Test Bank For Physical Examination and Health Assessment, 8th Edition

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1215314964808692111118133141155176194211228246266284303320337358382400414436449452458471Table of ContentsTable of ContentsChapter 01: Evidence-Based AssessmentChapter 02: Cultural AssessmentChapter 03: The InterviewChapter 04: The Complete Health HistoryChapter 05: Mental Status AssessmentChapter 06: Substance Use AssessmentChapter 07: Domestic and Family Violence AssessmentChapter 08: Assessment Techniques and Safety in the Clinical SettingChapter 09: General Survey and MeasurementChapter 10: Vital SignsChapter 11: Pain AssessmentChapter 12: Nutrition AssessmentChapter 13: Skin, Hair, and NailsChapter 14: Head, Face, Neck, and Regional LymphaticsChapter 15: EyesChapter 16: EarsChapter 17: Nose, Mouth, and ThroatChapter 18: Breasts, Axillae, and Regional LymphaticsChapter 19: Thorax and LungsChapter 20: Heart and Neck VesselsChapter 21: Peripheral Vascular System and Lymphatic SystemChapter 22: AbdomenChapter 23: Musculoskeletal SystemChapter 24: Neurologic SystemChapter 25: Male Genitourinary SystemChapter 26: Anus, Rectum, and ProstateChapter 27: Female Genitourinary SystemChapter 28: The Complete Health Assessment: AdultChapter 29: The Complete Physical Assessment: Infant, Child, and AdolescentChapter 30: Bedside Assessment and Electronic DocumentationChapter 31: The Pregnant WomanChapter 32: Functional Assessment of the Older AdultTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)1

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Chapter 01: Evidence-Based AssessmentMULTIPLE CHOICE1. 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 would be:a.Objective.b.Reflective.c.Subjective.d.Introspective.ANS: AObjective data are what the health professional observes by inspecting, percussing, palpating, and auscultatingduring the physical examination. Subjective data is what the personsaysabout him or herself during historytaking. The termsreflectiveandintrospectiveare not used to describe data.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care2. 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: CSubjective 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 physicalexamination. The termsreflectiveandintrospectiveare not used to describe data.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care3. The patients record, laboratory studies, objective data, and subjective data combine to form the:a.Data base.b.Admitting data.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)2

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c.Financial statement.d.Discharge summary.ANS: ATogether 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 Care4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses nextaction 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: CWhen 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 Care5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keepin 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: BNovice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.DIF: Cognitive Level: Understanding (Comprehension)Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)3

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MSC: Client Needs: General6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. Theseresponses are referred to as:a.Intuition.b.The nursing process.c.Clinical knowledge.d.Diagnostic reasoning.ANS: AIntuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data andact without consciously labeling it. The other options are not correct.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: General7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflectsEBP?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: CEBP is a systematic approach to practice that emphasizes the use of best evidence in combination with theclinicians experience, as well as patient preferences and values, when making decisions about care andtreatment. EBP is more than simply using the best practice techniques to treat patients, and questioningtradition 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 Care8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an exampleof a first-level priority problem?a.Patient with postoperative painb.Newly diagnosed patient with diabetes who needs diabetic teachingTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)4

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c.Individual with a small laceration on the sole of the footd.Individual with shortness of breath and respiratory distressANS: DFirst-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing anairway, supporting breathing, maintaining circulation, monitoring abnormal vital signs).DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problemsinclude which of these aspects?a.Low self-esteemb.Lack of knowledgec.Abnormal laboratory valuesd.Severely abnormal vital signsANS: CSecond-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 Care10. Which critical thinking skill helps the nurse see relationships among the data?a.Validationb.Clustering related cuesc.Identifying gaps in datad.Distinguishing relevant from irrelevantANS: BClustering 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 CareTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)5

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11. The nurse knows that developing appropriate nursing interventions for a patient relies on theappropriateness of the __________ diagnosis.a.Nursingb.Medicalc.Admissiond.CollaborativeANS: AAn accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomesfor which the nurse is accountable. The other items do not contribute to the development of appropriate nursinginterventions.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care12. The nursing process is a sequential method of problem solving that nurses use and includes which steps?a.Assessment, treatment, planning, evaluation, discharge, and follow-upb.Admission, assessment, diagnosis, treatment, and discharge planningc.Admission, diagnosis, treatment, evaluation, and discharge planningd.Assessment, diagnosis, outcome identification, planning, implementation, and evaluationANS: DThe nursing process is a method of problem solving that includes assessment, diagnosis, outcomeidentification, planning, implementation, and evaluation.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficultybreathing. How should the nurse prioritize these problems?a.Breathing, pain, and sleepb.Breathing, sleep, and painc.Sleep, breathing, and painTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)6

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d.Sleep, pain, and breathingANS: AFirst-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, andcirculation), 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 Care14. Which of these would be formulated by a nurse using diagnostic reasoning?a.Nursing diagnosisb.Medical diagnosisc.Diagnostic hypothesisd.Diagnostic assessmentANS: CDiagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for anursing diagnosis.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: General15. 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: AAs individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from othercolleagues who are knowledgeable in research, and often lack the time to visit the library to read research. Theother responses are not considered barriers.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: General16. What step of the nursing process includes data collection by health history, physical examination, andinterview?Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)7

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a.Planningb.Diagnosisc.Evaluationd.AssessmentANS: DData collection, including performing the health history, physical examination, and interview, is the assessmentstep of the nursing process.DIF: Cognitive Level: Remembering (Knowledge)MSC: Client Needs: General17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporateevidence-based clinical decision making into their practice. Which suggestion by the nurse manager wouldbest 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: DFacilitating support for EBP would include teaching the nurses how to conduct electronic searches; time tovisit the library may not be available for many nurses. Actually conducting research studies may be helpful inthe 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 Care18. When reviewing the concepts of health, the nurse recalls that the components of holistic health includewhich 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.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)8

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d.Holistic health views the mind, body, and spirit as interdependent.ANS: DConsideration of the whole person is the essence of holistic health, which views the mind, body, and spirit asinterdependent. The basis of disease originates from both the external environment and from within the person.Both the individual human and the external environment are open systems, continually changing and adapting,and each person is responsible for his or her own personal health state.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Safe and Effective Care Environment: Management of Care19. The nurse recognizes that the concept of prevention in describing health is essential because:a.Disease can be prevented by treating the external environment.b.The majority of deaths among Americans under age 65 years are not preventable.c.Prevention places the emphasis on the link between health and personal behavior.d.The means to prevention is through treatment provided by primary health care practitioners.ANS: CA natural progression to prevention rounds out the present concept of health. Guidelines to prevention placethe emphasis on the link between health and personal behavior.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: General20. The nurse is performing a physical assessment on a newly admitted patient. An example of objectiveinformation obtained during the physical assessment includes the:a.Patients history of allergies.b.Patients use of medications at home.c.Last menstrual period 1 month ago.d.2 5 cm scar on the right lower forearm.ANS: DObjective data are the patients record, laboratory studies, and condition that the health professional observes byinspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflectsubjective data.DIF: Cognitive Level: Applying (Application)Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)9

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care21. 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 intervalsb.An episodic data base because of the continuing, complex medical problems of this patientc.A complete health data base because of the nurses primary responsibility for monitoring thepatients healthd.An emergency data base because of the need to collect information and make accurate diagnosesrapidlyANS: CThe 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 nurseagency, or community health agency. In these settings, the nurse is the first health professional to see thepatient 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 Care22. Which situation is most appropriate during which the nurse performs a focused or problem-centeredhistory?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: DIn a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope thanthe completed data base. This mini data base primarily concerns one problem, one cue complex, or one bodysystem.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Safe and Effective Care Environment: Management of Care23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weeklysince she changed medications 2 months ago. The nurse should:a.Collect a follow-up data base and then check her blood pressure.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)10

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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 historyinformation may have changed.ANS: AA follow-up data base is used in all settings to follow up short-term or chronic health problems. The otherresponses are not appropriate for the situation.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Safe and Effective Care Environment: Management of Care24. A patient is brought by ambulance to the emergency department with multiple traumas received in anautomobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurseproceed with data collection?a.Collect history information first, then perform the physical examination and institute life-savingmeasures.b.Simultaneously ask history questions while performing the examination and initiating life-savingmeasures.c.Collect all information on the history form, including social support patterns, strengths, and copingpatterns.d.Perform life-saving measures and delay asking any history questions until the patient is transferredto the intensive care unit.ANS: BThe 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 Care25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurseknows 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.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)11

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d.Provide culturally sensitive and appropriate care.ANS: DThe inclusion of cultural considerations in the health assessment is of paramount importance to gathering datathat are accurate and meaningful and to intervening with culturally sensitive and appropriate care.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity26. In the health promotion model, the focus of the health professional includes:a.Changing the patients perceptions of disease.b.Identifying biomedical model interventions.c.Identifying negative health acts of the consumer.d.Helping the consumer choose a healthier lifestyle.ANS: DIn the health promotion model, the focus of the health professional is on helping the consumer choose ahealthier lifestyle.DIF: Cognitive Level: Remembering (Knowledge)MSC: Client Needs: Health Promotion and Maintenance27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain.Which would be the next appropriate action?a.Establish priorities.b.Identify expected outcomes.c.Evaluate the individuals condition, and compare actual outcomes with expected outcomes.d.Interpret data, and then identify clusters of cues and make inferences.ANS: CEvaluation is the next step after the implementation phase of the nursing process. During this step, the nurseevaluates the individuals condition and compares the actual outcomes with expected outcomes.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Safe and Effective Care Environment: Management of Care28. Which statementbestdescribes a proficient nurse? A proficient nurse is one who:Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)12

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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-termgoals for the patient.ANS: DThe proficient nurse, with more time and experience than the novice nurse, is able to understand a patientsituation as a whole rather than as a list of tasks. The proficient nurse is able to see how todays nursing actionscan apply to the point the nurse wants the patient to reach at a future time.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: GeneralMULTIPLE RESPONSE1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would beconsidered related cues that would be clustered together during data analysis?Select all that apply.a.Inspiratory wheezes noted in left lower lobesb.Hypoactive bowel soundsc.Nonproductive coughd.Edema, +2, noted on left hande.Patient reports dyspnea upon exertionf.Rate of respirations 16 breaths per minuteANS: A, C, E, FClustering related cues help the nurse recognize relationships among the data. The cues related to the patientsrespiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cuesrelated 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 CareMATCHINGPut the following patient situations in order according to the level of priority.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)13

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a.A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his ownblood 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.1. a = First-level priority problem2. b = Second-level priority problem3. c = Third-level priority problem1. ANS: B DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: 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 moreurgent health problems are addressed.2. ANS: C DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: 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 moreurgent health problems are addressed.3. ANS: A DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Safe and Effective Care Environment: Management of CareNOT: 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 moreurgent health problems are addressed.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)14

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Chapter 02: Cultural AssessmentMULTIPLE CHOICE1. The nurse is reviewing the development of culture. Which statement iscorrectregarding the development ofones culture? Culture is:a.Genetically determined on the basis of racial background.b.Learned through language acquisition and socialization.c.A nonspecific phenomenon and is adaptive but unnecessary.d.Biologically determined on the basis of physical characteristics.ANS: BCulture is learned from birth through language acquisition and socialization. It is not biologically orgenetically determined and is learned by the individual.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Whichstatement correctly reflects one of these characteristics?a.Cultures are static and unchanging, despite changes around them.b.Cultures are never specific, which makes them hard to identify.c.Culture is most clearly reflected in a persons language and behavior.d.Culture adapts to specific environmental factors and available natural resources.ANS: DCulture has four basic characteristics. Culture adapts to specific conditions related to environmental andtechnical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture islearned from birth through the process of language acquisition and socialization, but it is not most clearlyreflected in ones language and behavior.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specificand distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term?a.MoresTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)15

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b.Normsc.Cultured.Social learningANS: CThe culture that develops in any given society is always specific and distinctive, encompassing all of theknowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit thegiven definition.DIF: Cognitive Level: Remembering (Knowledge)MSC: Client Needs: Psychosocial Integrity4. When discussing the use of the termsubculture, 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 culturalvariations.d.Identifying fairly large groups of people with shared characteristics that are not common to allmembers of a culture.ANS: DWithin cultures, groups of people share different beliefs, values, and attitudes. Differences occur because ofethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture,they are referred to assubcultural groups.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largestand fastest growing population is:a.Hispanic.b.Black.c.Asian.d.American Indian.ANS: ATest Bank - Physical Examination and Health Assessment 8e (by Jarvis)16

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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: General6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather striparound 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: AThe nurse should inquire about the amulets meaning. Amulets, such as charms, are often considered animportant means of protection from evil spirits by some cultures.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity7. The nurse manager is explaining culturally competent care during a staff meeting. Which statementaccurately 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 bestpossible health care.d.Understands and attends to the total context of the patients situation.ANS: DCulturally competent implies that the caregiver understands and attends to the total context of the individualssituation. This competency includes awareness of immigration status, stress factors, other social factors, andcultural similarities and differences. It does not require the caregiver to speak the patients native language.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity8. The nurse recognizes that an example of a person who isheritage consistentwould be a:a.Woman who has adapted her clothing to the clothing style of her new country.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)17

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b.Woman who follows the traditions that her mother followed regarding meals.c.Man who is not sure of his ancestors country of origin.d.Child who is not able to speak his parents native language.ANS: BSomeone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the normsand customs of the new country.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the conceptof ethnicity with which statement?a.Ethnicity is dynamic and ever changing.b.Ethnicity is the belief in a higher power.c.Ethnicity pertains to a social group within the social system that claims shared values andtraditions.d.Ethnicity is learned from birth through the processes of language acquisition and socialization.ANS: CEthnicity pertains to a social group within the social system that claims to have variable traits, such as acommon geographic origin, migratory status, religion, race, language, values, traditions, symbols, or foodpreferences.Cultureis dynamic, ever changing, and learned from birth through the processes of languageacquisition and socialization. Religion is the belief in a higher power.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriatecomponent of ones spirituality?a.Belief in and the worship of God or godsb.Attendance at a specific church or place of worshipc.Personal effort made to find purpose and meaning in lifed.Being closely tied to ones ethnic backgroundTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)18

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ANS: CSpirituality refers to each persons unique life experiences and his or her personal effort to find purpose andmeaning in life. The other responses apply to religion.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity11. A woman who has lived in the United States for a year after moving from Europe has learned to speakEnglish and is almost finished with her college studies. She now dresses like her peers and says that her familyin Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?a.Assimilationb.Heritage consistencyc.Biculturalismd.AcculturationANS: AAssimilation is the process by which a person develops a new cultural identity and becomes like members ofthe dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern ofidentification; acculturation is the process of adapting to and acquiring another culture.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity12. 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: BAsking questions about participation in the religious traditions of family enables the nurse to assess a personsheritage. Simply asking about ones religion, smoking history, or health history does not reflect heritage.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For someindividuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurserecognizes that this difference is true, probably because Mexican-Americans:Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)19

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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: BThe nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, inpart, from the way in which members of the cultural group define health.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity14. The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms suchas bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory ofillness?a.Holisticb.Biomedicalc.Naturalisticd.MagicoreligiousANS: BAmong the biomedical explanations for disease is the germ theory, which states that microscopic organismssuch 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 perspectiveholds that supernatural forces dominate and cause illness or health.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity15. An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurseexpects 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.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)20

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ANS: AYin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten witha cold illness. The other explanations do not reflect the yin/yang theory.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao.Which statement most accurately reflects health in an Asian with this belief?a.A person is able to work and produce.b.A person is happy, stable, and feels good.c.All aspects of the person are in perfect balance.d.A person is able to care for others and function socially.ANS: CMany Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the personare in perfect balance. The other statements do not describe this theory.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity17. Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. Thisstatement most accurately reflects the views about illness from which theory?a.Naturalisticb.Biomedicalc.Reductionistd.MagicoreligiousANS: AThe naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From theperspective of the Chinese, for example, illness is not considered an introducing agent; rather, illness isconsidered a part of lifes rhythmic course and an outward sign of disharmony within. The other options are notcorrect.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial IntegrityTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)21

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18. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that hisor her illness was caused by:a.Germs and viruses.b.Supernatural forces.c.Eating imbalanced foods.d.An imbalance within his or her spiritual nature.ANS: BThe basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernaturalforces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good orevil. The other answers do not reflect the magicoreligious perspective.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity19. If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then thenurse can expect that she:a.Will comply with the treatment prescribed.b.Has obviously given up her belief in naturalistic causes of disease.c.May also be seeking the assistance of a shaman or medicine man.d.Will need extra help in dealing with her illness and may be experiencing a crisis of faith.ANS: CWhen self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual orreligious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific healthcare provider, patients may also seek help from folk or religious healers.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity20. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. Aculturally sensitive nurse would:a.Contact the hospital administrator about the best course of action.b.Automatically get a curandero for her, because requesting one herself is not culturally appropriate.c.Further assess the patients cultural beliefs and offer the patient assistance in contacting a curanderoTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)22

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or priest if she desires.d.Ask the family what they would like to do because Mexican-Americans traditionally give controlof decision making to their families.ANS: CIn addition to seeking help from the biomedical or scientific health care provider, patients may also seek helpfrom folk or religious healers. Some people, such as those of Mexican-American or American-Indian origins,may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the divisionof the person into parts is a Western concept).DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity21. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness ofbreath, and palpitations. Which statement most accurately reflects the nurses best course of action?a.The nurse should focus on performing a full cardiac assessment.b.The nurse should focus on psychosomatic complaints because the patient has just learned that hiswife has cancer.c.This patient is not in any danger at present; therefore, the nurse should send him home withinstructions to contact his physician.d.It is unclear what is happening with this patient; consequently, the nurse should perform anassessment in both the physical and the psychosocial realms.ANS: DWide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived,diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states intobodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese cultureis the heart).DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity22. Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is atruestatement regarding pain?a.Nurses attitudes toward their patients pain are unrelated to their own experiences with pain.b.Nurses need to recognize that many cultures practice silent suffering as a response to pain.c.A nurses area of clinical practice will most likely determine his or her assessment of a patientspain.d.A nurses years of clinical experience and current position are strong indicators of his or herTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)23

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response to patient pain.ANS: BSilent suffering is a potential response to pain in many cultures. The nurses assessment of pain needs to beembedded in a cultural context. The other responses are not correct.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity23. The nurse is reviewing concepts of cultural aspects of pain. Which statement istrueregarding pain?a.All patients will behave the same way when in pain.b.Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain.c.Cultural norms have very little to do with pain tolerance, because pain tolerance is alwaysbiologically determined.d.A patients expression of pain is largely dependent on the amount of tissue injury associated withthe pain.ANS: BIn addition to expecting variations in pain perception and tolerance, the nurse should expect variations in theexpression of pain. It is well known that individuals turn to their social environment for validation andcomparison. The other statements are incorrect.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity24. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer iscorrect? Spirituality:a.Is a personal search to discover a supreme being.b.Is an organized system of beliefs concerning the cause, nature, and purpose of the universe.c.Is a belief that each person exists forever in some form, such as a belief in reincarnation or theafterlife.d.Arises out of each persons unique life experience and his or her personal effort to find purpose inlife.ANS: DSpirituality arises out of each persons unique life experience and his or her personal effort to find purpose andmeaning in life. The other definitions reflect the concept of religion.DIF: Cognitive Level: Understanding (Comprehension)Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)24

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MSC: Client Needs: Psychosocial Integrity25. The nurse recognizes that working with children with a different cultural perspective may be especiallydifficult because:a.Children have spiritual needs that are influenced by their stages of development.b.Children have spiritual needs that are direct reflections of what is occurring in their homes.c.Religious beliefs rarely affect the parents perceptions of the illness.d.Parents are often the decision makers, and they have no knowledge of their childrens spiritualneeds.ANS: AIllness during childhood may be an especially difficult clinical situation. Children, as well as adults, havespiritual needs that vary according to the childs developmental level and the religious climate that exists in thefamily. The other statements are not correct.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial Integrity26. A 30-year-old woman has recently moved to the United States with her husband. They are living with thewomans sister until they can get a home of their own. When company arrives to visit with the womans sister,the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explainsthat her reaction to guests is simply because she does not know how to speak perfect English. This womancould be experiencing:a.Culture shock.b.Cultural taboos.c.Cultural unfamiliarity.d.Culture disorientation.ANS: ACulture shockis a term used to describe the state of disorientation or inability to respond to the behavior of adifferent cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with theindividuals perceptions and expectations. The other terms are not correct.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity27. After a symptom is recognized, the first effort at treatment is often self-care. Which of the followingstatements about self-care istrue? Self-care is:a.Not recognized as valuable by most health care providers.Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)25

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b.Usually ineffective and may delay more effective treatment.c.Always less expensive than biomedical alternatives.d.Influenced by the accessibility of over-the-counter medicines.ANS: DAfter a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-countermedications, the relatively high literacy level of Americans, and the influence of the mass media incommunicating health-related information to the general population have contributed to the high percentage ofcases of self-treatment.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity28. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basictenets of this theory?a.The causation of illness is based on supernatural forces that influence the humors of the body.b.Herbs and medicines are classified on their physical characteristics of hot and cold and the humorsof the body.c.The four humors of the body consist of blood, yellow bile, spiritual connectedness, and socialaspects of the individual.d.The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restorethe balance of the humors of the body.ANS: DThe hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile,and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness,and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness torestore the balance of the humors. The other statements are not correct.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity29. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of thesepatient conditions is most consistent with a cold condition?a.Patient with diabetes and renal failureb.Teenager with an abscessed toothc.Child with symptoms of itching and a rashTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)26

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d.Older man with gastrointestinal discomfortANS: DIllnesses believed to be caused by cold entering the body include earache, chest cramps, gastrointestinaldiscomfort, rheumatism, and tuberculosis. Those illnesses believed to be caused by heat, or overheating,include sore throats, abscessed teeth, rashes, and kidney disorders.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity30. When providing culturally competent care, nurses must incorporate cultural assessments into their healthassessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs withan older American-Indian patient?a.Are you of the Christian faith?b.Do you want to see a medicine man?c.How often do you seek help from medical providers?d.What cultural or spiritual beliefs are important to you?ANS: DThe nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seekassistance from a medicine man or shaman, but the nurse should not assume this. An open-ended questionregarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity31. During a class on cultural practices, the nurse hears the termcultural taboo. Which statement illustrates theconcept of a cultural taboo?a.Believing that illness is a punishment of sinb.Trying prayer before seeking medical helpc.Refusing to accept blood products as part of treatmentd.Stating that a childs birth defect is the result of the parents sinsANS: CCultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, andconsuming caffeine. The other answers do not reflect cultural taboos.DIF: Cognitive Level: Applying (Application)Test Bank - Physical Examination and Health Assessment 8e (by Jarvis)27

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MSC: Client Needs: Psychosocial Integrity32. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of:a.Family.b.Cultures.c.Spirituality.d.Subcultures.ANS: DWithin cultures, groups of people share different beliefs, values, and attitudes. Differences occur because ofethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture,they are referred to assubcultural groups.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity33. The nurse is reviewing concepts related to ones heritage and beliefs. The belief in divine or superhumanpower(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as:a.Culture.b.Religion.c.Ethnicity.d.Spirituality.ANS: BReligion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe,especially belief in or the worship of God or gods. Spirituality is born out of each persons unique lifeexperiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a socialgroup within the social system that claims to possess variable traits, such as a common geographic origin,religion, race, and others.DIF: Cognitive Level: Remembering (Knowledge)MSC: Client Needs: Psychosocial Integrity34. When planning a cultural assessment, the nurse should include which component?a.Family historyb.Chief complaintTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)28

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c.Medical historyd.Health-related beliefsANS: DHealth-related beliefs and practices are one component of a cultural assessment. The other items reflect otheraspects of the patients history.DIF: Cognitive Level: Understanding (Comprehension)MSC: Client Needs: Psychosocial Integrity35. Which of the following reflects the traditional health and illness beliefs and practices of those of Africanheritage? Health is:a.Being rewarded for good behavior.b.The balance of the body and spirit.c.Maintained by wearing jade amulets.d.Being in harmony with nature.ANS: DThe belief that health is being in harmony with nature reflects the health beliefs of those of African heritages.The other examples represent Iberian and Central and South American heritages, American-Indian heritages,and Asian heritages.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial IntegrityMULTIPLE RESPONSE1. The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care?Select allthat apply.a.Examine the patient within the context of ones own cultural health and illness practices.b.Select questions that are not complex.c.Ask questions rapidly.d.Touch patients within the cultural boundaries of their heritage.e.Pace questions throughout the physical examination.ANS: B, D, ETest Bank - Physical Examination and Health Assessment 8e (by Jarvis)29

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Patients should be examined within the context of their own cultural health and illness practices. Questionsshould be simply stated and not rapidly asked.DIF: Cognitive Level: Analyzing (Analysis)MSC: Client Needs: Psychosocial Integrity2. The nurse is asking questions about a patients health beliefs. Which questions are appropriate?Select all thatapply.a.What is your definition of health?b.Does your family have a history of cancer?c.How do you describe illness?d.What did your mother do to keep you from getting sick?e.Have you ever had any surgeries?f.How do you keep yourself healthy?ANS: A, C, D, FThe questions listed are appropriate questions for an assessment of a patients health beliefs and practices. Thequestions regarding family history and surgeries are part of the patients physical history, not the patients healthbeliefs.DIF: Cognitive Level: Applying (Application)MSC: Client Needs: Psychosocial IntegrityTest Bank - Physical Examination and Health Assessment 8e (by Jarvis)30

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