Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen – Test Bank

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Chapter 1. Nurse’s Role in Health Assessment

  1. After completing an initial assessment of a patient, the nurse has charted that his respirations

are eupneic and his pulse is 58 beats per minute. These types of data would be:

  1. Objective.
  2. Reflective.
  3. Subjective.
  4. Introspective.


  1. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of

data would be:

  1. Objective.
  2. Reflective.
  3. Subjective.
  4. Introspective.


  1. The patients record, laboratory studies, objective data, and subjective data combine to form


  1. Data base.
  2. Admitting data.
  3. Financial statement.
  4. Discharge summary.


  1. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The

nurses next action should be to:

  1. Immediately notify the patients physician.
  2. Document the sound exactly as it was heard.
  3. Validate the data by asking a coworker to listen to the breath sounds.
  4. Assess again in 20 minutes to note whether the sound is still present.



  1. The nurse is conducting a class for new graduate nurses. During the teaching session, the

nurse should keep in mind that novice nurses, without a background of skills and experience

from which to draw, are more likely to make their decisions using:

  1. Intuition.
  2. A set of rules.
  3. Articles in journals.
  4. Advice from supervisors.


  1. Expert nurses learn to attend to a pattern of assessment data and act without consciously

labeling it. These responses are referred to as:

  1. Intuition.
  2. The nursing process.
  3. Clinical knowledge.
  4. Diagnostic reasoning.


  1. The nurse is reviewing information about evidence-based practice (EBP). Which statement

best reflects EBP?

  1. EBP relies on tradition for support of best practices.
  2. EBP is simply the use of best practice techniques for the treatment of patients.
  3. EBP emphasizes the use of best evidence with the clinicians experience.
  4. The patients own preferences are not important with EBP.


  1. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which

is an example of a first-level priority problem?

  1. Patient with postoperative pain
  2. Newly diagnosed patient with diabetes who needs diabetic teaching
  3. Individual with a small laceration on the sole of the foot
  4. Individual with shortness of breath and respiratory distress


  1. When considering priority setting of problems, the nurse keeps in mind that second-level

priority problems include which of these aspects?

  1. Low self-esteem
  2. Lack of knowledge
  3. Abnormal laboratory values
  4. Severely abnormal vital signs



  1. Which critical thinking skill helps the nurse see relationships among the data?
  2. Validation
  3. Clustering related cues
  4. Identifying gaps in data
  5. Distinguishing relevant from irrelevant


  1. The nurse knows that developing appropriate nursing interventions for a patient relies on the

appropriateness of the __________ diagnosis.

  1. Nursing
  2. Medical
  3. Admission
  4. Collaborative


  1. The nursing process is a sequential method of problem solving that nurses use and includes

which steps?

  1. Assessment, treatment, planning, evaluation, discharge, and follow-up
  2. Admission, assessment, diagnosis, treatment, and discharge planning
  3. Admission, diagnosis, treatment, evaluation, and discharge planning
  4. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation


  1. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having

difficulty breathing. How should the nurse prioritize these problems?

  1. Breathing, pain, and sleep
  2. Breathing, sleep, and pain
  3. Sleep, breathing, and pain
  4. Sleep, pain, and breathing





  1. Which of these would be formulated by a nurse using diagnostic reasoning?
  2. Nursing diagnosis
  3. Medical diagnosis
  4. Diagnostic hypothesis
  5. Diagnostic assessment



  1. Barriers to incorporating EBP include:
  2. Nurses lack of research skills in evaluating the quality of research studies.
  3. Lack of significant research studies.
  4. Insufficient clinical skills of nurses.
  5. Inadequate physical assessment skills.




  1. What step of the nursing process includes data collection by health history, physical

examination, and interview?

  1. Planning
  2. Diagnosis
  3. Evaluation
  4. Assessment



  1. During a staff meeting, nurses discuss the problems with accessing research studies to

incorporate evidence-based clinical decision making into their practice. Which suggestion by the

nurse manager would best help these problems?

  1. Form a committee to conduct research studies.
  2. Post published research studies on the units bulletin boards.
  3. Encourage the nurses to visit the library to review studies.
  4. Teach the nurses how to conduct electronic searches for research studies.



  1. When reviewing the concepts of health, the nurse recalls that the components of holistic

health include which of these?

  1. Disease originates from the external environment.
  2. The individual human is a closed system.
  3. Nurses are responsible for a patients health state.
  4. Holistic health views the mind, body, and spirit as interdependent.




  1. The nurse recognizes that the concept of prevention in describing health is essential because:
  2. Disease can be prevented by treating the external environment.
  3. The majority of deaths among Americans under age 65 years are not preventable.
  4. Prevention places the emphasis on the link between health and personal behavior.
  5. The means to prevention is through treatment provided by primary health care practitioners.



  1. The nurse is performing a physical assessment on a newly admitted patient. An example of

objective information obtained during the physical assessment includes the:

  1. Patients history of allergies.
  2. Patients use of medications at home.
  3. Last menstrual period 1 month ago.
  4. 2 5 cm scar on the right lower forearm.




  1. 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?

  1. A follow-up data base to evaluate changes at appropriate intervals
  2. An episodic data base because of the continuing, complex medical problems of this patient
  3. A complete health data base because of the nurses primary responsibility for monitoring the patients d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly



  1. Which situation is most appropriate during which the nurse performs a focused or problemcentered


  1. Patient is admitted to a long-term care facility.
  2. Patient has a sudden and severe shortness of breath.
  3. Patient is admitted to the hospital for surgery the following day.
  4. Patient in an outpatient clinic has cold and influenza-like symptoms.



  1. A patient is at the clinic to have her blood pressure checked. She has been coming to the

clinic weekly since she changed medications 2 months ago. The nurse should:

  1. Collect a follow-up data base and then check her blood pressure.
  2. Ask her to read her health record and indicate any changes since her last visit.
  3. Check only her blood pressure because her complete health history was documented 2 months ago.


Obtain a complete health history before checking her blood pressure because much of her history information changed.




  1. A patient is brought by ambulance to the emergency department with multiple traumas

received in an automobile accident. He is alert and cooperative, but his injuries are quite severe.

How would the nurse proceed with data collection?

  1. Collect history information first, then perform the physical examination and institute life-saving measures.
  2. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
  3. Collect all information on the history form, including social support patterns, strengths, and coping d.

Perform life-saving measures and delay asking any history questions until the patient is transferred to unit.



  1. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination.

The nurse knows that including cultural information in his health assessment is important to:

  1. Identify the cause of his illness.
  2. Make accurate disease diagnoses.
  3. Provide cultural health rights for the individual.
  4. Provide culturally sensitive and appropriate care.



  1. In the health promotion model, the focus of the health professional includes:
  2. Changing the patients perceptions of disease.
  3. Identifying biomedical model interventions.
  4. Identifying negative health acts of the consumer.
  5. Helping the consumer choose a healthier lifestyle.



  1. The nurse has implemented several planned interventions to address the nursing diagnosis of

acute pain. Which would be the next appropriate action?

  1. Establish priorities.
  2. Identify expected outcomes.
  3. Evaluate the individuals condition, and compare actual outcomes with expected outcomes.
  4. Interpret data, and then identify clusters of cues and make inferences.


Chapter 2. The Interview and Health History


  1. The nurse is conducting an interview with a woman who has recently learned that she is

pregnant and who has come to the clinic today to begin prenatal care. The woman states that she

and her husband are excited about the pregnancy but have a few questions. She looks nervously

at her hands during the interview and sighs loudly. Considering the concept of communication,

which statement does the nurse know to be most accurate? The woman is:

  1. Excited about her pregnancy but nervous about the labor.
  2. Exhibiting verbal and nonverbal behaviors that do not match.
  3. Excited about her pregnancy, but her husband is not and this is upsetting to her.
  4. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this.



  1. Receiving is a part of the communication process. Which receiver is most likely to

misinterpret a message sent by a health care professional?

  1. Well-adjusted adolescent who came in for a sports physical
  2. Recovering alcoholic who came in for a basic physical examination
  3. Man whose wife has just been diagnosed with lung cancer
  4. Man with a hearing impairment who uses sign language to communicate and who has an



  1. The nurse makes which adjustment in the physical environment to promote the success of an


  1. Reduces noise by turning off televisions and radios
  2. Reduces the distance between the interviewer and the patient to 2 feet or less
  3. Provides a dim light that makes the room cozy and helps the patient relax
  4. Arranges seating across a desk or table to allow the patient some personal space



  1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later.

Which statement is true regarding note-taking?

  1. Note-taking may impede the nurses observation of the patients nonverbal behaviors.
  2. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
  3. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level
  4. The nurse asks, I would like to ask you some questions about your health and your usual daily

activities so that we can better plan your stay here. This question is found at the __________

phase of the interview process.

  1. Summary
  2. Closing
  3. Body
  4. Opening or introduction


  1. A woman has just entered the emergency department after being battered by her husband. The

nurse needs to get some information from her to begin treatment. What is the best choice for an

opening phase of the interview with this patient?

  1. Hello, Nancy, my name is Mrs. C.
  2. Hello, Mrs. H., my name is Mrs. C. It sure is cold today!
  3. Mrs. H., my name is Mrs. C. How are you?
  4. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.



  1. During an interview, the nurse states, You mentioned having shortness of breath. Tell me

more about that. Which verbal skill is used with this statement?

  1. Reflection
  2. Facilitation
  3. Direct question
  4. Open-ended question



  1. A patient has finished giving the nurse information about the reason he is seeking care. When

reviewing the data, the nurse finds that some information about past hospitalizations is missing.

At this point, which statement by the nurse would be most appropriate to gather these data?

  1. Mr. Y., at your age, surely you have been hospitalized before!
  2. Mr. Y., I just need permission to get your medical records from County Medical.
  3. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more d.

Mr. Y., I just need to get some additional information about your past hospitalizations. When was the were admitted for chest pain?



  1. In using verbal responses to assist the patients narrative, some responses focus on the patients

frame of reference and some focus on the health care providers perspective. An example of a

verbal response that focuses on the health care providers perspective would be:

  1. Empathy.
  2. Reflection.
  3. Facilitation.
  4. Confrontation.



  1. When taking a history from a newly admitted patient, the nurse notices that he often pauses

and expectantly looks at the nurse. What would be the nurses best response to this behavior?

  1. Be silent, and allow him to continue when he is ready.


  1. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there?
  2. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another


  1. A woman is discussing the problems she is having with her 2-year-old son. She says, He

wont go to sleep at night, and during the day he has several fits. I get so upset when that happens.

The nurses best verbal response would be:

  1. Go on, Im listening.
  2. Fits? Tell me what you mean by this.
  3. Yes, it can be upsetting when a child has a fit.
  4. Dont be upset when he has a fit; every 2 year old has fits.



  1. A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by

herself. During the course of the interview she states, I cant believe my boyfriend left me to do

this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses


  1. You feel alone.
  2. You cant believe he left you alone?
  3. It must be so hard to face this all alone.
  4. I would be angry, too; raising a child alone is no picnic.



  1. A man has been admitted to the observation unit for observation after being treated for a

large cut on his forehead. As the nurse works through the interview, one of the standard

questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco

use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open

pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:

  1. Mr. K., I know that you are lying.
  2. Mr. K., come on, tell me how much you smoke.
  3. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your


  1. The nurse has used interpretation regarding a patients statement or actions. After using this

technique, it would be best for the nurse to:

  1. Apologize, because using interpretation can be demeaning for the patient.
  2. Allow time for the patient to confirm or correct the inference.
  3. Continue with the interview as though nothing has happened.
  4. Immediately restate the nurses conclusion on the basis of the patients nonverbal response.



  1. During an interview, a woman says, I have decided that I can no longer allow my children to

live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses

best response would be:

  1. You are going to leave him?
  2. If you are afraid for your children, then why cant you leave?
  3. It sounds as if you might be afraid of how your husband will respond.
  4. It sounds as though you have made your decision. I think it is a good one.




  1. A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I

know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh,

dont worry about labor so much. I have been through it, and although it is painful, many good


medications are available to decrease the pain. Which statement is true regarding this response?

The nurses reply was a:

  1. Therapeutic response. By sharing something personal, the nurse gives hope to this woman.


Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion fears.


Therapeutic response. By providing information about the medications available, the nurse is giving woman.


Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot without medication.



  1. During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop

smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What

should I do? The nurses most appropriate response in this case would be:

  1. Id quit if I were you. The doctor really knows what he is talking about.
  2. Would you like some information about the different ways a person can quit smoking?
  3. Stopping your dependence on cigarettes can be very difficult. I understand how you feel.
  4. Why are you confused? Didnt the doctor give you the information about the smoking cessation program


  1. As the nurse enters a patients room, the nurse finds her crying. The patient states that she has

just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The

nurses most therapeutic response would be to say in a gentle manner:

  1. Youre afraid you might lose your breast?
  2. No, Im not sure what you are talking about.
  3. Ill wait here until you get yourself under control, and then we can talk.
  4. I can see that you are very upset. Perhaps we should discuss this later.



  1. A nurse is taking complete health histories on all of the patients attending a wellness

workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take

drugs, do you? This question is an example of:

  1. Talking too much.
  2. Using confrontation.
  3. Using biased or leading questions.
  4. Using blunt language to deal with distasteful topics.



  1. When observing a patients verbal and nonverbal communication, the nurse notices a

discrepancy. Which statement is true regarding this situation? The nurse should:

  1. Ask someone who knows the patient well to help interpret this discrepancy.
  2. Focus on the patients verbal message, and try to ignore the nonverbal behaviors.
  3. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
  4. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true


  1. During an interview, a parent of a hospitalized child is sitting in an open position. As the

interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against

his chest and crosses his legs. This changed posture would suggest that the parent is:

  1. Simply changing positions.
  2. More comfortable in this position.
  3. Tired and needs a break from the interview.

d. Uncomfortable talking about his sons


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