Health Assessment In Nursing 6th By Janet R. Weber – Test Bank

Complete Test Bank With Answers

Sample Questions Posted Below

1. 1. A client has presented to the clinic for the treatment of an ovarian cyst. Which of the following would be most important for the nurse to do immediately before performing this woman’s physical exam?
   1. A) Explain the purpose of the interview to the client.
   2. B) Construct the client’s family genogram.
   3. C) Establish the client’s reliability as historian.
   4. D) Collect necessary equipment essential to the exam.

1. 1. 2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client’s anxiety during the physical exam. Which of the following would be most appropriate?
   2. A) Ensuring client’s privacy by providing an examination gown
   3. B) Providing a comfortable, warm room temperature
   4. C) Arranging exam equipment on a bedside tray table
   5. D) Explaining why standard precautions are being used

1. 1. 3. A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which of the following actions?
   2. A) Performing hand hygiene between examinations of each body part
   3. B) Discarding in the trash can the safety pin that was used to assess sensory perception
   4. C) Wearing gloves to palpate the tongue and buccal membranes
   5. D) Wearing a gown, gloves, and mask during the physical exam

1. 1. 4. The nurse is using a Wood’s light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client’s symptoms?
   2. A) Parasitic infection
   3. B) Fungal infection
   4. C) Bacterial infection
   5. D) Allergic reaction

1. 1. 5. A nurse has gathered the necessary equipment for the physical assessment of an adult client. For which of the following assessments would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement?
   2. A) Mid-arm circumference
   3. B) Client’s height
   4. C) Skin lesion size
   5. D) Pupillary size
   6. 6. The nurse is preparing to assess an older adult client’s near vision. Which of the following pieces of equipment would be most appropriate for the nurse to use?
   7. A) Newspaper
   8. B) Snellen chart
   9. C) Ophthalmoscope
   10. D) Penlight

1. 1. 7. A nurse practitioner is performing a comprehensive physical examination of a 51-year- old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?
   2. A) Parasites
   3. B) Blood
   4. C) Bacteria
   5. D) Fungus

1. 1. 8. The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing?
   2. A) Extremity edema
   3. B) Joint flexion/extension
   4. C) Two-point discrimination
   5. D) Vibratory sensation

1. 1. 9. A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says ìAbsolutely not! There’s no way I’ll let you do that to me!î Which response by the nurse would be most appropriate?
   2. A) Explain the importance of the pelvic exam and Pap smear, but respect the client’s wishes and omit the exam.
   3. B) Tell the client that this is the only way she can be checked for cancer.
   4. C) Ask the client if she would prefer another practitioner to perform the exam.
   5. D) Proceed with the pelvic exam and document the client’s protests in the health record.

1. 1. 10. The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?
   2. A) Head and neck examination
   3. B) Palpation of lymph nodes
   4. C) Breast examination
   5. D) Vital signs
   6. 11. The nurse is to collect a throat culture from a client who has signs and symptoms of a respiratory infection, including frequent, productive coughing. The nurse demonstrates the best adherence to standard precautions by using which of the following pieces of equipment?
   7. A) Eye goggles
   8. B) Face mask
   9. C) Cover gown
   10. D) Face shield

1. 1. 12. The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which of the following actions would be most appropriate?
   2. A) Omit intrusive parts of the exam.
   3. B) Try to minimize position changes.
   4. C) Allow client to remain dressed.
   5. D) Dim the room light to ensure privacy.

1. 1. 13. The nurse is preparing to assess the peripheral pulses of a client. The nurse should place the client in which position?
   2. A) Sitting upright
   3. B) Supine
   4. C) Sims position
   5. D) Prone

1. 1. 14. When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate assessment data?
   2. A) Finger pad surface
   3. B) Palmar hand surface
   4. C) Dorsal hand surface
   5. D) Ulnar hand surface

1. 1. 15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse recognizes the need to perform deep palpation during the physical assessment. The nurse should perform which of the following actions?
   2. A) Use one hand and depress the skin 1 centimeter.
   3. B) Use the dominant hand to depress the skin one-half to three-quarters of an inch.
   4. C) Use both hands to depress the skin one-half of an inch.
   5. D) Use both hands to depress the skin 1 to 2 inches.
   6. 16. The emergency department (ED) nurse is assessing for kidney tenderness in a client who has presented with complaints of dysuria and back pain. What assessment technique should the nurse utilize?
   7. A) Deep palpation
   8. B) Indirect percussion
   9. C) Moderate palpation
   10. D) Blunt percussion

1. 1. 17. In the course of performing a client’s physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?
   2. A) Heart sounds
   3. B) Bowel sounds
   4. C) Breath sounds
   5. D) Femoral pulses

1. 1. 18. An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following?
   2. A) ìPlastic tubing should be longer than 3 feet.î
   3. B) ìThe bell is used after using the diaphragm.î
   4. C) ìWhen using the bell, push on it lightly.î
   5. D) ìA diaphragm picks up low-pitched sounds.î

1. 1. 19. A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which of the following statements should guide the nurse’s use of a stethoscope during this phase of assessment?
   2. A) Auscultation can be performed through clothing.
   3. B) The diaphragm should be held firmly against the body part.
   4. C) The bell of the stethoscope can best detect bowel sounds.
   5. D) Use of the bell is reserved for advanced practice nurses.

1. 1. 20. A nurse is appraising a colleague’s assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which of the following actions?
   2. A) Depressing the skin 1 to 2 centimeters with the dominant hand
   3. B) Feeling the surface structures using a circular motion
   4. C) Placing the nondominant hand on top of the dominant hand
   5. D) Using one hand to apply pressure and the other hand to feel the structure
   6. 21. The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination?
   7. A) Complete the examination as quickly as possible.
   8. B) Speak clearly and slowly when explaining a procedure.
   9. C) Begin the examination with auscultation instead of inspection.
   10. D) Maintain the supine position for each part of the examination.

1. 1. 22. The nurse assists a client into the dorsal recumbent position. Assessment of which area is contraindicated when the client is in this position?
   2. A) Chest
   3. B) Head
   4. C) Peripheral pulses
   5. D) Abdomen

1. 1. 23. The nurse is gathering the necessary equipment preparatory to examining a client’s ears. The nurse will be checking bone and air conduction of sound. Which of the following should the nurse obtain?
   2. A) Penlight
   3. B) Tongue depressor
   4. C) Tuning fork
   5. D) Otoscope

1. 1. 24. The nurse is evaluating the setting prior to beginning a client’s physical examination. The nurse should confirm the presence of which of the following? Select all that apply.
   2. A) Adequate lighting
   3. B) Cool room temperature
   4. C) Quiet surroundings
   5. D) Soft chair or table
   6. E) Table for equipment
   7. F) Door or curtain

1. 1. 25. The nurse is using her fingerpads to palpate a client’s body part during the physical examination. Which of the following would the nurse best be able to detect?
   2. A) Temperature
   3. B) Vibrations
   4. C) Pulses
   5. D) Fremitus
   6. 26. A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first?
   7. A) Inspection
   8. B) Palpation
   9. C) Percussion
   10. D) Auscultation

1. 1. 27. The nurse is percussing the area over the client’s lungs and hears a loud, low-pitched, hollow sound. The nurse documents this finding as which of the following?
   2. A) Flatness
   3. B) Resonance
   4. C) Tympany
   5. D) Dullness

1. 1. 28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to perform a comprehensive assessment. The client states, ìI’d really like to have my mom in the room. That’s okay, isn’t it?î How should the nurse best respond to the client’s request?
   2. A) ìOf course. There’s a chair in the exam room where she can sit.î
   3. B) ìThat’s no problem. I’ll just have to get you to sign a privacy waiver first.î
   4. C) ìThat’s fine, but be aware that some of the examinations might be embarrassing for you or her.î
   5. D) ìIt’s best to undergo the examination alone in order to make sure I get accurate data, but if you really want her present, we can do that.î

1. 1. 29. The nurse is inspecting the dominant hand of an older adult client and notes the presence of irregularly shaped brown lesions on the dorsal surface of the client’s hand. What action should the nurse perform next?
   2. A) Obtain a tissue sample for pathology
   3. B) Compare the appearance of the client’s other hand
   4. C) Palpate the lesions for tenderness and warmth
   5. D) Perform health promotion teaching about sun protection

1. 1. 30. A young man has presented to the clinic with a 2-week history of head congestion, fever, and malaise. What assessment technique should the nurse utilize to assess for sinus tenderness?
   2. A) Light palpation
   3. B) Deep palpation
   4. C) Direct percussion
   5. D) Blunt percussion

1. • 1. 1. A nurse on a postsurgical unit is admitting a client following the client’s cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client?
        1. A) Collecting accurate data
        2. B) Assisting the primary care provider
        3. C) Validating previous data
        4. D) Making clinical judgments
     1. 1. 2. A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?
        2. A) Gastroenterologist
        3. B) ED nurse
        4. C) Admissions clerk
        5. D) Diagnostic technician
     1. 1. 3. The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client’s care. What principle should the nurse apply when using the nursing process?
        2. A) Each step is independent of the others.
        3. B) It is ongoing and continuous.
        4. C) It is used primarily in acute care settings.
        5. D) It involves independent nursing actions.
     1. 1. 4. The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?
        2. A) Review the client’s medical record.
        3. B) Obtain basic biographic data.
        4. C) Consult clinical resources explaining the client’s diagnosis.
        5. D) Validate information with the client.
     1. 1. 5. Which of the following client situations would the nurse interpret as requiring an emergency assessment?
        2. A) A pediatric client with severe sunburn
        3. B) A client needing an employment physical
        4. C) A client who overdosed on acetaminophen
        5. D) A distraught client who wants a pregnancy test
        6. 6. In response to a client’s query, the nurse is explaining the differences between the physician’s medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client’s situation?
        7. A) Current physiologic status
        8. B) Effect of health on functional status
        9. C) Past medical history
        10. D) Motivation for adherence to treatment
     1. 1. 7. After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?
        2. A) Assessment
        3. B) Planning
        4. C) Implementation
        5. D) Evaluation
     1. 1. 8. The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?
        2. A) Reassess previously detected problems
        3. B) Provide information for the client’s record
        4. C) Address areas previously omitted
        5. D) Determine the need for crisis intervention
     1. 1. 9. The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?
        2. A) A 14-year-old girl who is crying because she thinks she is pregnant
        3. B) A 45-year-old man with chest pain and diaphoresis for 1 hour
        4. C) A 3-year-old child with fever, rash, and sore throat
        5. D) A 20-year-old man with a 3-inch shallow laceration on his leg
        6. 10. A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?
        7. A) Determine if pertinent data has been omitted
        8. B) Identify the need for referral
        9. C) Avoid biases and judgments
        10. D) Construct a plan of care
     1. 1. 11. The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data?
        2. A) Family history
        3. B) Occupation
        4. C) Appearance
        5. D) History of present health concern
     1. 1. 12. An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?
        2. A) Encourage the client to increase oral fluid intake.
        3. B) Provide the client with a bedtime protein snack.
        4. C) Assist the client with personal hygiene.
        5. D) Measure the client’s blood glucose four times daily.
     1. 1. 13. The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?
        2. A) An 80-year-old client who lives with her daughter
        3. B) A 50-year-old client newly diagnosed with diabetes
        4. C) An adult presenting for an influenza vaccination
        5. D) A teenager seeking information about contraception
     1. 1. 14. An instructor is reviewing the evolution of the nurse’s role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession?
        2. A) Natural senses
        3. B) Biomedical knowledge
        4. C) Simple technology
        5. D) Critical pathways
     1. 1. 15. When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force?
        2. A) Documentation
        3. B) Informatics
        4. C) Diversification
        5. D) Technology
     1. 1. 16. A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?
        2. A) Expansion of health care networks
        3. B) Decrease in client participation in care
        4. C) The shrinking cost of medical care
        5. D) Public mistrust of physicians
     1. 1. 17. A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation?
        2. A) Guaranteeing a continual assessment process
        3. B) Identifying abnormal data
        4. C) Assuring valid conclusions from analyzed data
        5. D) Allowing for drawing inferences and identifying problems
     1. 1. 18. A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first?
        2. A) Collect objective data.
        3. B) Validate important data.
        4. C) Collect subjective data.
        5. D) Document the data.
     1. 1. 19. A community health nurse is assessing an older adult client in the client’s home. When the nurse is gathering subjective data, which of the following would the nurse identify?
        2. A) The client’s feelings of happiness
        3. B) The client’s posture
        4. C) The client’s affect
        5. D) The client’s behavior
        6. 20. A nurse on the hospital’s subacute medical unit is planning to perform a client’s focused assessment. Which of the following statements should inform the nurse’s practice?
        7. A) The focused assessment should be done before the physical exam.
        8. B) The focused assessment replaces the comprehensive database.
        9. C) The focused assessment addresses a particular client problem.
        10. D) The focused assessment is done after gathering subjective data.
     1. 1. 21. The nurse is reviewing a client’s health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.
        2. A) ìI feel so tired sometimes.î
        3. B) Weight: 145 lbs
        4. C) Lungs clear to auscultation
        5. D) Client complains of a headache
        6. E) ìMy father died of a heart attack.î
        7. F) Pupils equal, round, and reactive to light
     1. 1. 22. The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse’s actions in their proper sequence from first to last.
        2. A) Identifying outcomes
        3. B) Determining client’s nursing problem
        4. C) Collecting information about the client
        5. D) Determining outcome achievement
        6. E) Carrying out interventions

     C,B,A,E,D

     1. 1. 23. A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?
        2. A) Inspection
        3. B) Therapeutic communication
        4. C) Interviewing
        5. D) Active listening
     1. 1. 24. The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment?
        2. A) Focus the assessment on the client as a member of her age group.
        3. B) Interpret the information about the client in context.
        4. C) Corroborate the client’s statements with trusted sources.
        5. D) Gather information from a variety of sources.
     1. 1. 25. A client comes to the health care provider’s office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
        2. A) Comprehensive assessment
        3. B) Ongoing assessment
        4. C) Focused assessment
        5. D) Emergency assessment
     1. 1. 26. A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is ìa bit sporadic.î How should the nurse best respond to this assessment finding?
        2. A) Identify a nursing diagnosis of Ineffective Health Maintenance.
        3. B) Identify a collaborative problem that should involve the occupational therapist.
        4. C) Make a referral to the unit’s social work department.
        5. D) Reassess the client’s blood glucose level.
     1. 1. 27. The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?
        2. A) The client’s motivation for change
        3. B) The client’s medical comorbidities
        4. C) The client’s learning style
        5. D) The client’s prognosis for recovery
     1. 1. 28. A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?
        2. A) Identify the most appropriate forms of medical intervention for the client.
        3. B) Determine the most likely prognosis for the client’s health problem.
        4. C) Identify the status of the client’s airway, breathing, and circulation.
        5. D) Establish a baseline for the comparison of future health changes.
     1. 1. 29. A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse’s plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?
        2. A) The client’s age
        3. B) The unit’s protocols
        4. C) The client’s acuity
        5. D) The nurse’s potential for liability
     1. 1. 30. A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
        2. A) Review the client’s medication administration record for analgesic use.
        3. B) Ask the client about the most recent experiences of pain.
        4. C) Meet with the client’s spouse and daughter to discuss the client’s pain.
        5. D) Collaborate with the physician who is treating the client.

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