Health and Physical Assessment in Nursing 3rd Edition Damico Test Bank

Health and Physical Assessment In Nursing 3rd Edition DAmico Test Bank
Health and Physical Assessment In Nursing 3rd

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D’Amico/Barbarito Health & Physical Assessment in Nursing, 3/e
Chapter 8
Question 1
Type: MCMA
The student nurse is preparing to perform a health history interview. Which statements indicate
that the student nurse requires further education regarding the purpose of the health history?
Standard Text: Select all that apply.
1. “As the nurse, I will mainly focus on the course of the client’s illness.”
2. “The client’s health history can be gathered during the initial interview.”
3. “I realize that the client is sick, but I also need to perform a wellness assessment.”
4. “The healthcare provider’s and nurse’s assessments should be almost identical with the same
focus.”
5. “The nurse typically has a more holistic point of view regarding the client’s health.”
Correct Answer: 1, 4
Rationale 1: The healthcare provider will typically focus on the client’s illness, while the nurse
will focus on the client.
Rationale 2: The nurse can gather the health history during the initial interview.
Rationale 3: The nurse should perform a wellness assessment as part of the health history.
Rationale 4: The healthcare provider’s focus and the nurse’s focus regarding the client’s health
differ significantly. The nurse’s health history may produce information about a medical
diagnosis, but the focus is on the client’s response to the health concern as a whole person. The
healthcare provider focuses on specific body systems or body parts of the client.
Rationale 5: The nurse does typically have a more holistic view of the client when compared to
the healthcare provider’s point of view.
Global Rationale: The healthcare provider will typically focus on the client’s illness, while the
nurse will focus on the client. The healthcare provider’s focus and the nurse’s focus regarding
the client’s health differ significantly. The nurse’s health history may produce information about
a medical diagnosis, but the focus is on the client’s response to the health concern as a whole
person. The healthcare provider focuses on specific body systems or body parts of the client. The
nurse can gather the health history during the initial interview. The nurse should perform a
wellness assessment as part of the health history. The nurse does typically have a more holistic
view of the client when compared to the healthcare provider’s point of view.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of
clinical interview, implementation of care plan, and evaluation of care.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health
and illness parameters in patients, using developmentally and culturally appropriate approaches,
NLN Competencies: Context and Environment: Conduct population-based transcultural health
assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8.1: Discuss the purpose of the nursing health history.

Copyright 2016 by Pearson Education, Inc.
MNL Learning Outcome: 2.1.2. Distinguish the phases of conducting the health history
interview of a client.
Page Number: p. 127
Question 2
Type: MCMA
The client has been diagnosed with an early stage of wide-angle glaucoma. The nurse is
performing a wellness assessment during the client’s initial interview. Which statements by the
client may be elicited during this portion of the health history?
1. “My mom was diagnosed with glaucoma when she was 60 years old.”
2. “I pay attention to the foods that I eat, because I want my body to stay well.”
3. “I think I do a good job of managing stress with yoga every day and running three times a
week.”
4. “My husband and I have three couples that we would classify as our very good friends.”
5. “Sometimes, my eyes feel very tired and sort of ache.”
Correct Answer: 2, 3, 4
Rationale 1: The nurse should ask about the client’s family history at some point during the
health history but not during the wellness assessment.
Rationale 2: The wellness assessment portion of the health history is designed to determine how
the client optimizes health and well-being. The nurse should determine how well the client is
nourishing the body during the wellness assessment.
managing stress during the wellness assessment.
interacting socially during the wellness assessment.
Rationale 5: The nurse should ask about the client’s symptoms related to the condition but not
during the wellness assessment.
Global Rationale: The wellness assessment portion of the health history is designed to
determine how the client optimizes health and well-being. The nurse should determine how the
client is nourishing the body, managing stress, and interacting socially. The client was diagnosed
with glaucoma; information about the client’s eyes may be gathered as the nurse focuses on the
client’s health concerns or illness. The nurse should ask about the client’s family history at some
point during the health history but not during the wellness assessment. The nurse should ask
about the client’s symptoms related to the condition but not during the wellness assessment.
Client Need Sub:
and illness parameters in patients, using developmentally and culturally appropriate approaches.

Nursing/Integrated Concepts: Nursing Process: Implementation
Page Number: p. 127
Question 3
Type: MCMA
The nurse is performing a focused interview with the client. Which behaviors indicate that the
client may be feeling anxious?
1. While seated, the client begins to wiggle his foot back and forth quickly.
2. The client leans back in his chair and seems to move away from the nurse.
3. The client crosses his arms and becomes very quiet.
4. The client leans forward in the chair and uncrosses his legs.
5. The client seems to be distracted and is no longer making direct eye contact with the nurse.
Correct Answer: 1, 2, 3, 5
Rationale 1: If the client seems restless, this can indicate that the client is anxious.
Rationale 2: The client who leans back in his chair may be anxious and feels invaded by the
nurse’s questions.
Rationale 3: The client who crosses his arms is expressing anxiety.
Rationale 4: The client who leans forward in his chair and uncrosses his arms is not displaying
anxiety. This behavior indicates that the client is preparing to “open up.”
Rationale 5: The client who seems distracted may be disengaging from the nurse’s interview
due to anxiety.
Global Rationale: If the client seems restless, this can indicate that the client is anxious. The
client who leans back in his chair may be anxious and feels invaded by the nurse’s questions.
The client who crosses his arms is expressing anxiety. The client who seems distracted may be
disengaging from the nurse’s interview due to anxiety. The client who leans forward in his chair
and uncrosses his arms is not displaying anxiety. This behavior indicates that the client may be
preparing to “open up” with the nurse.
Client Need Sub:
Learning Outcome: 8.2: Summarize components of the nursing health history for patients
across the life span.

Page Number: p. 142
Question 4
Type: MCMA
The nurse is preparing to interview the hospitalized client. Which statements by the client’s
nurse indicate that the interview should be postponed?
1. “I can’t seem to get her pain under control this morning.”
2. “I just gave her morphine sulfate through her IV for pain about 20 minutes ago.”
3. “She was anxious earlier and received some lorazepam.”
4. “She’s been oriented to ‘self’ only since admission.”
5. “I gave her some ibuprofen about 1 hour ago.”
Rationale 1: The nurse should postpone the interview if the client is in pain.
Rationale 2: The interview should be postponed if the client received opioid pain medications
because it may alter the ability for the client to adequately answer the nurse’s questions.
Rationale 3: The nurse should postpone the interview if the client was given lorazepam because
it can sedate the client.
Rationale 4: The nurse should postpone the interview if the client is confused.
Rationale 5: Ibuprofen will not impact the client’s ability to answer questions adequately, so the
interview does not need to be postponed.
Global Rationale: The nurse should postpone the interview if the client is in pain. The interview
should be postponed if the client received opioid pain medications because it may alter the
ability for the client to adequately answer the nurse’s questions. The nurse should postpone the
interview if the client was given lorazepam because it can sedate the client. The nurse should
postpone the interview if the client is confused. Ibuprofen will not impact the client’s ability to
answer questions adequately, so the interview does not need to be postponed.
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
assessments and interventions
Page Number: pp. 137–142

Question 5
Type: MCSA
The nurse says to the client, “Before the healthcare provider comes in to see you, we will need to
spend about 30 minutes talking about your current problem and any other health issues that
might impact how you are feeling right now.” The nurse is participating in which phase of the
health assessment interview?
1. Pre-interaction.
2. The initial interview.
3. The focused interview.
4. Closure of the interview.
Correct Answer: 2
Rationale 1: Pre-interaction is when the nurse prepares to meet the client and reviews any
available background information.
Rationale 2: The initial interview occurs when the nurse uses a period of time to talk with the
client and document any information that would aid in care for the current health issue.
Rationale 3: The focused interview occurs during the physical assessment, while providing
treatment, and while providing care to the client.
Rationale 4: Closure of the interview techniques can be used at the end of the initial interview or
the focused interview.
Global Rationale: This nurse is conducting the initial interview with this client. The health
assessment interview has three phases. Pre-interaction is when the nurse prepares to meet the
client and reviews any available background information. The initial interview occurs when the
nurse uses a period of time to talk with the client and document any information that would aid
in care for the current health issue. The focused interview occurs during the physical assessment,
while providing treatment, and while providing care to the client. Closure of the interview
techniques can be used at the end of the initial interview or the focused interview.
Client Need Sub:
Question 6
Type: MCSA

During the pre-interaction stage, the nurse is preparing for the initial interview. Which setting is
the least appropriate setting for the initial interview?
1. The client has been admitted to the hospital with pneumonia. The nurse is preparing to
interview the client in the client’s private hospital room.
2. The client lives at home. The nurse is preparing to interview the client in the client’s living
room.
3. The client lives at home. The nurse is preparing to interview the client at a small coffee shop
not far from the client’s home.
4. The client lives at home. The nurse is preparing to interview the client in the client’s backyard.
Correct Answer: 3
Rationale 1: It is appropriate to interview the client in the client’s private hospital room.
Rationale 2: When the client lives at home, it is appropriate to interview the client in his living
room.
Rationale 3: There should not be other people present during the interview because it may
hamper the client’s ability to share an adequate amount of information with the nurse.
Rationale 4: It is appropriate to interview the client in his own backyard.
Global Rationale: There should not be other people present during the interview because it may
hamper the client’s ability to share an adequate amount of information with the nurse. A nearby
coffee shop lacks privacy. It is appropriate to interview the client in the client’s private hospital
room. When the client lives at home, it is appropriate to interview the client in his living room. It
is appropriate to interview the client in his own backyard.
Client Need Sub:
Question 7
Type: MCSA
The nurse is gathering information regarding the client’s psychosocial history. Which question
would be included in this assessment?
1. “How did your father die?”
2. “Have you had any major surgeries?”
3. “Have you noticed any change in your vision?”
4. “How long have you worked for your current employer?”

Correct Answer: 4
Rationale 1: The nurse should gather information about the reasons for the father’s death when
creating the client’s genogram and documenting the client’s family history.
Rationale 2: Surgical history is a part of medical history.
Rationale 3: Information about vision changes would be included in the review of body systems.
Rationale 4: Elements of the psychosocial history within the health history include gathering
information about the client’s occupational history, education, financial background, roles and
relationships, family, social structure/emotional concerns, and self-concept.
Global Rationale: Elements of the psychosocial history within the health history include
gathering information about the client’s occupational history, education, financial background,
roles and relationships, family, social structure/emotional concerns, and self-concept. The nurse
should gather information about the reasons for the father’s death when creating the client’s
genogram and documenting the client’s family history. Surgical history is a part of medical
history. Assessment of vision would be included in the Review of Body Systems.
Client Need Sub:
Question 8
Type: MCSA
The nurse is obtaining information about a client’s past medical history. Which source would
provide the nurse with this data?
1. Medication list.
2. Immunization records.
3. Average amount of hours of sleep each night.
4. Marital status.
Correct Answer: 2
Rationale 1: The client’s medication list is related to current history. The description of the
client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related
traits, habits, or acts that affect the client’s health, which then can be compared to standard health
patterns, and identification of risk potential or subsequent nursing diagnoses can be determined.
Rationale 2: Past history includes information about childhood diseases; immunizations;
allergies; blood transfusions; major illnesses; hospitalizations; labor and deliveries; surgical

procedures; mental, emotional, or psychiatric health problems; and the use of alcohol, tobacco,
and other substances.
Rationale 3: The client’s sleep pattern is related to current health history. The description of the
Rationale 4: The client’s marital status is related to current history. The description of the
Global Rationale: Past history includes information about childhood diseases; immunizations;
allergies; blood transfusions; major illnesses; hospitalizations; labor and deliveries; surgical
procedures; mental, emotional, or psychiatric health problems; and the use of alcohol, tobacco,
and other substances. The medication list, sleep pattern, and marital status are related to current
history. The description of the client’s health patterns depicts a “lifestyle thread” that allows the
nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be
compared to standard health patterns, and identification of risk potential or subsequent nursing
diagnoses can be determined.
Cognitive Level: Understanding
Client Need Sub:
Question 9
Type: MCSA
The nurse is completing a focused interview. Which piece of information would the nurse
include during this interaction?
1. Identify new nursing diagnoses after clarifying previously obtained data.
2. Review information collected during client’s previous health screening activities.
3. Obtain biographic data about the client.
4. Review data from previous medical records.
Correct Answer: 1
Rationale 1: The purpose of the focused interview is to clarify previously obtained assessment
data, gather missing information about a specific health concern, update and identify new

diagnostic cues as they occur, guide the direction of a physical assessment as it is being
conducted, and identify or validate probable nursing diagnoses.
Rationale 2: Reviewing information collected during the client’s previous health screening
activities can be performed during the pre-interaction stage.
Rationale 3: Obtaining the client’s biographical information is included in the pre-interaction
stage.
Rationale 4: Gathering data from previous medical records is included in the pre-interaction
stage.
Global Rationale: The purpose of the focused interview is to clarify previously obtained
assessment data, gather missing information about a specific health concern, update and identify
new diagnostic cues as they occur, guide the direction of a physical assessment as it is being
conducted, and identify or validate probable nursing diagnoses. Gathering data from previous
medical records and biographic data about the client should be performed during the pre-
interaction stage.
Client Need Sub:
Question 10
Type: MCMA
The nurse is gathering client data from secondary sources. Which sources would the nurse utilize
to collect this data?
1. The client’s past medical records.
2. The client.
3. The history and physical.
4. The client’s physical therapist.
5. The client’s spouse.
Rationale 1: The client’s past medical records is a secondary source of information.
Rationale 2: The client is considered the primary source of information.
Rationale 3: The history and physical is a secondary source of information.
Rationale 4: The client’s physical therapist is a secondary source of information.

Rationale 5: The client’s spouse is a secondary source of information.
Global Rationale: Secondary sources are used to augment and validate previously obtained
data. The following are examples of secondary sources: medical records, the client’s history and
physical, a physical therapist who has worked with the client, other healthcare personnel who
have cared for the client, and the client’s spouse. The client is considered the primary source of
information.
Client Need Sub:
Question 11
Type: SEQ
The nurse is documenting the following information that has been collected during the health
history. Rank the following information in the order that it should be documented.
Standard Text: Click on the down arrow for each response in the right column and select the
correct choice from the list.
Response 1. Diagnosed with renal insufficiency in 1997.
Response 2. Malignant melanoma (stage I) removed from one site in 1992.
Response 3. Coronary artery bypass graft in July 2005.
Response 4. Diagnosed with hypertension in 2000.
Rationale 1: The third item is the client’s diagnosis of renal insufficiency in 1997.
Rationale 2: The fourth item is the client’s malignant melanoma that was removed from one site
in 1992.
Rationale 3: The first thing that should be documented is the coronary artery bypass graft in July
2005.
Rationale 4: The second item is that the client was diagnosed with hypertension in 2000.
Global Rationale: When recording data, the information should be written in descending order
from present to past. The first thing that should be documented is the coronary artery bypass
graft in July 2005. The second item is that the client was diagnosed with hypertension in 2000.
The third item is the client’s diagnosis of renal insufficiency in 1997. The fourth item is the
client’s malignant melanoma that was removed from one site in 1992.

Client Need Sub:
Learning Outcome: 8.3: Explain the importance of combining each component of the nursing
health history to provide holistic patient care.
Page Number: p. 137
Question 12
Type: MCSA
The nurse is interviewing an older African American client and determines that a teaching plan
should be implemented. Based on the client’s race, which statement by the client may prompt the
nurse to plan develop a teaching plan?
1. “My hands and feet are always cold.”
2. “I do not take calcium replacements.”
3. “My blood pressure is high most of the time.”
4. “I’m worried that my bones may be weak.”
Correct Answer: 3
Rationale 1: Caucasians have a greater risk for peripheral arterial disease than African
Americans. The client with cold hands and feet may have peripheral arterial disease.
Rationale 2: Osteoporosis risk is greater for Asians and Caucasians than for African Americans.
People with a high risk for developing osteoporosis should take calcium supplements.
Rationale 3: African Americans have a higher incidence of hypertension and hypertension-
related kidney failure than Caucasians.
Rationale 4: African Americans typically have higher bone densities than Caucasians and
Asians and are less likely to experience problems to due to osteoporosis.
Global Rationale: African Americans have a higher incidence of hypertension and
hypertension-related kidney failure than Caucasians. Caucasians have a greater risk for
peripheral arterial disease than African Americans. The client with cold hands and feet may have
peripheral arterial disease. Osteoporosis risk is greater for Asians and Caucasians than for
African Americans. African Americans typically have higher bone densities than Caucasians and
Asians.
Client Need Sub:

Learning Outcome: 8.4: Collect a nursing health history that incorporates patient-specific
findings related to health, illness, and wellness.
Question 13
Type: MCSA
During the course of a health history the nurse would like to review a client’s medications.
Which question is most important to ask when gathering the medication history?
1. “Can you tell me how much the co-pay is for your medications?”
2. “Do you carry health insurance?”
3. “Can you tell me about any over-the-counter or prescription medications that you take?”
4. “Where do you store your medications in your home?”
Correct Answer: 3
Rationale 1: When gathering the medication history, the nurse does not necessarily need to ask
about the client’s “co-pay.”
Rationale 2: When gathering the medication history, the nurse does not necessarily need to ask
whether the client carries health insurance or not.
Rationale 3: The nurse should gather information about medications that the client is currently
using. The nurse should request information about all prescribed and over-the-counter
medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins,
dietary supplements, or other substances should also be listed.
Rationale 4: The nurse does not necessarily need to ask where the client stores the medications
within the home.
Global Rationale: The nurse should gather information about medications that the client is
currently using. The nurse should request information about all prescribed and over-the-counter
medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins,
dietary supplements, or other substances should also be listed. The medication history does not
include the client’s co-pay amount, if the client has a prescription benefit plan or health
insurance, or where in the home the medications are stored.
Client Need Sub:

Page Number: p. 133
Question 14
Type: MCSA
A client has been brought to the emergency department (ED) by a family member. The client is
speaking incoherently. To obtain information about the client’s current health status, what should
the nurse do?
1. Call the client’s healthcare provider.
2. Call the Medical Records department to obtain other records for the client.
3. Discuss the situation with the family member who brought the client to the hospital.
4. Conduct a thorough physical assessment and document the health history as “unable to
obtain.”
Correct Answer: 3
Rationale 1: Speaking with the client’s healthcare provider may be helpful when attempting to
gather information about the client’s medical history. However, the family member may be able
to provide more information regarding the client’s current health status.
Rationale 2: Contacting the Medical Records department to ascertain this client’s old records
will be helpful when gathering information about the client’s health history.
Rationale 3: The primary and best source of information for the health assessment interview is
the client. In some situations, the client might be unwilling or unable to provide information. The
nurse should use another source of information if indicated. This client is incoherent and is
accompanied by a family member. The nurse should talk with the family member.
Rationale 4: The nurse should be able to gather information about the client’s current health
status from the family member who is accompanying the client. The nurse does not need to
document that this information is unavailable.
Global Rationale: The primary and best source of information for the health assessment
interview is the client. In some situations, the client might be unwilling or unable to provide
information. The nurse should use another source of information if indicated. This client is
incoherent and is accompanied by a family member. The nurse should talk with the family
members. Phoning the healthcare provider or calling Medical Records for other admission
information might be appropriate at a later time. The nurse should not document the health
history as “unable to obtain” since family members are available to provide this information.
Client Need Sub:

Page Number: p. 132
Question 15
Type: SEQ
The nurse is interviewing a client who has been admitted to the hospital with severe abdominal
pain. The nurse is assessing the client’s pain using the acronym OLDCART & ICE. Rank the
following the statements by the nurse in order of the way they are normally assessed.
Standard Text: Click on the down arrow for each response in the right column and select the
correct choice from the list.
Response 1. “How long have you had this pain?”
Response 2. “Would you please point to the location of your pain?”
Response 3. “How would you describe your pain? Is it sharp, dull, stabbing?”
Response 4. “Can you tell me when your pain first began?”
Rationale 1: The third step is to determine the duration of the client’s pain.
Rationale 2: The second step is to identify the location of the client’s pain.
Rationale 3: The nurse would then assess the characteristics of the client’s pain.
Rationale 4: Using OLDCART & ICE, the nurse would first assess onset of the client’s pain.
Global Rationale: Using OLDCART & ICE, the nurse would first assess onset of the client’s
pain. The second step is to identify the location of the client’s pain. The third step is to determine
the duration of the client’s pain. The nurse would then assess the characteristics of the client’s
pain.
Client Need Sub: Basic Care and Comfort

Question 16
Type: MCMA
When creating a pedigree, which items would the nurse consider as red flags?
1. Known genetic conditions.
2. Multiple family members with the same disease.
3. Late age of disease onset.
4. Death from chronic illness.
5. Multiple pregnancy losses.
Correct Answer: 1, 2, 5
Rationale 1: Known genetic conditions would raise a red flag with the nurse.
Rationale 2: Multiple family members with the same disease would raise a red flag with the
nurse.
Rationale 3: Early age of disease onset, not late age, would raise a red flag with the nurse.
Rationale 4: Sudden death, not death from a chronic disease, would raise a red flag with the
nurse.
Rationale 5: Multiple pregnancy losses would raise a red flag with the nurse.
Global Rationale: Known genetic conditions, multiple family members with the same disease,
and multiple pregnancy losses would raise a red flag with the nurse. Early age of disease onset,
not late age, would raise a red flag with the nurse. Sudden death, not death from a chronic
disease, would raise a red flag with the nurse.
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and
processes.
AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to
health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of
treatment effectiveness, using a constructed pedigree from collected family history information
as well as standardized symbols and terminology.
Learning Outcome: 8.5: Develop a pedigree.
Page Number: p. 136
Question 17
Type: MCMA
The nurse is developing a pedigree. Which pieces of information can be used to help identify the
widowed female?

1. A square is used to denote the female.
2. A circle is used to denote the male.
3. A horizontal line connects the circle and the square in the middle.
4. A line above the circle and square that is linked on the top of each shape.
5. The square has a diagonal line through the square from bottom left to upper right corner.
Correct Answer: 3, 5
Rationale 1: A square is used to denote a male.
Rationale 2: A circle is used to denote a female.
Rationale 3: When a horizontal line links the circle and the square in the middle, this indicates
that the male and female are married.
Rationale 4: A line above the circle and square that is linked on the top of each shape indicates
the male and female are siblings.
Rationale 5: A diagonal line through the square indicates the male has died.
Global Rationale: When a horizontal line connects the circle and the square in the middle, this
indicates that the male and female are married. A diagonal line through a square or circle
indicates that the person has died. A diagonal line through the square indicates the male has died.
A square is used to denote a male. A circle is used to denote a female. A line above the circle and
square that is linked on the top of each shape indicates the male and female are siblings.
Client Need Sub:
processes.
Question 18
Type: MCSA
The nurse is obtaining a family health history when the client reports that a grandparent had type
1 diabetes. Where should the nurse document this information?
1. Family pedigree.
2. Health practices.
3. Past medical history.
4. Present health/illness.
Correct Answer: 1

Rationale 1: A pedigree is a representation of family relationships and medical history, and is
the most effective method of recording large amounts of data gathered from a family’s health
history.
Rationale 2: Health practices and beliefs about health and illness are important for the nurse to
ascertain and are included in a general cultural assessment.
Rationale 3: Past medical history includes any major illness, injuries, hospitalizations, allergies,
immunizations, and childhood diseases.
Rationale 4: Present health/illness includes information about all of the client’s current health-
related issues, concerns, and problems as well as the reason for seeking care.
Global Rationale: A pedigree is a representation of family relationships and medical history,
and is the most effective method of recording large amounts of data gathered from a family’s
health history. Health practices and beliefs about health and illness are important for the nurse to
ascertain and are included in a general cultural assessment. Past medical history includes any
major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. Present
health/illness includes information about all of the client’s current health-related issues,
concerns, and problems as well as the reason for seeking care.
Client Need Sub:
processes.
Question 19
Type: HOTSPOT
The nurse has created a pedigree for the client using the client’s family history information.
Which option points to the individual who is still alive, a male, and a widower?
C
A
B
1. A.
2. B.
3. C.
4. D.
Correct Answer: 1
Rationale 1: A square is used to denote a male. A circle is used to denote a female. Diagonal
lines through the shape indicate that the individual has died. Married individuals are linked by a
single horizontal line.
Global Rationale: A square is used to denote a male. A circle is used to denote a female.
Diagonal lines through the shape indicate that the individual has died. Married individuals are
linked by a single horizontal line.
Client Need Sub:
processes.
Question 20
Type: MCSA
Which is the purpose of a health history when admitting a client into the hospital with an
exacerbation of a chronic disease process?
1. Documenting the client response to health concerns.
2. Documenting the client’s dietary history.
3. Documenting the client’s stress management skills.
4. Documenting the client’s social interactions.
Correct Answer: 1
Rationale 1: The purpose of a health history during an acute exacerbation of a chronic disease
process is to document the client’s response to health concerns.

Rationale 2: While documenting a client’s dietary history is included in a wellness assessment,
this is not appropriate during an acute exacerbation of a chronic disease process.
Rationale 3: While documenting a client’s stress management skills is included in a wellness
assessment, this is not appropriate during an acute exacerbation of a chronic disease process.
Rationale 4: While documenting a client’s social interactions skills is included in a wellness
assessment, this is not appropriate during an acute exacerbation of a chronic disease process.
Global Rationale: The purpose of the health history is to document the responses of the client to
actual and potential health concerns. Thus, the health history includes a wellness assessment
covering questions on how the client optimizes health and well-being in such areas as nutrition,
stress management, and social interaction.
Client Need Sub:
Page Number: p. 127
Question 21
Type: MCMA
Which are appropriate focuses for the health history collected by the nurse?
1. Physical status.
2. Patterns of daily living.
3. Wellness practices.
4. Self-care activities.
5. Medical diagnoses.
Rationale 1: The nursing health history focuses on the patient’s physical status, patterns of daily
living, wellness practices, and self-care activities as well as psychosocial, cultural,
environmental, and other factors that influence health status.

Rationale 5: Medical diagnoses are the focus of the health history collected by the medical
practitioner, not the nurse.
Global Rationale: The nursing health history focuses on the patient’s physical status, patterns of
daily living, wellness practices, and self-care activities as well as psychosocial, cultural,
Client Need Sub:
Page Number: p. 127
Question 22
Type: MCSA
Which piece of information will the nurse collect when assessing the client’s past medical
history?
1. Name.
2. Marital status.
3. Childhood illnesses.
4. Reason for seeking care.
Correct Answer: 3
Rationale 1: Name is collected when assessing biographical information.
Rationale 2: Marital status is collected when assessing biographical information.
Rationale 3: While assessing the client’s past medical history, it is appropriate to assess
information regarding childhood illnesses.
Rationale 4: The reason for seeking care is assessed in present health or illness.
Global Rationale: While assessing the client’s past medical history, it is appropriate to assess
information regarding childhood illnesses. Name and marital status is collected when assessing
biographical information. The reason for seeking care is assessed in present health or illness.
Client Need Sub:

Page Number: p. 128
Question 23
Type: MCSA
While conducting a review of systems assessment during a health history, which question is
appropriate?
1. “Have you ever had a surgical procedure?”
2. “What is your level of education?”
3. “Are you currently taking any medication?”
4. “Do you have a history of respiratory issues?”
Correct Answer: 4
Rationale 1: Questions regarding a history of surgical procedures are appropriate when
assessing past history.
Rationale 2: Questions regarding level of education are appropriate when assessing a
psychosocial history.
Rationale 3: Questions regarding current medications are appropriate when assessing present
health or illness.
Rationale 4: While all of these questions are appropriate to include in a health history, the only
question that is appropriate while conducting a review of systems is the item that asks about a
history of respiratory issues.
Global Rationale: While all of these questions are appropriate to include in a health history, the
only question that is appropriate while conducting a review of systems is the item that asks about
a history of respiratory issues.
Cognitive Level: Analyzing
Client Need Sub:

Page Number: p. 128
Question 24
Type: MCSA
Which is the priority when assessing the client’s sexual history?
1. Determining sexual health.
2. Asking about sexual orientation.
3. Establishing rapport.
4. Assessing age of secondary sex characteristics.
Correct Answer: 3
Rationale 1: While determining sexual history is important, this is not the priority.
Rationale 2: While asking about sexual orientation is important, this is not the priority.
Rationale 3: When assessing sexual history, the priority is for the nurse to develop a rapport
with the client.
Rationale 4: While assessing the age the client developed secondary sexual characteristics is
important, this is not the priority.
Global Rationale: Ideally, to allow for a holistic approach to assessing and caring for the client,
biographic data should include information related to sexual health, including sexual orientation
label. However, discussion of sensitive information, including that related to sexual health and
practices, requires the nurse to first establish trust and a rapport with the client.
Page Number: p. 129
Question 25
Type: MCSA
The nurse wants to assess the client’s self-esteem and emotional state. Which question is most
appropriate for the nurse to ask this client?
1. “Can you describe the image that you see when looking in the mirror?”
2. “Tell me about your financial status?”
3. “How often do you have a bowel movement?”
4. “Have you ever contracted a sexually transmitted infection?”

Correct Answer: 1
Rationale 1: The nurse should be prepared to address areas concerned with the client’s self-
esteem and emotional state. For example, clients may be asked to describe their image in a
mirror.
Rationale 2: While questions about financial status are appropriate, this is not appropriate when
assessing self-esteem and emotional state.
Rationale 3: While questions about bowel function are appropriate, this is not appropriate when
assessing self-esteem and emotional state.
Rationale 4: While questions about sexually transmitted infections are appropriate, this is not
appropriate when assessing self-esteem and emotional state.
Global Rationale: The nurse should be prepared to address areas concerned with the client’s
self-esteem and emotional state. For example, clients may be asked to describe their image in a
mirror. While the other questions are appropriate for the health history, they are not appropriate
when assessing self-esteem or emotional state.
Client Need Sub:
Question 26
Type: MCSA
Which documentation is appropriate after assessing head, neck, and lymphatics?
1. Occasional headaches relieved by acetaminophen. No history of injury, seizure, tremor,
dizziness. No neck swelling.
2. Denies hearing problems, never had specific exam. Nose patent, no injury, sense of smell
intact, clear drainage with cold. No trouble eating or swallowing. Dental exam annually, last
exam one month ago. Brushes and flosses twice daily.
3. Denies problems. “My bowels move every day with no problem. I get diarrhea when I’m
nervous sometimes.” Active bowel sounds present in all quadrants. Abdomen soft and non-
tender to palpation.
4. Denies problems. No history of UTI. I pass urine five or six times a day and more if I drink
more.
Correct Answer: 1
Rationale 1: This documentation is appropriate for the head, neck, and lymphatics.

Rationale 2: This documentation is appropriate for the ears, nose, mouth, and throat.
Rationale 3: This documentation is appropriate for the abdomen.
Rationale 4: This documentation is appropriate for the urinary system.
Global Rationale: “Occasional headaches relieved by acetaminophen. No history of injury,
seizure, tremor, dizziness. No neck swelling.” is appropriate documentation when assessing
head, neck and lymphatics. The other pieces of documentation are appropriate for other body
systems.
Client Need Sub:
Page Number: p. 141
Question 27
Type: MCSA
The nurse in the clinic is assessing an adult client who has 2+ ankle edema, crackles throughout
the lung fields, and dyspnea on exertion. The nurse concludes that the client will need lifestyle-
change teaching. Which is an important area for the nurse to assess next during the health
history?
1. The client’s family history.
2. If the client eats foods high in salt.
3. How many children the client has.
4. If the client is married or divorced.
Correct Answer: 2
Rationale 1: Family history is an important part of data gathering, but does not address the
client’s current lifestyle.
Rationale 2: The nurse realizes the client may be experiencing heart failure and asks the client
questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure,
such as smoking and dietary habits.
Rationale 3: Gathering psychosocial information such as marriage and children is important, but
in this case the nurse focuses on the client’s current problem and teaching needs.
Rationale 4: Gathering psychosocial information such as marriage and children is important, but
in this case the nurse focuses on the client’s current problem and teaching needs.
Global Rationale: The nurse realizes the client may be experiencing heart failure and asks the
client questions aimed at obtaining the client’s lifestyle habits that can contribute to the heart

failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage
and children is important, but in this case the nurse focuses on the client’s current problem and
teaching needs. Family history is also an important part of data gathering, but does not address
the client’s current lifestyle.
Client Need Sub:
Question 28
Type: MCSA
The nurse is examining a client with congestive heart failure who takes propranolol and
furosemide. The client complains of fatigue and an inability to finish tasks. Which conclusion by
the nurse is the most appropriate?
1. The medication needs adjustment.
2. The client has not been exercising.
3. The client is experiencing expected manifestations of the disease process.
4. The client should be hospitalized.
Correct Answer: 3
Rationale 1: Fatigue is not an indication that the medication needs adjusting.
Rationale 2: A lack of exercise would not cause the client to experience fatigue severe enough
to prevent the completion of tasks.
Rationale 3: Heart failure and the drugs prescribed for it cause the client to be fatigued.
Although this would be considered abnormal in most clients, it is expected in the client with
heart failure.
Rationale 4: The client does not need to be hospitalized for fatigue.
Global Rationale: Heart failure and the drugs prescribed for it cause the client to be fatigued.
Although this would be considered abnormal in most clients, it is expected in the client with
heart failure. The client does not need to be hospitalized for fatigue. Fatigue is not an indication
that the medication needs adjusting. A lack of exercise would not cause the client to experience
fatigue severe enough to prevent the completion of tasks.
Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation
Question 29
Type: MCSA
In obtaining a past history as part of a history of present illness (HPI), the nurse asks the client
about allergies to drugs, animals, insects, and other environmental agents. In addition to this
information and asking about how the reaction is treated, which is the most important allergy-
related information that the nurse should inquire about?
1. The location where the reaction occurred.
2. The type of reaction that occurred with exposure.
3. Exactly how long the symptoms lasted.
4. Immediate and extended family members with the same allergy.
Correct Answer: 2
Rationale 1: The location where the reaction occurred might be helpful in discerning the
potential cause of current signs and symptoms of allergies and how long the symptoms lasted
(e.g., recently visiting a relative who has several cats with symptoms improving upon leaving the
home), but what reaction occurs with exposure has greater importance than this information
when asking about past history.
Rationale 2: In addition to identifying the specific allergen to which the client is allergic (that is,
drugs, animals, insects, environmental agents) and how the reaction is treated, the nurse should
always ask about the type of reaction that occurs with exposure to the allergen. What occurs with
exposure is especially important in order to be able to help identify the severity of any potential
exposure as well as to obtain a better understanding of an individual’s perspective of what
constitutes an “allergy.” For example, the implications of a client telling the nurse that he or she
has an anaphylactic reaction to bee stings or to penicillin differs from the implications of a client
who reports an “allergy” to mosquito bites, which become reddened and itch.
Rationale 3: The location where the reaction occurred might be helpful in discerning the
potential cause of current signs and symptoms of allergies and how long the symptoms lasted
(e.g., recently visiting a relative who has several cats with symptoms improving upon leaving the
home), but what reaction occurs with exposure has greater importance than this information
when asking about past history.
Rationale 4: Similarly, knowing that family members have the same allergy is not as critical as
discerning what occurs with exposure to various allergens.
Global Rationale: In addition to identifying the specific allergen to which the client is allergic

(that is, drugs, animals, insects, environmental agents) and how the reaction is treated, the nurse
should always ask about the type of reaction that occurs with exposure to the allergen. What
occurs with exposure is especially important in order to be able to help identify the severity of
any potential exposure as well as to obtain a better understanding of an individual’s perspective
of what constitutes an “allergy.” For example, the implications of a client telling the nurse that he
or she has an anaphylactic reaction to bee stings or to penicillin differs from the implications of a
client who reports an “allergy” to mosquito bites, which become reddened and itch. The location
where the reaction occurred might be helpful in discerning the potential cause of current signs
and symptoms of allergies and how long the symptoms lasted (e.g., recently visiting a relative
who has several cats with symptoms improving upon leaving the home), but what reaction
occurs with exposure has greater importance than this information when asking about past
history. Similarly, knowing that family members have the same allergy is not as critical as
discerning what occurs with exposure to various allergens.
Client Need Sub: Reduction of Risk Potential
Question 30
Type: MCSA
The nurse is constructing a pedigree for a client. Which symbol designates the client’s biological
parents?
1.
2.
3.
4.
Correct Answer: 1

Health and Physical Assessment In Nursing 3rd Edition DAmico Test Bank
Rationale 1: This symbol indicates the client’s biological parents when constructing a pedigree.
Rationale 2: This symbol indicates an unaffected female when constructing a pedigree.
Rationale 3: This symbol indicates an unaffected family member, sex unknown.
Rationale 4: This symbol indicates identical twins.
Global Rationale: The square symbol connected to the circle with a straight line is the symbol
that indicates the client’s biological parents. The other symbols indicate an unaffected female,
unaffected family member (sex unknown), and identical twins.
Cognitive Level: Remembering
Client Need Sub:
processes.
Page Number: p. 135

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