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TEST BANK FOR HEALTH ASSESSMENT FOR NURSING PRACTICE
GUIDELINES QUESTIONS AND DETAILED RATIONALES GRADED
A+
Test Bank for Health Assessment for Nursing Practice
SECTION 1: FOUNDATIONS OF HEALTH ASSESSMENT (25
Questions)
1. A patient comes to the emergency department and tells the triage nurse that he
is "having a heart attack." What is the nurse's top priority at this time?
A) Determine the patient's personal data and insurance coverage.
B) Ask the patient to take a seat in the waiting room until his name is called.
C) Request that a nurse collect data for a comprehensive history.
D) Ask a nurse to start a focused assessment of this patient now.
Answer: D
Rationale: The nurse needs to begin an assessment as soon as possible that is focused
on this patient's cardiovascular system. The type of health assessment performed by the
nurse is driven by patient need. Personal data and insurance information can wait until
after the patient is assessed. Based on Maslow's hierarchy of needs, physiologic needs
take precedence. A comprehensive history is not indicated at this time.
2. Which situation illustrates a screening assessment?
A) A patient visits an obstetric clinic for the first time and the nurse conducts a detailed
history and physical examination.
B) A hospital sponsors a health fair at a local mall and provides cholesterol and blood
pressure checks to mall patrons.
C) The nurse in an urgent care center checks the vital signs of a patient who is
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complaining of leg pain.
D) A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
glucose level.
Answer: B
Rationale: A health fair that provides cholesterol and blood pressure checks is an
example of a screening assessment focused on disease detection. A detailed history and
physical examination is a comprehensive assessment. Checking vital signs for a patient
with leg pain is a problem-based/focused assessment. A return appointment for fasting
blood glucose is an episodic or follow-up assessment.
3. After completing an initial assessment of a patient, the nurse has charted that
his respirations are eupneic and his pulse is 58 beats per minute. These types of
data would be:
A) Objective
B) Reflective
C) Subjective
D) Introspective
Answer: A
Rationale: Objective data are measurable, observable, and verifiable data obtained
through physical examination, observation, or diagnostic tests. Respirations and pulse
rate are examples of objective data because they can be measured and verified.
4. A patient tells the nurse that he is very nervous, is nauseated, and feels hot.
These types of data would be:
A) Objective
B) Reflective
C) Subjective
D) Introspective
Answer: C
Rationale: Subjective data are what the patient reports or feels. Symptoms such as
nervousness, nausea, and feeling hot are subjective because they are perceived and
reported by the patient and cannot be directly measured by the nurse.
5. The patient's record, laboratory studies, objective data, and subjective data
combine to form the:
A) Data base
B) Admitting data
C) Financial statement
D) Discharge summary
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Answer: A
Rationale: The data base includes all information about the patient, including the
patient's record, laboratory studies, objective data, and subjective data. This
comprehensive data set forms the foundation for clinical decision-making.
6. When listening to a patient's breath sounds, the nurse is unsure of a sound that
is heard. The nurse's next action should be to:
A) Immediately notify the patient's physician.
B) Document the sound exactly as it was heard.
C) Validate the data by asking a coworker to listen to the breath sounds.
D) Assess again in 20 minutes to note whether the sound is still present.
Answer: C
Rationale: When unsure of assessment findings, the nurse should validate the data by
asking a coworker to listen and confirm the findings. This ensures accuracy before
documenting or notifying the provider.
7. For which person is a screening assessment indicated?
A) The person who had abdominal surgery yesterday
B) The person who is unaware of his high serum glucose levels
C) The person who is being admitted to a long-term care facility
D) The person who is beginning rehabilitation after a knee replacement
Answer: B
Rationale: A screening assessment is performed for the purpose of disease detection. In
this case, this person may have diabetes mellitus. A shift assessment is most appropriate
for the person recovering from surgery. A comprehensive assessment is performed
during admission to a facility.
8. The nurse is performing a physical assessment on a newly admitted patient. An
example of objective information obtained during the physical assessment
includes:
A) Patient's history of allergies
B) Patient's use of medications at home
C) Last menstrual period
D) 2 × 5 cm scar on the right lower forearm
Answer: D
Rationale: Objective data are measurable and observable. A scar is a physical finding
that can be seen and measured, making it objective data.
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9. A visiting nurse is making an initial home visit for a patient who has many
chronic medical problems. Which type of data base is most appropriate to collect?
A) A follow-up data base to evaluate changes at the time of subsequent visits
B) A problem-centered data base because the patient has multiple problems
C) A complete data base because it is the initial home visit
D) An emergency data base because of the need to collect information and institute
immediate action
Answer: C
Rationale: A complete data base is collected during an initial visit and includes a full
health history and physical examination, providing a baseline for future assessments.
10. Which of the following is considered a focused assessment?
A) A nurse assesses a patient's overall health status during an annual physical.
B) A nurse assesses a patient's chest pain in the emergency department.
C) A nurse collects a comprehensive health history for a new patient.
D) A nurse performs a screening for diabetes at a health fair.
Answer: B
Rationale: A focused assessment addresses a specific problem or concern, such as chest
pain in the emergency department.
11. The nurse is preparing to conduct a health history. Which of these statements
best describes the purpose of a health history?
A) To provide an opportunity for interaction between the patient and the nurse
B) To provide a form for obtaining the patient's biographic information
C) To document the normal and abnormal findings of a physical assessment
D) To provide a data base of subjective information about the patient's past and current
health
Answer: D
Rationale: The health history provides a data base of subjective information about the
patient's past and current health status.
12. A patient is brought to the emergency department by ambulance after a motor
vehicle accident. Which type of assessment should the nurse perform?
A) Comprehensive assessment
B) Focused assessment
C) Emergency assessment
D) Screening assessment
TEST BANK FOR HEALTH ASSESSMENT FOR NURSING PRACTICE
GUIDELINES QUESTIONS AND DETAILED RATIONALES GRADED
A+
Test Bank for Health Assessment for Nursing Practice
SECTION 1: FOUNDATIONS OF HEALTH ASSESSMENT (25
Questions)
1. A patient comes to the emergency department and tells the triage nurse that he
is "having a heart attack." What is the nurse's top priority at this time?
A) Determine the patient's personal data and insurance coverage.
B) Ask the patient to take a seat in the waiting room until his name is called.
C) Request that a nurse collect data for a comprehensive history.
D) Ask a nurse to start a focused assessment of this patient now.
Answer: D
Rationale: The nurse needs to begin an assessment as soon as possible that is focused
on this patient's cardiovascular system. The type of health assessment performed by the
nurse is driven by patient need. Personal data and insurance information can wait until
after the patient is assessed. Based on Maslow's hierarchy of needs, physiologic needs
take precedence. A comprehensive history is not indicated at this time.
2. Which situation illustrates a screening assessment?
A) A patient visits an obstetric clinic for the first time and the nurse conducts a detailed
history and physical examination.
B) A hospital sponsors a health fair at a local mall and provides cholesterol and blood
pressure checks to mall patrons.
C) The nurse in an urgent care center checks the vital signs of a patient who is
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complaining of leg pain.
D) A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
glucose level.
Answer: B
Rationale: A health fair that provides cholesterol and blood pressure checks is an
example of a screening assessment focused on disease detection. A detailed history and
physical examination is a comprehensive assessment. Checking vital signs for a patient
with leg pain is a problem-based/focused assessment. A return appointment for fasting
blood glucose is an episodic or follow-up assessment.
3. After completing an initial assessment of a patient, the nurse has charted that
his respirations are eupneic and his pulse is 58 beats per minute. These types of
data would be:
A) Objective
B) Reflective
C) Subjective
D) Introspective
Answer: A
Rationale: Objective data are measurable, observable, and verifiable data obtained
through physical examination, observation, or diagnostic tests. Respirations and pulse
rate are examples of objective data because they can be measured and verified.
4. A patient tells the nurse that he is very nervous, is nauseated, and feels hot.
These types of data would be:
A) Objective
B) Reflective
C) Subjective
D) Introspective
Answer: C
Rationale: Subjective data are what the patient reports or feels. Symptoms such as
nervousness, nausea, and feeling hot are subjective because they are perceived and
reported by the patient and cannot be directly measured by the nurse.
5. The patient's record, laboratory studies, objective data, and subjective data
combine to form the:
A) Data base
B) Admitting data
C) Financial statement
D) Discharge summary
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Answer: A
Rationale: The data base includes all information about the patient, including the
patient's record, laboratory studies, objective data, and subjective data. This
comprehensive data set forms the foundation for clinical decision-making.
6. When listening to a patient's breath sounds, the nurse is unsure of a sound that
is heard. The nurse's next action should be to:
A) Immediately notify the patient's physician.
B) Document the sound exactly as it was heard.
C) Validate the data by asking a coworker to listen to the breath sounds.
D) Assess again in 20 minutes to note whether the sound is still present.
Answer: C
Rationale: When unsure of assessment findings, the nurse should validate the data by
asking a coworker to listen and confirm the findings. This ensures accuracy before
documenting or notifying the provider.
7. For which person is a screening assessment indicated?
A) The person who had abdominal surgery yesterday
B) The person who is unaware of his high serum glucose levels
C) The person who is being admitted to a long-term care facility
D) The person who is beginning rehabilitation after a knee replacement
Answer: B
Rationale: A screening assessment is performed for the purpose of disease detection. In
this case, this person may have diabetes mellitus. A shift assessment is most appropriate
for the person recovering from surgery. A comprehensive assessment is performed
during admission to a facility.
8. The nurse is performing a physical assessment on a newly admitted patient. An
example of objective information obtained during the physical assessment
includes:
A) Patient's history of allergies
B) Patient's use of medications at home
C) Last menstrual period
D) 2 × 5 cm scar on the right lower forearm
Answer: D
Rationale: Objective data are measurable and observable. A scar is a physical finding
that can be seen and measured, making it objective data.
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9. A visiting nurse is making an initial home visit for a patient who has many
chronic medical problems. Which type of data base is most appropriate to collect?
A) A follow-up data base to evaluate changes at the time of subsequent visits
B) A problem-centered data base because the patient has multiple problems
C) A complete data base because it is the initial home visit
D) An emergency data base because of the need to collect information and institute
immediate action
Answer: C
Rationale: A complete data base is collected during an initial visit and includes a full
health history and physical examination, providing a baseline for future assessments.
10. Which of the following is considered a focused assessment?
A) A nurse assesses a patient's overall health status during an annual physical.
B) A nurse assesses a patient's chest pain in the emergency department.
C) A nurse collects a comprehensive health history for a new patient.
D) A nurse performs a screening for diabetes at a health fair.
Answer: B
Rationale: A focused assessment addresses a specific problem or concern, such as chest
pain in the emergency department.
11. The nurse is preparing to conduct a health history. Which of these statements
best describes the purpose of a health history?
A) To provide an opportunity for interaction between the patient and the nurse
B) To provide a form for obtaining the patient's biographic information
C) To document the normal and abnormal findings of a physical assessment
D) To provide a data base of subjective information about the patient's past and current
health
Answer: D
Rationale: The health history provides a data base of subjective information about the
patient's past and current health status.
12. A patient is brought to the emergency department by ambulance after a motor
vehicle accident. Which type of assessment should the nurse perform?
A) Comprehensive assessment
B) Focused assessment
C) Emergency assessment
D) Screening assessment
