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Chapter 01: Evidence-Based Assessment 142
Chapter 02: Cultural Competence 156
Chapter 03: The Interview 177
Chapter 04: The Complete Health History 195
Chapter 05: Mental Status Assessment 212
Chapter 06: Substance Use Assessment 229
Chapter 07: Domestic and Family Violence Assessments 247
Chapter 08: Assessment Techniques and Safety in the Clinical Setting 267
Chapter 09: General Survey, Measurement, Vital Signs 285
Chapter 10: Pain Assessment: The Fifth Vital Sign 304
Chapter 11: Nutritional Assessment 321
Chapter 12: Skin, Hair, and Nails 338
Chapter 13: Head, Face, and Neck, Including Regional Lymphatics 359
Chapter 14: Eyes 384
Chapter 15: Ears 402
Chapter 16: Nose, Mouth, and Throat 416
Chapter 17: Breasts and Regional Lymphatics 438
Chapter 18: Thorax and Lungs 451
Chapter 19: Heart and Neck Vessels 454
Chapter 20: Peripheral Vascular System and Lymphatic System 460
Chapter 21: Abdomen 473
Chapter 22: Musculoskeletal System
Chapter 23: Neurologic System
Chapter 24: Male Genitourinary System
Chapter 25: Anus, Rectum, and Prostate
Chapter 26: Female Genitourinary System
Chapter 27: The Complete Health Assessment: Adult
Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent
Chapter 29: Bedside Assessment of the Hospitalized Patient
Chapter 30: The Pregnant Woman
Chapter 31: Functional Assessment of the Older Adult
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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 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) REF: p. 2
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 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) REF: p. 2
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.
