Nursing Health Assessment A Best Practice
Approach 4th Edition Jensen Test Bank
Course
Nursing Health Assessment A Best Practice
Approach
Question 1
During the health history interview, which action best promotes a therapeutic nurse-patient
relationship?
A. Asking only closed-ended questions
B. Frequently interrupting the patient
C. Using active listening and open-ended questions
D. Completing the assessment as quickly as possible
Answer: C. Using active listening and open-ended questions
Rationale:
Open-ended questions encourage patients to describe their concerns in their own words. Active
listening promotes trust, improves communication, and results in a more comprehensive health
history.
Question 2
Which component of the health history is collected first?
A. Family history
B. Review of systems
C. Biographical data
D. Past medical history
Answer: C. Biographical data
Rationale:
Biographical information (name, age, sex, occupation, and source of information) establishes
patient identification and begins the assessment process.
Question 3
,A patient states, "I've had chest pain for two days." Which assessment framework best explores
this complaint?
A. Glasgow Coma Scale
B. PQRST symptom analysis
C. Braden Scale
D. Morse Fall Scale
Answer: B. PQRST symptom analysis
Rationale:
PQRST (Provocation, Quality, Region/Radiation, Severity, Time) systematically evaluates
symptoms and guides clinical decision-making.
Question 4
Which vital sign is generally considered the most sensitive indicator of physiological instability?
A. Respiratory rate
B. Pulse rate
C. Temperature
D. Blood pressure
Answer: A. Respiratory rate
Rationale:
Changes in respiratory rate often occur before changes in other vital signs during clinical
deterioration.
Question 5
The normal adult oral body temperature is approximately:
A. 34.5°C (94.1°F)
B. 37°C (98.6°F)
C. 38.8°C (101.8°F)
D. 39.5°C (103.1°F)
Answer: B. 37°C (98.6°F)
,Rationale:
Normal oral temperature averages 37°C (98.6°F), though slight variations occur throughout the
day.
Question 6
When palpating the abdomen, the nurse should assess for:
A. Tenderness and masses
B. Heart murmurs
C. Lung resonance
D. Pupillary response
Answer: A. Tenderness and masses
Rationale:
Palpation identifies tenderness, organ enlargement, masses, guarding, and rigidity.
Question 7
Which assessment technique should be performed FIRST during the abdominal examination?
A. Palpation
B. Percussion
C. Inspection
D. Deep palpation
Answer: C. Inspection
Rationale:
The abdominal assessment sequence is Inspection → Auscultation → Percussion → Palpation to
avoid altering bowel sounds.
Question 8
Normal bowel sounds are typically heard:
A. Every 30 seconds
B. Every 5–15 seconds
, C. Once every minute
D. Every 2 minutes
Answer: B. Every 5–15 seconds
Rationale:
Normal bowel sounds occur approximately 5–30 times per minute.
Question 9
When assessing skin turgor, decreased elasticity may indicate:
A. Fever
B. Dehydration
C. Hypertension
D. Hyperglycemia
Answer: B. Dehydration
Rationale:
Poor skin recoil commonly reflects decreased hydration, particularly in younger adults.
Question 10
Which finding is considered a normal age-related skin change in older adults?
A. Increased skin elasticity
B. Thinner, drier skin
C. Excessive diaphoresis
D. Increased subcutaneous fat
Answer: B. Thinner, drier skin
Rationale:
Aging causes decreased collagen, reduced sebaceous gland activity, and thinner epidermis.
Question 11
A normal adult pulse rate ranges from:
Approach 4th Edition Jensen Test Bank
Course
Nursing Health Assessment A Best Practice
Approach
Question 1
During the health history interview, which action best promotes a therapeutic nurse-patient
relationship?
A. Asking only closed-ended questions
B. Frequently interrupting the patient
C. Using active listening and open-ended questions
D. Completing the assessment as quickly as possible
Answer: C. Using active listening and open-ended questions
Rationale:
Open-ended questions encourage patients to describe their concerns in their own words. Active
listening promotes trust, improves communication, and results in a more comprehensive health
history.
Question 2
Which component of the health history is collected first?
A. Family history
B. Review of systems
C. Biographical data
D. Past medical history
Answer: C. Biographical data
Rationale:
Biographical information (name, age, sex, occupation, and source of information) establishes
patient identification and begins the assessment process.
Question 3
,A patient states, "I've had chest pain for two days." Which assessment framework best explores
this complaint?
A. Glasgow Coma Scale
B. PQRST symptom analysis
C. Braden Scale
D. Morse Fall Scale
Answer: B. PQRST symptom analysis
Rationale:
PQRST (Provocation, Quality, Region/Radiation, Severity, Time) systematically evaluates
symptoms and guides clinical decision-making.
Question 4
Which vital sign is generally considered the most sensitive indicator of physiological instability?
A. Respiratory rate
B. Pulse rate
C. Temperature
D. Blood pressure
Answer: A. Respiratory rate
Rationale:
Changes in respiratory rate often occur before changes in other vital signs during clinical
deterioration.
Question 5
The normal adult oral body temperature is approximately:
A. 34.5°C (94.1°F)
B. 37°C (98.6°F)
C. 38.8°C (101.8°F)
D. 39.5°C (103.1°F)
Answer: B. 37°C (98.6°F)
,Rationale:
Normal oral temperature averages 37°C (98.6°F), though slight variations occur throughout the
day.
Question 6
When palpating the abdomen, the nurse should assess for:
A. Tenderness and masses
B. Heart murmurs
C. Lung resonance
D. Pupillary response
Answer: A. Tenderness and masses
Rationale:
Palpation identifies tenderness, organ enlargement, masses, guarding, and rigidity.
Question 7
Which assessment technique should be performed FIRST during the abdominal examination?
A. Palpation
B. Percussion
C. Inspection
D. Deep palpation
Answer: C. Inspection
Rationale:
The abdominal assessment sequence is Inspection → Auscultation → Percussion → Palpation to
avoid altering bowel sounds.
Question 8
Normal bowel sounds are typically heard:
A. Every 30 seconds
B. Every 5–15 seconds
, C. Once every minute
D. Every 2 minutes
Answer: B. Every 5–15 seconds
Rationale:
Normal bowel sounds occur approximately 5–30 times per minute.
Question 9
When assessing skin turgor, decreased elasticity may indicate:
A. Fever
B. Dehydration
C. Hypertension
D. Hyperglycemia
Answer: B. Dehydration
Rationale:
Poor skin recoil commonly reflects decreased hydration, particularly in younger adults.
Question 10
Which finding is considered a normal age-related skin change in older adults?
A. Increased skin elasticity
B. Thinner, drier skin
C. Excessive diaphoresis
D. Increased subcutaneous fat
Answer: B. Thinner, drier skin
Rationale:
Aging causes decreased collagen, reduced sebaceous gland activity, and thinner epidermis.
Question 11
A normal adult pulse rate ranges from:
