Chapter 8Health Assessment My Nursing Test Banks

Chapter 8Health Assessment

MULTIPLE CHOICE

1.A client is brought to the emergency department with injuries sustained from a motor vehicle accident. The nurse will conduct which of the following types of health assessments?

1.

Focused

2.

Comprehensive

3.

Emergency

4.

Follow-up

ANS: 3

An emergency assessment is a rapid assessment of a client who is experiencing a life-threatening problem or crisis. A focused assessment is limited in scope to focus on a particular need or health care problem or potential health care risk. A comprehensive assessment is usually completed on admission to a health care agency or first visit to a health care provider. A follow-up assessment is also considered an ongoing assessment that includes systematic monitoring and observation related to specific health problems or risk factors.

PTS:1DIF:ApplyREF:Types of Assessment

2.The nurse is collecting data for a comprehensive assessment. Data that can be seen, heard, or felt by someone other than the person experiencing them are called:

1.

primary.

2.

objective.

3.

subjective.

4.

secondary.

ANS: 2

Objective data (signs) can be seen, heard, and/or felt by someone else. Subjective data (symptoms) rely on the feelings or opinions of the person experiencing them. Primary and secondary refer to the sources of data.

PTS:1DIF:UnderstandREF:Types of Data

3.A recently admitted client answers all health assessment questions clearly and provides the necessary information. The nurse realizes that this assessment data is considered:

1.

primary.

2.

objective.

3.

subjective.

4.

secondary.

ANS: 1

The primary source of data is the patient. Secondary sources are those sources that are not from the patient (i.e., family and significant others).Objective and subjective refer to the types of data.

PTS:1DIF:AnalyzeREF:Sources of Data

4.A client is complaining of a headache and an upset stomach. The nurse realizes that this type of data is:

1.

primary.

2.

objective.

3.

subjective.

4.

secondary.

ANS: 3

Subjective data referred to as symptoms cannot be readily observed by another. Objective data are measurable and observable. Primary and secondary refer to the sources of data.

PTS:1DIF:AnalyzeREF:Types of Data

5.The nurse is beginning the introductory portion of the health interview process. This part of the assessment is considered the:

1.

orientation phase.

2.

initiation phase.

3.

working phase.

4.

closure phase.

ANS: 1

The orientation phase is the beginning of a nurse-patient interview. The orientation phase sets the relationship and establishes the goals for the interaction. The working phase of the interview focuses on the details of data collection. The closure phase is a time for review and evaluation of the progress of the interventions toward the intended goals. Initiation is not a phase in the interview process.

PTS: 1 DIF: Understand REF: Phases of the Interview Process

6.The nurse completes a comprehensive health assessment with a client. This assessment is completed so that when future assessments are made they can be:

1.

incorporated into the initial assessment.

2.

considered a new baseline.

3.

compared to the initial assessment.

4.

disregarded.

ANS: 3

The comprehensive health assessment contains the full health history and physical assessment. This initial assessment is the baseline for future assessment and is used as a comparison. A comprehensive assessment is the initial assessment. Future assessments are not considered the new baseline. Future assessments will not be disregarded.

PTS: 1 DIF: Analyze REF: Comprehensive Assessment

7.The nurse is assessing a client for a cardiac thrill. To best assess this thrill, the nurse should do which of the following?

1.

Use the ulnar surface of the hand.

2.

Use the dorsal aspect of the hand.

3.

Use the fingertips.

4.

Use a stethoscope.

ANS: 1

The ulnar surface of the hand is best for assessing vibrations which would be used to assess for a cardiac thrill. The dorsal aspect of the hand is best for assessing temperature. The fingertips are best for assessing fine sensation. A stethoscope is not used to assess for a cardiac thrill.

PTS:1DIF:Apply

REF: Nursing Strategy: Parts of Hand Used for Palpation

8.The nurse is using percussion to assess a clients lung region. Which of the following would be considered a normal assessment finding?

1.

Flatness

2.

Dullness

3.

Tympany

4.

Resonance

ANS: 4

Resonance is a normal percussion sound of the lungs, and it indicates normal lungs. Flatness indicates severe pneumonia. Dullness indicates atelectasis. Tympany indicates a large pneumothorax.

PTS: 1 DIF: Analyze REF: Table 8-1 Characteristics of Percussion Sounds

9.A 17-year-old male client tells the nurse that he hopes he stops growing since he is already over 6 feet tall. Which of the following should the nurse respond to this client?

1.

You have reached your full adult stature by age 17.

2.

You have until age 21 to reach your full adult height.

3.

You wont reach your full height until age 25.

4.

You have reached your full height and will begin to lose height every year.

ANS: 2

Full adult stature in men is reached at approximately age 21 and women by age 17. The adult male will not continue to grow in height up to age 25. The client has not yet reached his full height and will not begin to lose height every year.

PTS:1DIF:Apply

REF:Variations Related to Health Assessment Practices: Adult

10.The nurse is assessing a week-old male client. Which of the following will the nurse assess as a common variation because of the clients gender?

1.

Physiologically more mature

2.

More motor activity

3.

Responsive to tactile stimulation

4.

Smaller in size

ANS: 2

Male infants are larger with more muscle mass. They exhibit more motor activity than females. Females are physiologically more mature, respond to tactile stimulation, and are smaller in size.

PTS: 1 DIF: Apply REF: Physical Variations Related to Gender

11.The nurse desires to provide care according to the American Nurses Association Code of Ethics. Which of the following is the primary ethical responsibility of the nurse when providing client care?

1.

To do no harm

2.

To do good

3.

Protect the clients right to make their own decisions

4.

To tell the truth

ANS: 3

The primary ethical responsibility of the nurse is to protect the clients right to make their own decisions. The ethical principle of nonmaleficence means to do no harm. The ethical principle of beneficence means to do good. The ethical principle of veracity means to tell the truth.

PTS:1DIF:Analyze

REF: Ethical Considerations Related to Data Collection; Table 8-2 Overview of Ethical Principles

12.While completing an assessment, the nurse learns that the client has been a victim of domestic violence with multiple bruises and a possible fractured arm. Which of the following should the nurse do with this information?

1.

Document the assessment findings in the clients medical record.

2.

Report the findings of domestic violence to the appropriate regulatory agency.

3.

Document the assessment findings and have the client moved to a private room.

4.

Notify the physician.

ANS: 2

Confidentiality is the protection of private information gathered about a client during the provision of health care services. However, the nurse does have the duty to report or disclose information in the event of suspected abuse. The nurse should report the findings of domestic violence to the appropriate regulatory agency. Documenting the assessment findings is important; however, the nurse needs to report these findings. The client does not need to be moved to a private room. Notifying the physician is not sufficient.

PTS:1DIF:ApplyREF:Confidentiality

13.The fetus of a pregnant client is diagnosed with a genetic defect that can be corrected immediately upon birth. The nurse realizes that this newborn will benefit from which of the following genetic advancements?

1.

Eugenics

2.

Genetic engineering

3.

Euthenics

4.

Genetic testing

ANS: 3

Euthenics involves the techniques for correcting defects in individuals after they have been born. Eugenics involves the selection and recombination of genes already existing in the gene pool. Genetic engineering entails changing a particular molecule in the structure of a gene to either eliminate a certain bad trait or to improve the genotype. Genetic testing is the testing of an individual at significant risk because of family history or because of symptoms.

PTS: 1 DIF: Analyze REF: Genetic Screening and Counseling

14.During the health history, a client tells the nurse that she is allergic to penicillin. In which area of the history should the nurse document this information?

1.

Management of health

2.

Activities of daily living

3.

Psychosocial history

4.

Demographic information

ANS: 1

Areas included under management of health include allergies and any side or untoward effects to medications, food, or environmental substances. Allergies are not documented under activities of daily living, psychosocial history, or demographic information.

PTS: 1 DIF: Apply REF: Box 8-1 Elements of Health History

MULTIPLE RESPONSE

1.The nurse is assessing a clients activities of daily living. Which of the following will be included in this nurses assessment? (Select all that apply.)

1.

Nutrition

2.

Elimination

3.

Sleep

4.

Self-identity

5.

Cognition

6.

Values

ANS: 1, 2, 3, 5

Elements of activities of daily living include nutrition/metabolic patterns, elimination patterns, activity/exercise patterns, sleep/rest patterns, and cognition/perception patterns. Self-identity is included within the psychosocial history. Values is an independent section within the health history.

PTS: 1 DIF: Apply REF: Box 8-1 Elements of Health History

2.A client has just learned of a diagnosis of type 2 diabetes mellitus. The client is anxious about the diagnosis. Which of the following should the nurse assess regarding this clients ability to cope with the new problem? (Select all that apply.)

1.

How do you typically handle problems in your life?

2.

What helps you when you feel tense?

3.

Are you still actively employed?

4.

Who do you talk with when you have a problem?

5.

Do you take drugs or alcohol when stressed?

6.

Who is your health insurance carrier?

ANS: 1, 2, 4, 5

When clients are coping with a stressful situation, the nurse should assess the client by asking the following questions: Do you take drugs or alcohol in response to stress? Who is most helpful when you need to talk about problems? When crises or problems occur in your life, how do you handle them? What helps you when you feel stressed? Asking about employment and the name of the clients health insurance carrier will not explain how the client copes with new problems or stress.

PTS: 1 DIF: Apply REF: Patient Playbook: Coping with Problems

3.The nurse is assessing a 10-month-old client. Which of the following should be the nurses focus during this assessment? (Select all that apply.)

1.

Respiratory volume

2.

Safety

3.

Heart size

4.

Prevention of infection

5.

Developmental milestones

6.

Musculoskeletal system development

ANS: 2, 4, 5

For an infant, the nurses assessment must focus on safety, prevention of infection, and developmental milestones. Respiratory volume, heart size, and musculoskeletal system development are not areas in which the nurse should focus for a 10-month-old client.

PTS:1DIF:Apply

REF:Variations Related to Health Assessment Practices: Infant

4.The nurse routinely cares for non-English-speaking clients. Which of the following must the nurse do to develop cultural competence? (Select all that apply.)

1.

Learn a foreign language.

2.

Identify own cultural beliefs related to health and health care.

3.

Engage in cross-cultural interactions with people from diverse cultural backgrounds.

4.

Become knowledgeable about the predominant cultural groups within ones own geographic area.

5.

Relocate to another country to learn the culture.

6.

Become skilled at cultural data assessments.

ANS: 2, 3, 4, 6

Developing cultural competence requires cultural awareness, cultural knowledge, cultural skills, and cultural encounter. Cultural awareness includes the identification of ones own cultural beliefs related to health and health care. Cultural knowledge includes becoming knowledgeable about the predominant cultural groups within ones own geographic area. Cultural skills includes becoming skilled at cultural data assessments. Cultural encounter includes engaging in cross-cultural interactions with people from diverse cultural backgrounds. Cultural competence does not mean the nurse needs to learn a foreign language nor relocate to another country to learn the culture.

PTS: 1 DIF: Apply REF: Culture

5.The nurse is preparing to conduct a client interview. Which of the following behaviors should the nurse use when conducting this interview? (Select all that apply.)

1.

Do not impose personal beliefs onto the client.

2.

Listen to verbal and nonverbal cues.

3.

Focus on the client.

4.

Maintain eye contact according to cultural variation.

5.

Allow for silence.

6.

Keep the client on track and prevent rambling.

ANS: 1, 2, 3, 4, 5

Behaviors that the nurse should implement when conducting a client interview include being aware of personal beliefs and not imposing beliefs onto the client, listening and attending to verbal and nonverbal cues, staying focused on the client, maintaining eye contact within cultural sensitivity, and allowing for silence. Keeping the client on track to prevent rambling is not a behavior that the nurse should use when conducting the client interview.

PTS:1DIF:Apply

REF:Nursing Strategy: Prepare Yourself for the Patient Interview

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