Questions
1. 1.ID: 9477077870
A nurse performing a physical assessment of a client gathers both subjective and objective data.
Which finding would the
... [Show More] nurse document as subjective data?
A. The client appears anxious.
B. Blood pressure is 170/80 mm Hg.
C. The client states that he has a rash. Correct
D. The client has diminished reflexes in the legs.
Rationale: The purpose of a physical assessment is to collect both subjective and objective data.
Subjective data, collected during the health history, consist of information that the client gives about
himself or herself. Objective data are obtained through physical examination and vital signs
measurements, what the nurse observes, and laboratory study and diagnostic test results.
TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the
nurse would obtain during the physical examination. Review: the difference between subjective and
objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St.
Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical DecisionMaking/Clinical Judgment, EvidenceBased Practice/Evidence
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9477073956
A nurse is reviewing the findings of a physical examination that have been documented in a client's
record. Which piece of information does the nurse recognize as objective data?
A. The client is allergic to strawberries.B. The last menstrual period was 30 days ago.
C. The client takes acetaminophen (Tylenol) for headaches.
D. A 1 × 2inch scar is present on the lower right portion of the
abdomen. Correct
Rationale: Subjective data, collected during the health history, consist of information that the client
gives about himself or herself. Objective data are obtained through physical examination and vital
signs measurements, what the nurse observes, and laboratory study and diagnostic test results.
Allergies, the date of the client’s last menstrual period, and the reported use of medication for
headaches are all subjective data.
TestTaking Strategy: Eliminate the options that are comparable or alike and include data that the
nurse would obtain from the client during the health history. Review: the difference between
subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 2, 55). St.
Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical DecisionMaking/Clinical Judgment, EvidenceBased Practice/Evidence
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477071188
A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who
was recently discharged from the hospital. Which type of database does the nurse use to obtain
information from the client?
A. Episodic
B. Followup
C. Emergency
D. Complete Correct
Rationale: A complete database includes a complete health history and a full physical examination. It
describes the client’s current and past state of health and forms a baseline against which all future
changes can be measured. The complete database is collected in a primary care setting such as a
pediatric or family practice clinic, an independent or group private practice, a college health service,
a women’s healthcare agency, a visiting nurse agency, or a community health agency. An episodic
database is compiled for a limited or shortterm problem and is focused mainly on one problem or
one body system. A followup database is used to evaluate an identified problem at regular andappropriate intervals. An emergency database involves the rapid collection of the data that are often
compiled as lifesaving measures are being performed.
TestTaking Strategy: Noting the words “initial home visit” in the question will direct you to the correct
option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.8). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Technology and Informatics
HESI Concepts: EvidenceBased Practice/Evidence, Informatics/Technology
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477071128
A nurse is examining a 25yearold client who was seen in the clinic 2 weeks ago for symptoms of a
cold and is now complaining of chest congestion and cough. The nurse should proceed with the
examination by collecting which?
A. Data related to followup care
B. A complete (total health) database
C. Data related to the respiratory system Correct
D. Data related to the treatment for the cold
Rationale: An episodic database is compiled for a limited or shortterm problem and is focused
mainly on one problem or body system. The history and examination will be focused primarily on the
respiratory system in this client. A complete database includes a complete health history and a full
physical examination. It describes the client’s current and past state of health and forms a baseline
against which all future changes can be measured. A followup database is used to evaluate an
identified problem at regular and appropriate intervals.
TestTaking Strategy: Focusing on the data in the question and noting the words “now complaining
of chest congestion and cough” will direct you to the correct option. Review: the different types of
databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Gas Exchange
HESI Concepts: EvidenceBased Practice/Evidence, Oxygenation/Gas Exchange
Awarded 1.0 points out of 1.0 possible points.5. 5.ID: 9477071111
A client is brought to the emergency department after a motor vehicle accident. The client is alert
and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with
data collection?
A. Collect health history information first, then perform the physical
examination
B. Ask health history questions while performing the examination and
initiating emergency measures Correct
C. Collect all information requested on the history form, including social
support, strengths, and coping patterns
D. Perform emergency measures and not ask any health history questions
until the client's fractures have been treated in the operating room
Rationale: If the client is alert and cooperative and if the situation is not lifethreatening, the nurse
should attempt to obtain as much subjective and objective data as possible while caring for the
client. Collecting health history information and then performing the physical examination does not
address the priority, which is treating the client. Collecting all data requested on the history does not
specifically address the client’s immediate problems. Performing emergency measures and not
asking any health history questions does not address data collection before treatment.
TestTaking Strategy: Focus on the data in the question and note the words “alert and cooperative.”
Noting that the client has not sustained lifethreatening injuries will direct you to the correct option.
Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Health Care Quality
HESI Concepts: EvidenceBased Practice/Evidence, Health Policy/Systems—Health Care Quality
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 9477073919
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup.
Which type of database does the nurse use in performing an assessment?
A. Emergency
B. Followup Correct
C. Complete (total)D. Problemcentered
Rationale: A followup database is compiled to evaluate the status of an identified problem at regular
and appropriate intervals. An emergency database calls for rapid collection of the data, often at the
same time lifesaving measures are being performed. A complete database includes a complete
health history and a full physical examination. It describes the client’s current and past state of
health and forms a baseline against which all future changes can be measured. An episodic
database (problemcentered) is compiled for a limited or shortterm problem. It is focused mainly on
one problem or body system.
TestTaking Strategy: Focus on the subject, a checkup 3 months after a diagnosis. Noting the words
“at the clinic for a checkup” in the question will direct you to the correct option. Review: the different
types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 8). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Technology and Informatics
HESI Concepts: EvidenceBased Practice/Evidence, Informatics/Technology
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 9477073943
A MexicanAmerican client with epilepsy is being seen at the clinic for an initial examination. What is
the primary purpose of including cultural information in the health assessment?
A. Confirm the medical diagnosis
B. Make accurate nursing diagnoses
C. Identify any hereditary traits related to the epilepsy
D. Determine what the client believes has caused the epilepsy Correct
Rationale: The primary purpose for including cultural information in the health assessment is to
determine what the client believes has caused the illness. In MexicanAmerican culture, epilepsy is
seen as a reflection of physical imbalance. Although the nurse may obtain data related to family
history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including
cultural information in the health assessment. A nurse gathers assessment data but does not
confirm a medical diagnosis.
TestTaking Strategy: Eliminate the option that indicates to confirm a medical diagnosis, because
this is not the role of the nurse. To select from the remaining options, recall that cultural beliefs exist
in relation to the cause of a disease; this will direct you to the correct option. Review: the nurse’s role
in data collection and cultural considerations .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 52). St. Louis:Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Cultural Awareness
Priority Concepts: Culture, Evidence
HESI Concepts: Cultural/Spiritual, EvidenceBased Practice/Evidence
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 9477071171
A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both
arms and notes that the skin is warm. What does the nurse determine?
A. The client has a fever
B. The skin temperature is normal Correct
C. The client needs to drink additional fluids
D. The client needs to have the blanket removed
Rationale: To assess skin temperature, the nurse would first note the temperature of his or her own
hands, then use the backs (dorsa) of the hands to palpate the client’s skin bilaterally. The skin
should be warm, and the temperature should be equal bilaterally; warmth suggests normal
circulatory status. The hands and feet may feel slightly cooler in a cool environment. Giving the client
additional fluids, removing the blanket, and checking for a fever are all incorrect responses to this
finding.
TestTaking Strategy: Focus on the data in the question. Note the word “warm.” Recalling that
warmth suggests normal circulatory status will direct you to the correct option. Review: normal skin
temperature .
References: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered
collaborative care (6th ed., p. 467). St. Louis: Saunders.
Jarvis, C. (2008). Physical examination and health assessment (5th ed., p. 232). St. Louis:
Saunders.
Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Integumentary
Priority Concepts: Evidence, Thermoregulation
HESI Concepts: EvidenceBased Practice/Evidence, Intracranial Regulation—Thermoregulation
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 9477071124
A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse
document this finding?A. Xerosis Correct
B. Pruritus
C. Seborrhea
D. Actinic keratoses
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum
and is often marked by a pattern of fine lines, scaling, and itching. Causes include toofrequent
bathing, low humidity, and decreased production of sebum in aging skin. Pruritus is the symptom of
itching, an uncomfortable sensation that prompts the urge to scratch the skin. Seborrhea is one of
several common skin conditions in which an overproduction of sebum results in excessive oiliness or
dry scales. Actinic keratoses are redtan scaly plaques that grow over the years, becoming raised
and roughened. A silverywhite scale may adhere to the plaque. They occur on sunexposed
surfaces and are directly related to sun exposure. Actinic keratoses are premalignant and may
develop into squamous cell carcinoma.
TestTaking Strategy: Knowledge of the characteristics of various skin conditions and lesions is
needed to answer this question. This knowledge and noting the words “very dry” in the question will
direct you to the correct option. Review: the conditions identified in the options .
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical nursing: Patientcentered
collaborative care (6th ed., pp. 465, 480). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Adult Health/Integumentary
Priority Concepts: Evidence, Tissue Integrity
HESI Concepts: EvidenceBased Practice/Evidence, Tissue Integrity
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 9477073962
A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should
the nurse perform to prepare for this diagnostic test?
A. Darken the room Correct
B. Obtain informed consent from the client
C. Obtain a scalpel and a slide for diagnostic evaluation
D. Obtain medication to anesthetize the skin area before proceeding with
the examination
Rationale: A handheld longwa [Show Less]