Essential Health Assessment 1st Edition Thompson Test Bank Chapter 1: Understanding Health Assessment
1. The World Health Organization (WHO) established
... [Show More] a global strategy called “Health for All.” The goal for this strategy is: 1. All individuals to get the same health care throughout their life spans. 2. The government to supply money to care for all the people in the world. 3. Resources for health care to be evenly distributed and accessible. 4. Health-care providers can never deny patients health care.
2. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to: 1. Diagnose and treat patients. 2. Identify normal and abnormal findings. 3. Refer patients with abnormal findings. 4. Counsel patients with psychosocial needs.
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police presence outside his door because the patient is a known drug dealer in the community. You know that nurses must treat all patients as persons. This is called: 1. Caring. 2. Holistic process. 3. Person-centered care (PCC). 4. Standards of care.
4. The science-based framework updated every 10 years by the U.S. Department of Health and Human Services that has set national goals and objectives for health promotion and disease prevention is: 1. Healthy People. 2. Healthy People 2020. 3. U.S. Preventive Task Force. 4. World Health Organization.
5. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age 48. The doctor recommended that this patient have a colonoscopy this year. This is an example of:
1. Primary health prevention. 2. Secondary health prevention. 3. Tertiary health prevention.
1 | P a g e6. A patient in the hospital puts on his call light and tells the person answering that he “thinks he
is running a fever and has stomach discomfort.” You are the registered nurse in charge. What
should you do?
1. Ask the medical assistant to go to the patient’s room and assess his complaints.
2. Go check to see if the patient has an order for Tylenol for a fever.
3. Page the resident on call immediately to assess the patient.
4. Go to the patient’s room and assess for fever and the epigastric discomfort.
7. You are leading an interdisciplinary team conference to discuss how to provide better care for a
challenging patient who has behavioral problems. There are several areas that need to be problem
solved and new ideas formulated to create an improved plan of care. What cognitive skills are you
using?
1. Critical thinking
2. Clinical decision making
3. Intuitive thinking
4. Clinical reasoning
8. Best practice assessment techniques and instruments have been validated by:
1. American Nurses Association.
2. Code ofEthics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and Affordable Care Act.
9. Health and illness are determined by many factors. What are the determinants of health
identified by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
1. Genetics and biology
2. Gender and occupation
3. Individual behavior
4. Social environment
5. Physical environment
6. Health services
10. The U.S. health-care system is evolving, and care is becoming more focused on which of the
following? Select all that apply.
1. Wellness2. Functional status
3. Disease prevention
4. Health promotion
5. Acute illness management
11. You are performing a health assessment on a 32-year-old female patient who reports “feeling
fatigued all the time.” She states, “I have not had a physical in over 8 years because I did not have
medical insurance.” The patient will be having a physical today. What will be part of the health
assessment? Select all that apply.
1. Collecting data on past health
2. Collecting data on present health
3. Collecting data on significant other’s health
4. Assessing factors influencing health
5. Performing a physical examination
12. You are working with a patient as a copartner in care. The patient has multiple medical
problems. Put the following steps of the nursing process in the correct order (1 –5). (Enter the
number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.)
1. Planning
2. Evaluation
3. Assessment
4. Implementation
5. Diagnosis
13. You are working on a medical surgical unit and are caring for a 24-year-old patient who is 3
hours post-op. The patient seems confused and restless since you assessed her an hour ago. You
have a gut feeling that something is very wrong. This is an example of
thinking.
14. The four techniques of health assessment include inspection, palpation, percussion, and
.
Answers
1. The World Health Organization (WHO) established a global strategy called “Health for All.” The
goal for this strategy is:
1. All individuals to get the same health care throughout their life spans.
2. The government to supply money to care for all the people in the world.
3. Resources for health care to be evenly distributed and accessible.
4. Health-care providers can never deny patients health care.
ANS: 3
3 | P a g ePage: 1
Feedback
1. This is incorrect. “Health for All” does not mean that all individuals get the same
health care throughout their life spans.
2. This is incorrect. “Health for All” does not mean the government will supply money
to care for all the people in the world.
3. This is correct. “Health for All” means that resources for health care are evenly
distributed and accessible to everyone.
4. This is incorrect. “Health for All” does not mean that health-care providers can deny
patients health care.
2. Health assessment is a foundational and priority nursing skill. This essential skill requires
registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normal and abnormal findings.
3. Refer patients with abnormal findings.
4. Counsel patients with psychosocial needs.
ANS: 2
Page: 5-6
Feedback
1. This is incorrect. The role of the RN is not to diagnose and treat patients.
2. This is correct. Assessing patients and being able to identify normal from abnormal
findings is an essential role of the RN.
3. This is incorrect. RNs in collaboration with the health-care providers do refer patients.
This is not the essential and foundational role in health assessment.
4. This is incorrect. RNs do counsel patients, but it is not the essential and foundational
role in health assessment.
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police
presence outside his door because the patient is a known drug dealer in the community. You
know that nurses must treat all patients as persons. This is called:
1. Caring.
2. Holistic process.
3. Person-centered care (PCC).
4. Standards of care.
ANS: 3
Page: 2
Feedback
1. This is incorrect. Caring is displaying a concern for patients.
2. This is incorrect. The holistic caring process is a relational process; the nurse
collaborates with the individual to pursue goals for health and well-being.
3. This is correct. The new movement in health care is person-centered care (PCC),
which emphasizes the intrinsic value of treating all patients as persons.4. This is incorrect. Standards of care identify standards of professional nursing practice.
4. The science-based framework updated every 10 years by the U.S. Department of Health and
Human Services that has set nationalgoals andobjectivesfor health promotion and disease
prevention is:
1. Healthy People.
2. Healthy People 2020.
3. U.S. Preventive Task Force.
4. World Health Organization.
ANS: 2
Page: 2
Feedback
1. This is incorrect. Healthy People is the general title for the nation’s federal initiative.
2. This is correct. Healthy People 2020 specifically identifies science-based, national goals
and objectives with 10-year targets designed to guide national health promotion and
disease prevention efforts to improve the health of all people in the United States.
3. This is incorrect. The U.S. Preventive Services Task Force’s goal is to use evidence-
based medicine to improve the health of all Americans by making evidence-based
recommendations about clinical preventive services such as screenings, counseling
services, and preventive medications.
4. This is incorrect. The World Health Organization is a specialized agency of the United
Nations working to improve the health of the world’s people.
5. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age
48. The doctor recommended that this patient have a colonoscopy this year. This is an example
of:
1. Primary health prevention.
2. Secondary health prevention.
3. Tertiary health prevention.
ANS: 2
Page: 4
Feedback
1. This is incorrect. This is not an example of primary prevention. Primary prevention is
the prevention of disease and disability and focuses on improving an individual’s
overall health and well-being. Immunizations and health education are examples of
primary prevention.
2. This is correct. Colonoscopy is an example of secondary prevention, which
encompasses early screenings and detection of disease and treatment of diseases.
5 | P a g e3. This is incorrect. This is not an example of tertiary prevention. Tertiary prevention
encompasses the restoration of health after illness or disease has occurred. A
rehabilitation program for stroke patients is an example of tertiary prevention.
6. A patient in the hospital puts on his call light and tells the person answering that he “thinks he
is running a fever and has stomach discomfort.” You are the registered nurse in charge. What
should you do?
1. Ask the medical assistant to go to the patient’s room and assess his complaints.
2. Go check to see if the patient has an order for Tylenol for a fever.
3. Page the resident on call immediately to assess the patient.
4. Go to the patient’s room and assess for fever and the epigastric discomfort.
ANS: 4
Page: 5
Feedback
1. This is incorrect. The medical assistant role should never be to assess a patient.
2. This is incorrect. The first priority would be to assess the patient prior to checking
medication orders for fever.
3. This is incorrect. The nurse should first assess the patient to give an objective report
to the resident.
4. This is correct. Assessing a patient is always a priority role of the RN. This is a role
that should never be delegated to the licensed practical nurse or unlicensed assistive
personnel.
7. You are leading an interdisciplinary team conference to discuss how to provide better care for a
challenging patient who has behavioral problems. There are several areas that need to be problem
solved and new ideas formulated to create an improved plan of care. What cognitive skills are you
using?
1. Critical thinking
2. Clinical decision making
3. Intuitive thinking
4. Clinical reasoning
ANS: 1
Page: 5
Feedback
1. This is correct. Critical thinking is a unique problem-solving, reflective process.
2. This is incorrect. Clinical decision making determines what is needed and when it is
needed.3. This is incorrect. Intuitive thinking is a “gut feeling” that something is wrong or that
the nurse should do something, even if there is no real evidence to support that
feeling.
4. This is incorrect. Clinical reasoning uses an individual’s history, physical signs,
symptoms, laboratory data, and diagnostic imaging to arrive at a diagnosis and
formulate a treatment plan.
8. Best practice assessment techniques and instruments have been validated by:
1. American Nurses Association.
2. Code ofEthics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and Affordable Care Act.
ANS: 3
Page: 7
Feedback
1. This is incorrect. The American Nurses Association is the professional nursing
organization providing standards of nursing care, promoting a safe and ethical work
environment, and advocating health-care issues.
2. This is incorrect. The Code ofEthics for Nurses With Interpretive Statements provides a
statement of the ethical values and duties of every individual who enters the nursing
profession.
3. This is correct. Best practice assessments and instruments have been validated by
research. Nursing research and evidence-based practice guide our assessments and
clinical decisions to provide safe and effective care.
4. This is incorrect. The Patient Protection and Affordable Care Act, known as
Obamacare, has goals to provide higher-quality, safer, and more affordable and
accessible care.
9. Health and illness are determined by many factors. What are the determinants of health
identified by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
1. Genetics and biology
2. Gender and occupation
3. Individual behavior
4. Social environment
5. Physical environment
6. Health services
ANS: 1, 3, 4, 5, 6
Page: 2
Feedback
7 | P a g e1. This is correct. The CDC identifies genetics and biology (i.e., age and sex) as a
determinant of health.
2. This is incorrect. Occupation is not identified as a determinant of health.
3. This is correct. The CDC identifies individual behavior (i.e., alcohol use, unprotected
sex, smoking) as a determinant of health.
4. This is correct. The CDC identifies social environment (i.e., income and lifestyle) as a
determinant of health.
5. This is correct. The CDC identifies physical environment (i.e., where the individual
lives) as a determinant of health.
6. This is correct. The CDC identifies health services (i.e., insurance and access to health
care) as a determinant of health.
10. The U.S. health-care system is evolving, and care is becoming more focused on which of the
following? Select all that apply.
1. Wellness
2. Functional status
3. Disease prevention
4. Health promotion
5. Acute illness management
ANS: 1, 3, 4
Page: 1
Feedback
1. This is correct. The U.S. health-care system is evolving, and care is becoming more
focused on wellness.
2. This is incorrect. The U.S. health-care system is not becoming more focused on the
individual’s functional status.
3. This is correct. The U.S. health-care system is evolving, and care is becoming more
focused on disease prevention.
4. This is correct. The U.S. health-care system is evolving, and care is becoming more
focused on health promotion.
5. This is incorrect. The U.S. health-care system is becoming more focused on chronic
illness management, not acute illness management.
11. You are performing a health assessment on a 32-year-old female patient who reports “feeling
fatigued all the time.” She states, “I have not had a physical in over 8 years because I did not have
medical insurance.” The patient will be having a physical today. What will be part of the health
assessment? Select all that apply.
1. Collecting data on past health
2. Collecting data on present health
3. Collecting data on significant other’s health
4. Assessing factors influencing health5. Performing a physical examination
Page: 4
ANS: 1, 2, 4, 5,
Feedback
1. This is correct. Data on past health will be collected and reviewed.
2. This is correct. Data on present health will be collected and reviewed.
3. This is incorrect. Data on a significant other’s health will not be included; however,
discussing who the patient lives with may be discussed as part of the psychosocial
history.
4. This is correct. Factors influencing health and health promotion topics will be
reviewed.
5. This is correct. A physical examination will be done on this patient.
12. You are working with a patient as a copartner in care. The patient has multiple medical
problems. Put the following steps of the nursing process in the correct order (1–5). (Enter the
number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.)
1. Planning
2. Evaluation
3. Assessment
4. Implementation
5. Diagnosis
ANS: 35142
Page: 5
Feedback: The five steps of the nursing process are as follows: Assessment is the first, essential
step requiring the nurse to collect and analyze information about the whole individual. Diagnosis
involves analyzing a patient’s potential or actual health problem. Planning/Outcomes involves
working with the individual as a copartner in care to meet the needs or short- and long-term
goals of the individual. Implementation of interventions includes the nursing and individual
actions and plan of care to meet the individual’s goals. Evaluation is the ongoing process that
assesses whether the short- and long-term goals have been met.
13. You are working on a medical surgical unit and are caring for a 24-year-old patient who is 3
hours post-op. The patient seems confused and restless since you assessed her an hour ago.
You have a gut feeling that something is very wrong. This is an example of thinking.
ANS: intuitive
Page: 6
Feedback: Intuitive thinking is a “gut feeling” that something is wrong or that the nurse should do
something, even if there is no real evidence to support that feeling.
9 | P a g e14. The four techniques of health assessment include inspection, palpation, percussion, and
.
ANS: auscultation
Page: 6
Feedback: Assessment is a “doing” process. The four techniques of physical assessment are
inspection (looking), palpation (using your hands to feel surface characteristics), percussion
(tapping different areas of the body to assess underlying structures), and auscultation (listening
for sounds).
Chapter 2: Interviewing the Patient for the Health History
1. The nursing instructor is teaching a group of students the components of the health history
interview. Which principles of behavior should the student remember when conducting a
health assessment history? Select all that apply.
1. Remain sensitive.
2. Be nonjudgmental.
3. Give the appearance only of being genuine.
4. Demonstrate professional behaviors.
5. Show indifference.
2. In order to conduct effective assessments and health histories, the nurse must use a patient-
centered approach using therapeutic communication. Which dimensions of patient-centered care
should the nurse include? Select all that apply.
1. Empathy and compassion
2. Conditional regard
3. Genuineness
4. Respect
5. Caring
3. A patient comes to the clinic for an annual examination. To prepare for the health history
interview the nurse knows to include all of the following components EXCEPT (Select all that
apply):
1. Reading the patient record as the health history is being conducted
2. Leaving the patient dressed until it is time to perform the physical assessment
3. Conducting the interview in a private place away from noise 4. Allowing a short, limited amount
of time to conduct the interview
5. Standing at all times when talking to the patient.4. The nurse is preparing to conduct a complete health history on a new patient who has just
arrived at the walk-in clinic. The nurse is going to use the CLEAR mnemonic to collect
information. What does CLEAR stand for? Select all that apply.
1. Center
2. Communicate
3. Listen
4. Empathy
5. Empower
6. Attention
7. Advocate
8. Respect
5. You are taking a health history on a patient who has not seen a health-care provider in many
years. He states, “I do not want to be here, but my wife is forcing me to see this doctor. All
doctors want to do is put patients on drugs!” You know that communication skills will be very
important during this patient encounter. What is the purpose of communication? Select all that
apply.
1. Share information.
2. Share and exchange thoughts and feelings.
3. Send data only.
4. Confirm patient complaints.
5. Make a diagnosis.
6. Communication is both verbal and nonverbal. The following are nonverbal visual cues to be
aware of during an interview. Select all that apply.
1. Slouching in the chair
2. Frowning
3. No eye contact
4. Gestures 6. Tone of voice
5. Age-appropriate appearance
7. Crying and moaning
7. A patient and her husband arrive at the community health center for a follow-up assessment.
The patient has recently had a stroke and is aphasiac. She understands what you are saying but
is unable to talk. Which of the following nursing interventions should be followed? Select all that
apply.
1. Ask the husband the best way to communicate with his wife.
2. Find a large blackboard to write your questions on.
3. Offer the patient a white board or paper and pen.
4. Speak slowly and loudly so the patient understands.
5. Communicate one question or sentence at a time.
11 | P a g e8. Communication is a reciprocal conversation. Identify barriers to communication. Select all that
apply.
1. Asking too many questions
2. Leading the patient
3. Silence
4. Offering false reassurance
5. Stereotyping
6. Summarizing
9. As the nurse prepares for a patient interview he or she recalls that effective communication
includes which of the following? Select all that apply.
1. Avoid medical jargon.
2. Be authoritative.
3. Keep questions simple and clear.
4. Stand over the patient.
5. Avoid excessive note taking.
10. The mnemonic CLEAR is foundational for successful interviewing. The student nurse
recognizes that this stands for which of the following terms?
1. Center, Listen, Empathy, Attention, and Respect
2. Calm, Listen, Empathy, Attention, and Respect
3. Center, Listen, Eye Contact, Attention, and Respect
4. Calm, Listen, Eye Contact, Attention, and Respect
11. The nurse is conducting a health history interview and suspects that the patient may have a
hearing deficit. Which consideration is most appropriate for the nurse to make?
1. Write down all questions for the patient.
2. Reduce any background noise in the room.
3. Speak quickly and use short, simple sentences.
4. Complete the health history as quickly as possible to reduce stress.
12. The patient has disclosed a visual impairment to the nurse. Which is the priority action for the
nurse to remember before starting the physical assessment?
1. Speak clearly and loudly at all times during the assessment.
2. Acknowledge the patient by putting a hand on his or her shoulder.
3. Give short directions throughout the assessment.
4. Ask the patient how much he or she can see.
13. A patient’s culture can influence the interview process. The nursing student recognizes that
which of the following is true about how culture can influence the interview process?1. A patient may have different definitions and perceptions of health and illness.
2. A patient cannot refuse to discuss personal matters out of concern for privacy.
3. A patient may project his or her own cultural beliefs on the nurse.
4. A patient may try to portray the cultural beliefs of the nurse.
14. When conducting the interview, the nurse needs to determine the reliability of the data
collected. Which primary source would be considered the most reliable for the health history
information?
1. The patient who is alert and oriented to person, place, and time
2. The significant other who is answering all the questions
3. The patient’s medical record from the primary care provider
4. An interpreter who speaks the patient’s native language
15. The nurse is preparing to conduct a health history on a patient and organizes the interview in
a head-to-toe sequence. Which type of health history is the nurse going to conduct?
1. Comprehensive
2. Focused
3. Problem-based
4. Follow-up
16. The nurse is preparing to conduct a health history on a patient seen in the health clinic 2 days
ago. Which type of health history is the nurse going to conduct?
1. Comprehensive
2. Focused
3. Problem-based
4. Follow-up
17. The nurse is preparing to conduct a health history on a patient being seen in the emergency
room. Which type of health history is the nurse going to conduct?
1. Comprehensive
2. Focused
3. Basic
4. Follow-up
18. While conducting a health history during admission to the medical floor, the nurse asks the
patient “Have you ever had surgery?” This question is an example of which type of
communication technique?
1. Open-ended question
2. Closed question
3. Indirect question
4. Clarification question
13 | P a g e19. The nursing student is learning how to use various therapeutic communication techniques.
The student recognizes which of these as an example of confrontation?
1. “You look angry.”
2. “This must be very hard for you.”
3. “Do you feel worried about your dog?”
4. “How can I help you?”
20. You are completing a health history on a 32-year-old woman who is reporting that “she may
have a problem using heroin and other drugs.” You are being attentive to the patient’s report
and nonverbal cues. The patient is looking down as she is telling her story. What
communication technique is the nurse demonstrating?
1. Silence
2. Respect
3. Active listening
4. Exploring
21. A home health nurse is assessing a 94-year-old patient with a severe cognitive impairment.
The daughter with whom the patient lives states that her mom only eats less than half of all
her meals. What will you document?
1. Patient is reliable. Cared for by her daughter. Eating half of her meals.
2. Report by daughter. Eating 50% of her meals. Patient lives with her daughter.
3. Patient is unreliable. Report by daughter. Patient is only eating less than 50% of each meal.
4. Patient is unreliable. Eating about 50% of each meal.
22. A nurse in the emergency department is completing an emergency assessment for a teenager
just admitted for injuries from a motor vehicle accident. Which of the following
documentations is a pertinent negative report?
1. “My leg hurts so bad. I can’t stand it.”
2. Denies headache and blurry vision.
3. Reports feeling nauseous and dizzy.
4. “It wasn’t my fault. I couldn’t stop.”
23. Which question or statement would be the best approach to elicit further information when
conducting a health history interview?
1. “Why didn’t you go to the doctor when you began to have this pain?”
2. “Are you feeling better now than you did during the night?”
3 “Tell me more about what you think is causing your pain.”
4. “You should not wait to get medical help next time.”24. A resident at an assisted living facility comes to the nurse’s office and states, “My bowel
movements have been fluctuating for the last 2 weeks.” How should the nurse respond?
1. “What do you mean by fluctuating?”
2. “Why don’t you use a laxative every night?”
3. “When was the last time that you moved your bowels?”
4. “Everyone experiences bowel problems as they age.”
25. During the summarization phase of the interview it is important to
1. Encourage the patient to tell his orherhistory ofpresent illness.
2. Complete documenting the data as told by the patient.
3. Clarify the patient’s report, needs, feelings, and concerns.
4. Ask the patient if he or she has any questions.
26. The nurse has completed a health history. Both objective and subjective information have
been obtained during the assessment. Which is classified as subjective data? 1. Patient appears
sleepy
2. No distress noted
3. Abdomen is soft and nontender
4. Patient states she feels anxious and tense
27. You are assessing a patient who does not seem to understand your questions and
explanations. What should be your next action?
1. Continue on with the assessment.
2. Speak slowly and loudly so the patient can hear you.
3. Ask the patient if he or she understands what you are saying.
4. Omit the explanations and continue with the assessment.
28. A patient is having his annual physical examination. You are doing a health history related to
male breasts. You ask the patient if he has ever palpated his breasts. He responds, “I cannot
believe that you asked me that question. I am not a woman and cannot get breast cancer.” The
nurse responds, “You sound surprised. You don’t think that men can get breast cancer?” What
type of communication technique is the nurse using?
1. Focusing
2. Facilitation
3. Reflecting
4. Exploring
29. Your patient reports that he thinks that he may have a problem with drinking too much beer.
The nurse states, “So, do you drink about two beers every day?” What type of communication
technique is this question?
1. Leading the patient
15 | P a g e2. Transitional statement 3. Clarification 4. Exploring
30. You are about to start the health history. The patient is present with his daughter. Which of the following priority steps should you take before you start the health history? 1. Organize your thoughts prior to the assessment. 2. Wash your hands in front of the patient. 3. Obtain permission from the patient for the daughter to be present. 4. Assess your professional appearance and demeanor.
31. The patient just had abdominal surgery and reports that she is feeling bloated and crampy. The nurse inspects her abdomen and finds it to be bloated. The nurse tells the patient, “You will feel better tomorrow.” This is an example of which communication technique?
1. Respect 2. Using cliche s 3. Giving opinions 4. Using patronizing language
32. The visiting nurse is going to start an interview at a patient’s home. The patient is watching television. The patient is hard of hearing and reports that her left ear is her good ear. Which nursing intervention should take highest priority?
1. Speak in simple, focused sentences. 2. Ask to have the television volume turned down. 3. Be descriptive when giving directions. 4. Use drawings and a white board to ask questions.
33. You are about to start an interview with the husband and wife present. The husband tells the nurse that his wife may not tell her everything that she needs to know. He states that in his wife’s culture, feelings are considered private and difficult to share. Sharing one’s feelings with others often creates a sense of vulnerability or is looked on as evidence of weakness. What culture is his wife?
1. Chinese heritage 2. German heritage 3. American Eskimo 4. Italian heritage
34. Which consideration should the nurse recognize as priority when interviewing the patient? 1. Gender [Show Less]