Health Assessment in Nursing 5th Edition by Janet R. Weber, Jane H. Kelley – Test Bank

 

 

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Sample Test

 cHAPTER 0

Page 1
1. A client 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?
A) Explain the purpose of the interview to the client.
B) Construct the client’s family genogram.
C) Establish the client’s reliability as historian.
D) Collect necessary equipment essential to the exam.
2. A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test
and pelvic examination. The nurse is implementing actions to help reduce a client’s
anxiety during the physical exam. Which of the following would be most appropriate?
A) Ensuring client’s privacy by providing an examination gown
B) Providing a comfortable, warm room temperature
C) Arranging exam equipment on a bedside tray table
D) Explaining why standard precautions are being used
3. A nurse is admitting a new client 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?
A) Performing hand hygiene between examinations of each body part
B) Discarding in the trash can the safety pin that was used to assess sensory perception
C) Wearing gloves to palpate the tongue and buccal membranes
D) Wearing a gown, gloves, and mask during the physical exam
4. The nurse is using a Wood’s light for a client who has complaints of itching, burning,
and peeling of the skin between his toes. The nurse is assessing for what etiology of the
client’s symptoms?
A) Parasitic infection
B) Fungal infection
C) Bacterial infection
D) Allergic reaction
5. A nurse has gathered the necessary equipment for the physical assessment of an adult
client. For which of the following assessments would it be most appropriate for a nurse
to use a centimeter-scale ruler for measurement?
A) Mid-arm circumference
B) Client’s height
C) Skin lesion size
D) Pupillary size
Page 2
6. The nurse is preparing to assess an older adult client’s near vision. Which of the
following pieces of equipment would be most appropriate for the nurse to use?
A) Newspaper
B) Snellen chart
C) Ophthalmoscope
D) Penlight
7. A nurse practitioner is performing a comprehensive physical examination of a 51-yearold
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?
A) Parasites
B) Blood
C) Bacteria
D) Fungus
8. The nurse is examining an older adult client and using a goniometer. Which of the
following would the nurse be assessing?
A) Extremity edema
B) Joint flexion/extension
C) Two-point discrimination
D) Vibratory sensation
9. A female client 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?
A) Explain the importance of the pelvic exam and Pap smear, but respect the client’s
wishes and omit the exam.
B) Tell the client that this is the only way she can be checked for cancer.
C) Ask the client if she would prefer another practitioner to perform the exam.
D) Proceed with the pelvic exam and document the client’s protests in the health
record.
10. The nurse is preparing to perform a physical examination on a female client who has
been transferred to the medical unit from the emergency department. The nurse should
begin the collection of objective data with which of the following examinations?
A) Head and neck examination
B) Palpation of lymph nodes
C) Breast examination
D) Vital signs
Page 3
11. The nurse is to collect a throat culture from a client who has signs and symptoms of a
respiratory infection, including frequent, productive coughing. The nurse demonstrates
the best adherence to standard precautions by using which of the following pieces of
equipment?
A) Eye goggles
B) Face mask
C) Cover gown
D) Face shield
12. The nurse is preparing to perform the physical examination of an older adult client who
will begin rehabilitation from an ischemic stroke. Which of the following actions would
be most appropriate?
A) Omit intrusive parts of the exam.
B) Try to minimize position changes.
C) Allow client to remain dressed.
D) Dim the room light to ensure privacy.
13. The nurse is preparing to assess the peripheral pulses of a client. The nurse should place
the client in which position?
A) Sitting upright
B) Supine
C) Sims position
D) Prone
14. When assessing the temperature of the feet of an older client with diabetes, the nurse
would use which part of the hand to obtain the most accurate assessment data?
A) Finger pad surface
B) Palmar hand surface
C) Dorsal hand surface
D) Ulnar hand surface
15. A client has a documented history of hepatomegaly (liver enlargement), and the nurse
recognizes the need to perform deep palpation during the physical assessment. The
nurse should perform which of the following actions?
A) Use one hand and depress the skin 1 centimeter.
B) Use the dominant hand to depress the skin one-half to three-quarters of an inch.
C) Use both hands to depress the skin one-half of an inch.
D) Use both hands to depress the skin 1 to 2 inches.
Page 4
16. The emergency department (ED) nurse is assessing for kidney tenderness in a client
who has presented with complaints of dysuria and back pain. What assessment
technique should the nurse utilize?
A) Deep palpation
B) Indirect percussion
C) Moderate palpation
D) Blunt percussion
17. In the course of performing a client’s physical assessment, the nurse has changed from
using the diaphragm of the stethoscope to using the bell. The nurse is most likely
assessing which of the following?
A) Heart sounds
B) Bowel sounds
C) Breath sounds
D) Femoral pulses
18. An instructor is teaching a student about the proper use of a stethoscope. The instructor
determines the need for additional teaching when the student states which of the
following?
A) ìPlastic tubing should be longer than 3 feet.î
B) ìThe bell is used after using the diaphragm.î
C) ìWhen using the bell, push on it lightly.î
D) ìA diaphragm picks up low-pitched sounds.î
19. A nurse is preparing to perform the physical examination of an adult client who has
presented to the clinic for the first time. Which of the following statements should guide
the nurse’s use of a stethoscope during this phase of assessment?
A) Auscultation can be performed through clothing.
B) The diaphragm should be held firmly against the body part.
C) The bell of the stethoscope can best detect bowel sounds.
D) Use of the bell is reserved for advanced practice nurses.
20. A nurse is appraising a colleague’s assessment technique as part of a continuing
education initiative. The nurse demonstrates the proper technique for light palpation by
performing which of the following actions?
A) Depressing the skin 1 to 2 centimeters with the dominant hand
B) Feeling the surface structures using a circular motion
C) Placing the nondominant hand on top of the dominant hand
D) Using one hand to apply pressure and the other hand to feel the structure
Page 5
21. The nurse is preparing to examine an older adult client. Which of the following would
be most appropriate for the nurse to do during the examination?
A) Complete the examination as quickly as possible.
B) Speak clearly and slowly when explaining a procedure.
C) Begin the examination with auscultation instead of inspection.
D) Maintain the supine position for each part of the examination.
22. The nurse assists a client into the dorsal recumbent position. Assessment of which area
is contraindicated when the client is in this position?
A) Chest
B) Head
C) Peripheral pulses
D) Abdomen
23. The nurse is gathering the necessary equipment preparatory to examining a client’s ears.
The nurse will be checking bone and air conduction of sound. Which of the following
should the nurse obtain?
A) Penlight
B) Tongue depressor
C) Tuning fork
D) Otoscope
24. The nurse is evaluating the setting prior to beginning a client’s physical examination.
The nurse should confirm the presence of which of the following? Select all that apply.
A) Adequate lighting
B) Cool room temperature
C) Quiet surroundings
D) Soft chair or table
E) Table for equipment
F) Door or curtain
25. The nurse is using her fingerpads to palpate a client’s body part during the physical
examination. Which of the following would the nurse best be able to detect?
A) Temperature
B) Vibrations
C) Pulses
D) Fremitus
Page 6
26. A nurse is reviewing the four basic physical examination techniques and their sequence
prior to receiving a new client from postanesthetic recovery. The nurse should plan to
perform which technique first?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
27. The nurse is percussing the area over the client’s lungs and hears a loud, low-pitched,
hollow sound. The nurse documents this finding as which of the following?
A) Flatness
B) Resonance
C) Tympany
D) Dullness
28. A 20-year-old female client has presented to the clinic, and the nurse is preparing to
perform a comprehensive assessment. The client states, ìI’d really like to have my mom
in the room. That’s okay, isn’t it?î How should the nurse best respond to the client’s
request?
A) ìOf course. There’s a chair in the exam room where she can sit.î
B) ìThat’s no problem. I’ll just have to get you to sign a privacy waiver first.î
C) ìThat’s fine, but be aware that some of the examinations might be embarrassing for
you or her.î
D) ìIt’s best to undergo the examination alone in order to make sure I get accurate
data, but if you really want her present, we can do that.î
29. The nurse is inspecting the dominant hand of an older adult client and notes the
presence of irregularly shaped brown lesions on the dorsal surface of the client’s hand.
What action should the nurse perform next?
A) Obtain a tissue sample for pathology
B) Compare the appearance of the client’s other hand
C) Palpate the lesions for tenderness and warmth
D) Perform health promotion teaching about sun protection
30. A young man has presented to the clinic with a 2-week history of head congestion,
fever, and malaise. What assessment technique should the nurse utilize to assess for
sinus tenderness?
A) Light palpation
B) Deep palpation
C) Direct percussion
D) Blunt percussion
Page 7
Page 8
Answer Key
1. D
2. A
3. C
4. B
5. C
6. A
7. B
8. B
9. A
10. D
11. D
12. B
13. B
14. C
15. D
16. D
17. A
18. C
19. B
20. B
21. B
22. D
23. C
24. A, C, E, F
25. C
26. A
27. B
28. A
29. B
30. C

 

CHAPTER 04

Page 1
1. A nurse is completing the intake assessment of an older adult who has just relocated to a
long-term care facility. Which of the following nursing actions would be most important
to ensure accurate data when gathering the resident’s information?
A) Documenting the data
B) Validating the data
C) Identifying client support systems
D) Determining client needs
2. A nurse is assessing a female client whose worsening sciatica has prompted her to seek
care. Which of the client’s following statements would the nurse most likely need to
validate?
A) ìI don’t generally have problems with pain.î
B) ìI feel very weak and tired right now.î
C) ìI’ve had two cesarean deliveries.î
D) ìMy mother died of breast cancer in her sixties.î
3. A client who had a mastectomy is being discharged home on postoperative day 1.
Knowing that the client lives alone, which data would be most important for the nurse to
validate for this client?
A) If the client has transportation for follow-up appointments
B) If the client usually functions independently
C) What support systems are in place to assist the client
D) If the client has a religious belief regarding illness
4. When describing the importance of documenting initial assessment data to a group of
new nurses, which of the following would the nurse emphasize as the primary reason?
A) Health care institutions have established policies regarding documentation.
B) Incorrect conclusions may be made without documentation of the nurse’s opinions.
C) It satisfies legal standards established by health care organizations and institutions.
D) It becomes the foundation for the entire nursing process.
5. A nurse has documented the nursing history and physical examination of a client. This
health information is best described as which of the following?
A) Subjective data and objective data
B) Interpretation and inference
C) Observation and inspection
D) Data and results
Page 2
6. The nurse is caring for a client with influenza symptoms and is documenting the initial
and ongoing assessment database. Which of the following would the nurse emphasize as
the major rationale for this action?
A) Reducing the fragmentation of care
B) Maximizing the efficiency of care
C) Promoting communication between disciplines
D) Facilitating achievement of professional standards
7. A nurse has completed a client’s initial assessment and is now interpreting and making
inferences from the data. The nurse is involved in which phase of the nursing process?
A) Analysis
B) Planning
C) Implementation
D) Evaluation
8. A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal
findings on her recent mammogram. Which of the following statements best reflects
appropriate documentation by the nurse?
A) ìClient depressed because of fear of breast biopsyî
B) ìClient with lower back painî
C) ìClient has unkempt appearance and avoids eye contactî
D) ìClient has good lung sounds in right and left lungsî
9. A nurse is working in a health care facility that uses charting by exception. Which of the
following would the nurse expect to document?
A) Liver palpation normal
B) No tenderness on palpation
C) Bowel sounds normoactive
D) Decreased range of motion in right shoulder
10. A task force has been established at a hospital with the aim of overhauling the
assessment forms that are used throughout the facility. Which of the following options is
most likely to help standardize the process of data collection?
A) Open-ended form
B) Integrated cued checklist form
C) Cued or checklist form
D) Nursing minimum data set
Page 3
11. A nurse is providing in-service training to a group of nurses in a facility that has just
begun to use an integrated cued checklist for documentation. Which of the following
would the nurse identify as a major advantage of this type of documentation?
A) It helps nurses to cluster assessment data.
B) It provides lines for the nurses’ comments.
C) It includes specialized data particular to each client.
D) It standardizes data collection.
12. A group of nursing students is reviewing the purposes of assessment documentation in
preparation for a class discussion. The students demonstrate understanding of the
information when they identify which of the following as one of the primary purposes?
A) It provides a chronologic source of client assessment data.
B) It creates a database for care that was not rendered to the client.
C) It replaces the client acuity classification system.
D) It directly formulates the nursing diagnoses.
13. A nurse is comparing the subjective data and objective data obtained from an
assessment of a client who is thought to have hepatitis A. This nurse’s comparison will
achieve what benefit to this client’s care?
A) Formulation of nursing diagnoses
B) Identification of missing data
C) Determination of documentation form to use
D) Validation of data
14. A nurse is preparing an in-service education program for a group of staff nurses about
documentation, including documentation of assessment data. The nurse demonstrates
understanding of the significance of documentation by including a discussion of which
of the following as playing a role in this area? Select all that apply.
A) Joint Commission
B) State nurse practice act
C) Medicare
D) Local or city government
E) Institutional agency
15. A nurse has completed an assessment of a client with cholecystitis and is about to
document the findings. Which statement best reflects accurate documentation?
A) Client appears upset about upcoming surgery.
B) Client was interviewed about previous history of hypertension.
C) Skin pale, warm, and dry without evidence of lesions.
D) Client’s oral intake is satisfactory.
Page 4
16. A nurse is using a nursing minimum data set to document findings following the
assessment of a client. This nurse is most likely providing care in which setting?
A) Acute care facility
B) Long-term care facility
C) Urgent care center
D) Health clinic
17. While performing the initial assessment of a client, the client tells the nurse that this is
his first hospitalization and that he has no previous surgeries. The nurse should
document which of the following?
A) Client denies prior hospitalizations and surgeries
B) Client has not been hospitalized before nor has he had any surgery
C) Client answered no to previous hospitalizations or surgery
D) Negative for past hospitalizations
18. An instructor is describing various ways that a nurse can validate data to a group of
nursing students. The instructor determines that additional teaching is necessary when
the students identify which of the following as a reliable method?
A) Repeating the assessment
B) Asking additional questions
C) Having the client repeat what was said
D) Checking findings with another health care professional
19. A nurse is working on an acute neurological unit. Which assessment form would the
nurse most likely use to document assessment data?
A) Open-ended form
B) Focused assessment form
C) Frequent assessment form
D) Ongoing assessment form
20. A group of students is reviewing information from class about the purposes of
assessment documentation. The students demonstrate understanding of the material
when they state which of the following?
A) ìDocumentation helps support reimbursement but gives little epidemiologic data.î
B) ìDocumentation provides a permanent legal record of care given and not given.î
C) ìDocumentation is a viable means of communication but is repetitious.î
D) ìDocumentation helps determine client education needs but not staff mix.î
Page 5
21. A nurse is providing a verbal update to a client’s primary care provider because of the
client’s worsening nausea. When using an SBAR format to provide a report, the nurse
should complete the report with which of the following statements?
A) ìWhat would you like to do to address this client’s nausea?î
B) ìI think this client would benefit from an antiemetic.î
C) ìThis client has no recent history of any nausea or vomiting.î
D) ìThis client rates his nausea as seven out of ten.î
22. A surgical client’s pain has become increasingly severe overnight, and she has received
her maximum current doses of analgesics. The nurse has consequently phoned the
surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new
order, how should the nurse best validate this information?
A) Read the order back to the surgeon for confirmation.
B) Compare the order with the standard timing and dosage of the analgesic.
C) Compare the order to the client’s existing medication administration record (MAR).
D) Have another nurse read the order that the nurse has transcribed.
23. An audit of a hospital unit’s incident reports reveals that several errors have resulted
from incomplete or inaccurate information during change-of-shift handoff. In order to
prevent such errors, what practice should be encouraged on the unit?
A) Delegate handoff reports to unlicensed care providers who have fewer demands on
their time.
B) Use an intermediary to receive report from the first nurse and then provide the
handoff report to the second nurse.
C) Involve as few people as possible in the verbal report.
D) Encourage nurses to perform handoff as quickly as possible.
24. A client has illuminated his call light and tells the nurse that he is having ìten out of tenî
pain. The nurse’s initial inspection reveals that the client is watching videos on his tablet
computer and appears to be at ease physically and emotionally. How should the nurse
validate the client’s subjective complaint of pain?
A) Ask the client to repeat his rating of his pain.
B) Observe the client for several seconds to see if his demeanor or his behavior
changes.
C) Consult the client’s medication administration record (MAR) to check for recent
analgesic use.
D) Perform further assessments addressing various aspects of the client’s pain.
Page 6
25. A hospital nurse is admitting a client with a documented history of acute pancreatitis,
liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding
would most clearly warrant validation?
A) The client’s blood pressure is 148/88 mm Hg.
B) The client is oriented to person and place but not to time.
C) The client states that she only drinks alcohol on a social basis.
D) The client states, ìMy skin’s kind of yellow because of my liver.î
26. A small, rural hospital is revising the policies and procedures surrounding
documentation in an effort to align practices with the Health Information Technology
for Economic and Clinical Health (HITECH) Act. How can the requirements of this
legislation best be met?
A) Expand the use of the Nursing Minimum Data Set.
B) Eliminate the use of verbal handoffs between nurses.
C) Increase interdisciplinary collaboration in the hospital.
D) Increase the use of electronic health records (EHRs) in the hospital.
27. The nurse is reviewing and analyzing data from the initial assessment of a newly
admitted client who is a 79-year-old man. What assessment finding most clearly
indicates a need for further data?
A) The man has male pattern baldness.
B) The man has a diffuse rash on his torso.
C) The man’s heart rate is 63 beats per minute.
D) The man had an inguinal hernia repair in 2008.
28. There has been some resistance to the planned transition to electronic health records
(EHRs) in a hospital system, with many caregivers questioning the rationale for this
change in practice. What potential advantage of EHRs should administrators cite?
A) Increased influence for the nursing profession
B) Elimination of documentation
C) Improved continuity of care
D) Reduced nursing workload
29. While assisting an older adult with morning hygiene, the nurse notes a lesion on the
client’s coccyx region. How should the nurse best document this objective assessment
finding?
A) ìPossible pressure ulcer observed over client’s coccyx region.î
B) ìReddened area noted on skin surface superficial to client’s coccyx.î
C) ìArea of nonblanching erythema noted over client’s coccyx, 2 cm ◊ 2 cm.î
D) ìImpaired Skin Integrity related to decreased mobility.î
Page 7
30. A nurse is conscientious in adhering to the requirements of the Health Insurance
Portability and Accountability Act (HIPAA) when providing care for clients. What
action best meets these legal requirements for care?
A) Having a colleague audit the nurse’s documentation to ensure objectivity
B) Maintaining the privacy and confidentiality of clients’ medical records
C) Using electronic records whenever possible, rather than paper-based records
D) Collaborating with the client and his or her family prior to documenting
Page 8
Answer Key
1. B
2. A
3. C
4. D
5. A
6. C
7. A
8. C
9. D
10. C
11. A
12. A
13. D
14. A, B, C, E
15. C
16. B
17. A
18. C
19. B
20. B
21. B
22. A
23. C
24. D
25. C
26. D
27. B
28. C
29. C
30. B