Nursing Health Assessment A Best Practice Approach 1st edition by Jensen -Test Bank

 

 

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Sample Test

Chapter 03- The Health History

 

1.	During the interview process, the nurse obtains what type of data from the patient?
	A)  Primary    B)  Secondary    C)  Objective    D)  Oral

 

2.	The nurse is admitting a new patient to the unit. While reviewing old records of this patient, the nurse knows that the data being gathered are what kind of data?
	A)  Primary    B)  Secondary    C)  Subjective    D)  Objective

 

3.	The nursing instructor is discussing with students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor’s best answer? (Select all that apply.)
	A)	During a hospital admission
	B)	At a clinic visit for a fall
	C)	In the emergency department after a car accident
	D)	During an annual physical examination
	E)	At a screening for sports participation

 

4.	Student nurses are practicing taking comprehensive health histories from one another. What components should be included in a comprehensive health history? (Select all that apply.)
	A)	When coughing began
	B)	Pain location
	C)	Pain duration
	D)	Pain intensity
	E)	What was eaten for breakfast

 

5.	The nurse is gathering a complete history of the patient’s present illness. The nurse knows that the most appropriate way to begin to gather this information is what?
	A)	Assessing the patient’s vital signs
	B)	Gathering a complete list of the patient’s medications
	C)	Asking open-ended questions
	D)	Asking focused questions

 

6.	A clinical instructor is discussing with a clinical group how to take a history of the patient’s present illness. A student asks how to best guide the interview. What would be the instructor’s most appropriate answer?
	A)	Follow the cues of the patient during the interview
	B)	Use a written checklist to make sure you cover all necessary areas
	C)	Use a head-to-toe approach to make sure you do not miss anything
	D)	Use a focused approach, asking only about symptoms of the present illness

 

7.	A genogram is developed to visually show what?
	A)	Family tree	C)	Family relationships
	B)	Family health patterns	D)	Nationalities of family members

 

8.	A group of student nurses is presenting information on Gordon’s framework for assessing a patient. What type of assessment would they be talking about?
	A)  Comprehensive    B)  Focused    C)  Functional    D)  Emergency

 

9.	When using Gordon’s framework for a functional health assessment, the nurse asks a patient, “Have you made any changes in your environment because of vision, hearing, or memory decrease?” What functional health pattern is the nurse assessing?
	A)  Vision    B)  Hearing    C)  Coping    D)  Cognition

 

10.	The nurse is caring for a 77-year-old woman who has been admitted with a fractured hip. While doing the admission assessment, the patient states, “I tripped over the small rug we have in front of the sink.” What subject would this report indicate that needs teaching during this patient’s hospital stay?
	A)	The need to eliminate rugs on the patient’s floors
	B)	The need to have wall-to-wall carpeting throughout the patient’s house
	C)	The need for the patient to use a walker when she goes into the kitchen
	D)	The need for the patient to be in a wheelchair

 

11.	After completing the interview process, the nurse analyzes the data collected in order to?
	A)	Establish a baseline from which to start interviewing the family
	B)	Develop nursing interventions
	C)	Communicate information to the physician
	D)	Communicate information to other staff members

 

12.	The nursing instructor is explaining to students the difference between the language used when a nurse talks to the patient and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?
	A)	Document according to the orders of the physician
	B)	Talk to the patient and document exactly the same
	C)	Use medical terminology when documenting in the medical record
	D)	Document exactly as the patient talks

 

13.	The nurse is caring for an 82-year-old man and is reviewing information obtained in the health history assessment. The nurse knows that it is important to identify the pattern of illnesses and recognize how they might be related because this patient is what?
	A)  In the hospital    B)  Stoic    C)  An older adult    D)  Chronically ill

 

14.	Through what process do the patient and the nurse work together to develop a plan of care?
	A)	Functional assessment	C)	Therapeutic communication
	B)	Use of subjective and objective data	D)	Use of Gordon’s framework

 

15.	A nurse is assessing a patient and collecting only the most important information. What type of assessment is the nurse doing?
	A)  Functional    B)  Emergency    C)  Comprehensive    D)  Focused

 

16.	A student is working with a floor nurse who is admitting a new patient to the unit. The nurse asks the patient if he has traveled outside the United States in the past 12 months. The student knows that this information is part of what area of the comprehensive health history?
	A)	Activities	C)	Demographical data
	B)	Present illness	D)	History of illnesses

 

17.	Why is it important for the nurse to reconcile all the hospitalized patient’s medication lists with the medication that the patient regularly takes at home?
	A)	So the physician can order the correct drugs for the hospitalized patient
	B)	So the patient’s medication record correlates with the patient’s medication history
	C)	So the patient continues taking the correct drugs
	D)	So the physician can make sure to change the patient’s drugs

 

18.	The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as he or she does the assessment. The instructor explains that the use of the mnemonic is to?
	A)	Remember the elements that are important to assess for
	B)	Remember the parts of a focused assessment
	C)	Remember the order of the assessment
	D)	Remember how to document assessment findings

 

19.	While admitting a patient to the unit, the patient states, “I am allergic to sulfa drugs.” How would the nurse verify this information?
	A)	Ask family members
	B)	Ask the physician
	C)	Ask the patient about the response to the allergen
	D)	Compare against the patient’s legal records

 

20.	A new patient is admitted to the clinic. The nurse assesses how the effects of health or illness affect the patient’s quality of life. What type of assessment is this nurse performing?
	A)  Comprehensive    B)  Functional    C)  Emergency    D)  Focused

 

 

Answer Key

 

1.	A
2.	B
3.	A, D, E
4.	B, C, D
5.	C
6.	A
7.	B
8.	C
9.	D
10.	A
11.	B
12.	C
13.	C
14.	C
15.	B
16.	C
17.	C
18.	A
19.	D
20.	B

 

Chapter 04- Techniques of Physical Examination and Equipment

1.	What tool does the nurse use to auscultate the patient’s abdomen?
	A)  None    B)  Fetoscope    C)  Sonoscope    D)  Stethoscope

 

2.	When caring for patients in any health care environment, what is the most important technique for preventing infection?
	A)	Sterile technique	C)	Hand hygiene
	B)	Standard precautions	D)	Use of gloves

 

3.	What steps are involved in the patient-to-patient transmission of pathogens? (Select all that apply.)
	A)	The nurse uses an alcohol-based hand rub for hand hygiene
	B)	Organisms are transferred from the patient to the nurse’s hands
	C)	Organisms survive on the nurse’s hands for less than 1 minute
	D)	The nurse’s contaminated hands come into direct contact with another patient
	E)	Organisms are present in the patient’s immediate environment

 

4.	According to the 2009 guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.)
	A)	To help maintain a sterile environment
	B)	To reduce transient contamination of the hands
	C)	To reduce the risk of infecting personnel
	D)	To prevent the transmission of bacteria from nurses to patients
	E)	To reduce the number of bacteria in the health care environment

 

5.	A nursing instructor is discussing techniques used in the inspection of a patient. What would the instructor list as necessary or important when inspecting a patient?
	A)	Adequate exposure	C)	Therapeutic touch
	B)	Dim lighting	D)	Therapeutic communication

 

6.	The nurse is assessing a patient who is new to the unit. During inspection of the patient, what will the nurse do?
	A)	Tell the patient that modesty is not necessary
	B)	Make sure that the patient is covered
	C)	Look for internal abnormalities
	D)	Smell for odors

 

7.	A new graduate nurse is inspecting a patient. What is a challenge this nurse will face?
	A)	Maintaining patient modesty	C)	Identifying subtle differences
	B)	Learning how to perform inspection	D)	Documenting what is normal

 

8.	For what is light palpation appropriate? (Select all that apply.)
	A)	Inflamed areas of skin
	B)	Internal organs
	C)	Skin texture
	D)	Deep pain
	E)	Surface lesions

 

9.	Nursing students are in the laboratory practicing palpation. What would they learn about the best depth for moderate palpation?
	A)  ½ to 1 cm    B)  1 to 2 cm    C)  1 to 2½ cm    D)  2 to 3 cm

 

10.	When percussing a patient, where would the nurse expect to find the loudest tones?
	A)  Over the liver    B)  Over the bladder    C)  Over the spleen    D)  Over the lungs

 

11.	A patient presents at the clinic complaining of a possible sinus infection. How would the nurse assess the sinuses in this patient?
	A)  Indirect percussion    B)  Palpation    C)  Direct percussion    D)  Auscultation

 

12.	A student nurse is spending clinical hours on the medical-surgical unit with an experienced nurse. The student is assessing a patient using indirect percussion. The student hears what sound while percussing the center of the patient’s abdomen?
	A)  Resonance    B)  Tympany    C)  Dullness    D)  Damping

 

13.	When auscultating the patient’s lungs, how should the nurse position the earpieces of the stethoscope?
	A)	Pointed toward the nose	C)	At a 90° angle from the nose
	B)	Pointed toward the occiput	D)	At a 45° angle to the occiput

 

14.	While beginning assessment of a patient’s abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?
	A)	The bell	C)	The earpieces
	B)	The small side of the chestpiece	D)	The diaphragm

 

15.	Student nurses are in the laboratory learning auscultation techniques. How would they learn to hold the chestpiece on the patient?
	A)	Place the endpiece between the thumb and the index finger
	B)	Place the index and middle fingers on top of the stethoscope
	C)	Place the endpiece between the index and the middle fingers
	D)	Place the thumb and index finger on top of the stethoscope

 

16.	When assessing a patient, the first skill used is inspection. What purpose does inspection serve?
	A)	Gathering information	C)	Observing modesty
	B)	Feeling abnormalities	D)	Identifying internal abnormalities

 

17.	The clinical instructor is discussing a patient with a student nurse. The instructor asks the student why she used percussion on the patient. What would be the student’s most accurate response?
	A)	To identify abnormalities	C)	To elicit tenderness
	B)	To hear bowel sounds	D)	To produce tympany

 

18.	A nurse in the emergency department is assessing a patient admitted with suspected appendicitis. What type of palpation over the right lower quadrant of this patient would the nurse use?
	A)  None    B)  Light palpation    C)  Deep palpation    D)  Moderate palpation

 

19.	It is necessary to accurately describe the sounds heard while percussing a patient. When subjectively describing the percussion sound, what is the nurse describing?
	A)  Quality    B)  Intensity    C)  Duration    D)  Pitch

 

 

Answer Key

 

1.	D
2.	C
3.	B, D, E
4.	B, C, D
5.	A
6.	D
7.	C
8.	A, C, E
9.	B
10.	D
11.	C
12.	B
13.	A
14.	D
15.	C
16.	A
17.	C
18.	A
19.	A