Chapter 23 Documenting the Head-to-Toe Health Assessment

Chapter 23  Documenting the Head-to-Toe Health Assessment

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Which documentation by a nurse is most descriptive?
a.
Heart sounds normal.
b.
Few ectopic beats heard during auscultation.
c.
S1 murmur is heard at second right sternal border.
d.
Pulse within normal limits.

ANS: C

Feedback
A
This information is not specific without a description of what is considered “within normal limits” for hair color, texture, length, etc.
B
This description is not specific because the number of permanent teeth is not detailed.
C
This is the most descriptive data, specifying what is heard and the location.
D
This description would be more descriptive if the pain scale were used to indicate the level of tenderness and if the location on the abdomen were documented.

DIF: Cognitive Level: Apply REF: 540
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

2. The nurse documents which data under the category of present health status?
a.
Heart sounds normal.
b.
Few ectopic beats heard during auscultation.
c.
Apical pulse palpated at 5th left intercostal space, midclavicular line
d.
Pulse within normal limits.

ANS: D

Feedback
A
This information is not specific without a description of what is considered “within normal limits” for heart sounds
B
This description is not specific
C
This is the most descriptive data, specifying what is heard and the location.
D
This description would be more descriptive such as which pulse and the rate

DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

3. Which data do nurses document under the category of past health history?
a.
Chronic diseases
b.
Immunizations received
c.
Allergies to medications or food
d.
Causes of death of the patient’s parents

ANS: B

Feedback
A
Chronic diseases are documented under the present health status category.
B
Immunizations are documented under the past health history category.
C
Allergies to medications or food are documented under the present health status category.
D
Causes of death of parents are documented under the family history category.

DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

4. A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?
a.
Review of systems
b.
Present health status
c.
Past health history
d.
Functional ability

ANS: A

Feedback
A
In the review systems part of the history, the nurse asks patients whether they have had symptoms from specific body systems. Patients either deny or admit to having the symptoms.
B
The present health status category contains data on chronic diseases, medications, and allergies.
C
The past health history category contains data on childhood diseases, surgeries and hospitalizations, and immunizations.
D
The functional ability category contains data on patient’s activities, including maintaining a home and working full-time.

DIF: Cognitive Level: Understand REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care