TEST BANK FOR HEALTH ASSESSMENT IN
NURSING KELLY TESTBANK- LATEST
VERSION||RATED A++||COMPLETE STUDY
GUIDE.
A nurse on a postsurgical unit is admitting a patient following the patient's cholecystectomy
(gall bladder removal). What is the overall purpose of assessment for this patient?
• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments
• A patient 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 patient during the initial comprehensive
assessment?
• Gastroenterologist
• ED nurse
• Admissions clerk
• Diagnostic technician
• The nurse has completed an initial assessment of a newly admitted patient and is
applying the nursing process to plan the patient's care. What principle should the nurse
apply when using the nursing process?
• Each step is independent of the others.
• It is ongoing and continuous.
• It is used primarily in acute care settings.
• It involves independent nursing actions.
• The nurse who provides care at an ambulatory clinic is preparing to meet a patient
and perform a comprehensive health assessment. Which of the following actions
should the nurse perform first?
• Review the patient's medical record.
• Obtain basic biographic data.

• Consult clinical resources explaining the patient's diagnosis.
• Validate information with the patient.
• Which of the following patient situations would the nurse interpret as requiring
an emergency assessment?
• A pediatric patient with severe sunburn
• A patient needing an employment physical
• A patient who overdosed on acetaminophen
• A distraught patient who wants a pregnancy test
• In response to a patient'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 patient's situation?
• Current physiologic status
• Effect of health on functional status
• Past medical history
• Motivation for adherence to treatment
• 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?
• Assessment
• Planning
• Implementation
• Evaluation
• The nurse has completed the comprehensive health assessment of a patient 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?
• Reassess previously detected problems
• Provide information for the patient's record
• Address areas previously omitted
• Determine the need for crisis intervention
• The nurse is working in an ambulatory care clinic that is located in a busy, inner-
city neighborhood. Which patient would the nurse determine to be in most need of
an emergency assessment?
• A 14-year-old girl who is crying because she thinks she is pregnant

• A 45-year-old man with chest pain and diaphoresis for 1 hour
• A 3-year-old child with fever, rash, and sore throat
• A 20-year-old man with a 3-inch shallow laceration on his leg
• A nurse has completed gathering some basic data about a patient who has multiple
health problems that stem from heavy alcohol use. The nurse has then reflected on her
personal feelings about the patient and his circumstances. The nurse does this
primarily to accomplish which of the following?
• Determine if pertinent data has been omitted
• Identify the need for referral
• Avoid biases and judgments
• Construct a plan of care
• The nurse is collecting data from a patient 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?
• Family history
• Occupation
• Appearance
• History of present health concern
• An older adult patient 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?
• Encourage the patient to increase oral fluid intake.
• Provide the patient with a bedtime protein snack.
• Assist the patient with personal hygiene.
• Measure the patient's blood glucose four times daily.
• The nurse at a busy primary care clinic is analyzing the data obtained from the
following patients. For which patients would the nurse most likely expect to
facilitate a referral?
• An 80-year-old patient who lives with her daughter
• A 50-year-old patient newly diagnosed with diabetes
• An adult presenting for an influenza vaccination
• A teenager seeking information about contraception

• 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?
• Natural senses
• Biomedical knowledge
• Simple technology
• Critical pathways
• 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?
• Documentation
• Informatics
• Diversification
• Technology
• 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?
• Expansion of health care networks
• Decrease in patient participation in care
• The shrinking cost of medical care
• Public mistrust of physicians
• A nurse has documented the findings of a comprehensive assessment of a new
patient. What is the primary rationale that the nurse should identify for accurate and
thorough documentation?
• Guaranteeing a continual assessment process
• Identifying abnormal data
• Assuring valid conclusions from analyzed data
• Allowing for drawing inferences and identifying problems
• A nurse has received a report on a patient 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?
• Collect objective data.
• Validate important data.
• Collect subjective data.
• Document the data.

• A community health nurse is assessing an older adult patient in the patient's home.
When the nurse is gathering subjective data, which of the following would the nurse
identify?
• The patient's feelings of happiness
• The patient's posture
• The patient's affect
• The patient's behavior
• A nurse on the hospital's subacute medical unit is planning to perform a patient's
focused assessment. Which of the following statements should inform the nurse's
practice?
• The focused assessment should be done before the physical exam.
• The focused assessment replaces the comprehensive database.
• The focused assessment addresses a particular patient problem.
• The focused assessment is done after gathering subjective data.
• The nurse is reviewing a patient'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.
• ìI feel so tired sometimes.î
• Weight: 145 lbs
• Lungs clear to auscultation
• patient complains of a headache
• ìMy father died of a heart attack.î
• Pupils equal, round, and reactive to light
• The nurse has been applying the nursing process in the care of an adult patient
who is being treated for acute pancreatitis. Place the nurse's actions in their proper
sequence from first to last.
• Identifying outcomes
• Determining patient's nursing problem
• Collecting information about the patient
• Determining outcome achievement
• Carrying out interventions
C,B,A,E,D

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• 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?
• Inspection
• Therapeutic communication
• Interviewing
• Active listening
• The nurse is performing a health assessment on a community-dwelling patient
who is recovering from hip replacement surgery. Which of the following actions
should the nurse prioritize during assessment?
• Focus the assessment on the patient as a member of her age group.
• Interpret the information about the patient in context.
• Corroborate the patient's statements with trusted sources.
• Gather information from a variety of sources.
• A patient comes to the health care provider's office for a visit. The patient 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?
• Comprehensive assessment
• Ongoing assessment
• Focused assessment
• Emergency assessment
• A nurse has assessed a patient who was admitted to the medical unit to treat acute
complications of type 1 diabetes. During the assessment, the patient 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?
• Identify a nursing diagnosis of Ineffective Health Maintenance.
• Identify a collaborative problem that should involve the occupational therapist.
• Make a referral to the unit's social work department.
• Reassess the patient's blood glucose level.
• The nurse is utilizing the Health Belief Model in the care of a patient whose type 1
diabetes is inadequately controlled. When implementing this model, the nurse
should begin by assessing which of the following?
• The patient's motivation for change
• The patient's

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• A nurse will complete an initial comprehensive assessment of a 60-year-old patient
who is new to the clinic. What goal should the nurse identify for this type of
assessment?
• Identify the most appropriate forms of medical intervention for the patient.
• Determine the most likely prognosis for the patient's health problem.
• Identify the status of the patient's airway, breathing, and circulation.
• Establish a baseline for the comparison of future health changes.
• A nurse who provides care in a hospital setting is creating a plan of nursing care for
a patient 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?
• The patient's age
• The unit's protocols
• The patient's acuity
• The nurse's potential for liability
• A patient 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?
• Review the patient's medication administration record for analgesic use.
• Ask the patient about the most recent experiences of pain.
• Meet with the patient's spouse and daughter to discuss the patient's pain.
• Collaborate with the physician who is treating the patient.
Answer Key
• D
• B
• B
• A
• C
• B
• A
• A
• B
• C
• C
• D
• B

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• A
• D
• A
• C
• C
• A
• C
• A, D, E
• C, B, A, E, D
• A
• B
• C
• A
• A
• D
• C
• B
• A nurse is preparing to assess a patient who is new to the clinic. When beginning
the collection of the patient database, which of the following actions should the
nurse prioritize?
• Establishing a trusting relationship
• Determining the patient's strengths
• Identifying potential health problems
• Making clinical inferences
• A nurse is interpreting and validating information from an older adult patient who
has been experiencing a functional decline. The nurse is in which phase of the
interview?
• Introductory
• Working
• Summary
• Closing
• A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy,
and the nurse is collecting subjective data prior to surgery. Which statement by the
nurse could be construed as judgmental?
• “How often do your adult children typically visit you?”
• “Your husband's death must have been very difficult for you.”
• “You must quit smoking because it affects others, not only you.”

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• “How would you describe your feelings about getting older?”
• A nurse is interviewing a 22-year-old patient of the campus medical clinic. Which
nonverbal behavior should the nurse adopt to best facilitate communication during
this phase of assessment?
• Standing while the patient is seated
• Using a moderate amount of eye contact
• Sitting across the room from the patient
• Minimizing facial expressions
• A nurse is providing feedback to a colleague after observing the colleague's interview
of a newly admitted patient. Which of the following would the nurse identify as an
example of a closed-ended question or statement?
• “Tell me about your relationship with your children?”
• “Tell me what you eat in a normal day?”
• “Are you allergic to any medications?”
• “What is your typical day like?”
• A patient has presented to the emergency department and is having difficulty
describing her vague sensation of physical discomfort and unease. How can the
nurse best elicit meaningful assessment data about the nature of the patient's
complaint?
• Ignore the complaint for now and return to it later in the assessment.
• Provide a laundry list of descriptive words.
• Restate the question using simpler terms.
• Wait in silence until the patient can determine the correct words.
• A nurse is eliciting a patient's health history and the patient asks, “Can I take the
herb ginkgo biloba with my other medications?” What action would be best if the
nurse is unsure of the answer?
• Promise to find out the information for the patient.
• Change the subject and return to this topic later.
• Teach the patient to only take prescribed medications.
• Encourage the patient to ask the pharmacist or primary care provider.
• The nurse is preparing to assess the mental status of a 90-year-old patient who is
being admitted to the hospital from a long-term care facility. Which of the
following should the nurse assess first?
• The patient's sensory abilities
• The patient's general intelligence

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• The presence of any phobias
• The patient's judgment and insight
• A nurse provides care in a rural hospital that serves a community that has few
minority residents. When interviewing a patient from a minority culture, the nurse has
enlisted the assistance of a “culture broker.” How can this individual best facilitate
the patient's care?
• By interpreting the patient's language and culture
• By evaluating the patient's culturally based health practices
• By teaching the patient about health care
• By making the patient feel comfortable and safe
• Upon entering an exam room, the patient states, “Well! I was getting ready to leave.
My schedule is very busy and I don't have time to waste waiting until you have the
time to see me!” Which response by the nurse would be most appropriate?
• “Our schedule is very busy also. We got to you as soon as we could.”
• “No one is forcing you to be here, and you are free to leave at any time.”
• “Would you like to report your complaints to someone with power?”
• “You're certainly justified in being upset, but I am ready to begin

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• “When did it start?”
• “How does it feel?”
• “How would you rate your pain?”
• A medical nurse has completed the review of systems component of the patient's
health history. Which assessment finding should the nurse document under the
review of systems?
• “High school diploma plus 2 years of college”
• “Caregiver reliable source of information”
• “Menarche at age 13”
• “Lungs clear to auscultation bilaterally”
• A patient has been admitted following an unexplained weight loss of 15 pounds over
the past 3 months. How should the nurse best assess the subjective component of the
patient's nutritional status?
• Ask the patient to explain MyPlate.
• Obtain a 24-hour diet recall.
• Ask about the contents of one typical meal.
• Elicit the patient's favorite foods.
• A patient's elevated body mass index (BMI) has prompted the nurse to assess the
patient's activity and exercise level. Which statement would indicate to the nurse that
the patient is getting the recommended amount of exercise?
• “I walk briskly on the treadmill once or twice a week.”
• “I play basketball with a team every Friday night without fail.”

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• “Do you always wear your seatbelt when driving?”
• “How much beer, wine, or alcohol do you drink?”
• “Do you use condoms with each sexual encounter?”
• “Could you describe how you perform self-breast exams?”
• A nurse is creating a genogram of a patient's family health history. The nurse should
use which of the following symbols to denote the patient's female relatives?
• Circle
• Square
• Triangle
• Rectangle
• A patient has just been admitted to the postsurgical unit from postanesthetic recovery,
and the nurse is in the introductory phase of the patient interview. Which of the
following activities should the nurse perform first?
• Collaborate with the patient to identify problems.
• Explain the purpose of the interview.
• Determine the patient's vital signs.
• Obtain family health history data.
• During the interview, the patient states, “Is today the 12th? My wife died 2 months
ago today.” Which of the following responses would be most appropriate?
• “What was the cause of your wife's death?”
• “How does that make you feel right now?”
• “You probably must be sad.”
• “Are you feeling sad, depressed, angry, or upset?”
• The nurse is using the mnemonic “COLDSPA” to assess a

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• “I had surgery 5 years ago to repair an inguinal hernia.”
• “I have been having some pain when I urinate for the last several days.”
• A nurse is teaching a recent nursing graduate about the significance of verbal and
nonverbal communication during patient care. The new graduate demonstrates an
understanding of these techniques by citing what example of verbal
communication?
• Maintaining an open attitude
• Using silence appropriately
• Providing a laundry list of descriptors when needed
• Maintaining an open and encouraging facial expression
• The admission of a new resident to a long-term care facility has necessitated a
thorough health history. Place the following focuses in the correct sequence in which
the nurse should perform them, beginning with the section obtained first.
• Family health history
• Reason for seeking care
• Biographic data
• Review of body systems
• History of present concern
• Past health history
C,B,E,F,A,D
• The nurse is completing a review of systems for a patient. Which of the following
information would the nurse document related to the patient's musculoskeletal
system? Select all that apply.
• Joint stiffness
• Rhinorrhea
• Shortness of breath
• Chest pain
• Muscle strength
• Knee swelling
• The nurse is completing an assessment of a 50-year-old female patient who has
sought care for recurrent migraines that have not responded to treatment. Following
the review of systems, how should the nurse best document unremarkable results of
the subjective portion of the gastrointestinal assessment?
• “patient's gastrointestinal health is within reference ranges for age.”

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• “patient denies GI signs and symptoms.”
• “Gastrointestinal problems are absent.”
• “patient denies recent constipation, diarrhea, bowel incontinence, or abdominal
pain.”
• A 60-year-old woman with a bunion will undergo surgery later today. The patient
tells the nurse in the surgical daycare admitting department, “I'm sure I've been
asked these questions before. Can't we just focus on my foot and not all these other
topics?” How should the nurse best explain the rationale for obtaining a health
history?
• “In general, it's necessary for us to gather as much information about each patient
as possible.”
• “We want to make sure your nursing care matches your needs as closely as
possible.”
• “The care team needs to cross-reference your diagnostic testing with
the information that I'm asking you about.”
• “We don't want to make the mistake of

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• C
• B
• C
• B
• A
• A
• A
• D
• D
• C
• A
• C
• B
• C
• B
• D
• A
• B
• B
• C
• C
• C
• C, B, E, F, A, D
• A, E, F
• D
• B
• A
• D
• A patient 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?
• Explain the purpose of the interview to the patient.
• Construct the patient's family genogram.
• Establish the patient's reliability as historian.
• Collect necessary equipment essential to the exam.
• A young adult patient has come to the clinic for her scheduled Pap (Papanicolaou)
test and pelvic examination. The nurse is implementing actions to help reduce a
patient's anxiety during the physical exam. Which of the following would be most
appropriate?

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• Ensuring patient's privacy by providing an examination gown
• Providing a comfortable, warm room temperature
• Arranging exam equipment on a bedside tray table
• Explaining why standard precautions are being used
• A nurse is admitting a new patient 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?
• Performing hand hygiene between examinations of each body part
• Discarding in the trash can the safety pin that was used to assess sensory
perception
• Wearing gloves to palpate the tongue and buccal membranes
•

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• 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?
• Parasites
• Blood
• Bacteria
• Fungus
• The nurse is examining an older adult patient and using a goniometer. Which of
the following would the nurse be assessing?
• Extremity edema
• Joint flexion/extension
• Two-point discrimination
• Vibratory sensation
• A female patient 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?

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• Face mask
• Cover gown
• Face shield
• The nurse is preparing to perform the physical examination of an older adult patient
who will begin rehabilitation from an ischemic stroke. Which of the following actions
would be most appropriate?
• Omit intrusive parts of the exam.
• Try to minimize position changes.
• Allow patient to remain dressed.
• Dim the room light to ensure privacy.
• The nurse is preparing to assess the peripheral pulses of a patient. The nurse should
place the patient in which position?
• Sitting upright
• Supine
• Sims position
•

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• Begin the examination with auscultation instead of inspection.
• Maintain the supine position for each part of the examination.
• The nurse assists a patient into the dorsal recumbent position. Assessment of which
area is contraindicated when the patient is in this position?
• Chest
• Head
• Peripheral pulses
• Abdomen
• The nurse is gathering the necessary equipment preparatory to examining a patient's
ears. The nurse will be checking bone and air conduction of sound. Which of the
following should the nurse obtain?
• Penlight
• Tongue depressor
• Tuning fork
• Otoscope
• The nurse is evaluating the setting prior to beginning a patient's physical
examination. The nurse should confirm the presence of which of the following?
Select all that apply.

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• Collaborating with the patient and his or her family prior to documenting
Answer Key
• B
• A
• C
• D
• A
• C
• A
• C
• D
• C
• A
• A
• D
• A, B, C, E
• C
• B
• A
• C
• B
• B
• B
• A
• C
• D
• C
• D
• B
• C
• C
• B
• A nurse has completed a comprehensive assessment of a patient and has begun the
process of data analysis. Data analysis should allow the nurse to produce which of
the following direct results?
• Outcomes evaluation
• Nursing diagnoses
• Holistic interventions

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Test Bank for Health Assessment in Nursing, 7th North American Edition (Chapters 1-34)

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