Test Bank for Contemporary Medical Surgical Nursing, 2nd Edition : Daniels

Test Bank for Contemporary Medical Surgical

Nursing, 2nd Edition : Daniels

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Chapter 8--Health 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: 1 DIF: Apply REF: 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: 1 DIF: Understand REF: 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: 1 DIF: Analyze REF: 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: 1 DIF: Analyze REF: 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: 1 DIF: Apply

REF: Nursing Strategy: Parts of Hand Used for Palpation

8. The nurse is using percussion to assess a client’s 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 won’t 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: 1 DIF: 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 client’s 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: 1 DIF: 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 client’s 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: 1 DIF: Apply REF: 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 client’s activities of daily living. Which of the following will be included in
this nurse’s 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 client’s 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
client’s 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 nurse’s 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 nurse’s 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: 1 DIF: 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 one’s own
Test Bank for Contemporary Medical Surgical Nursing, 2nd Edition : Daniels

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 one’s own cultural beliefs related
to health and health care. Cultural knowledge includes becoming knowledgeable about the
predominant cultural groups within one’s 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: 1 DIF: Apply

REF: Nursing Strategy: Prepare Yourself for the Patient Interview

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