the religious traditions of family enables the nurse to assess a persons heritage. Simply asking about ones religion, smoking history, or health history does not reflect heritage. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Psychosocial Integrity
- In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans:
a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick.
ANS: B The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity
- The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious
ANS: B Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Psychosocial Integrity
- An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with:
a. Foods that are hot or yang. b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be cold. d. No treatment is tried because diarrhea is an expected part of life.
