TEST BANK FOR:
Nursing Health Assessment: A Best Practice
Approach 3rd Edition
By Sharon Jensen Latest Update.
WWW.THENURSINGMASTERY.COM
,Table Of Contents
Chapter 1. Nurse’s Role In Health Assessment ............................................................................................................................ 2
Chapter 2. The Interview And Health History............................................................................................................................ 12
Chapter 3. Techniques Of Physical Assessment ......................................................................................................................... 30
Chapter 4. Documentation And Interdisciplinary Communication ............................................................................................. 43
Chapter 5. Vital Signs And General Survey ............................................................................................................................... 54
Chapter 6. Pain Assessment....................................................................................................................................................... 72
Chapter 7. Nutrition Assessment ................................................................................................................................................ 77
Chapter 8. Assessment Of Developmental Stages ...................................................................................................................... 87
Chapter 9. Mental Health And Violence Assessment ................................................................................................................. 89
Chapter 10. Assessment Of Social, Spiritual, And Cultural Health.......................................................................................... 102
Chapter 11. Skin, Hair, And Nails ............................................................................................................................................ 114
Chapter 11. Skin, Hair, And Nails ............................................................................................................................................ 114
Chapter 12. Head And Neck With Lymphatics ........................................................................................................................ 128
Chapter 13. Eyes....................................................................................................................................................................... 142
Chapter 14. Ears ....................................................................................................................................................................... 154
Chapter 15. Nose, Mouth, And Throat ..................................................................................................................................... 166
Chapter 16. Thorax And Lungs ................................................................................................................................................ 179
Chapter 17. Heart And Neck Vessels ....................................................................................................................................... 189
Chapter 18. Peripheral Vascular With Lymphatics................................................................................................................... 202
Chapter 19. Breasts And Axillae .............................................................................................................................................. 213
Chapter 20. Abdominal ............................................................................................................................................................ 223
Chapter 21. Musculoskeletal..................................................................................................................................................... 236
Chapter 22. Neurological And Mental Status ........................................................................................................................... 248
Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen
Test Bank
Chapter 1. Nurse’s Role In Health Assessment
1. 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.
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, c. Subjective.
d. Introspective
.Ans: A
Objective Data Are What The Health Professional Observes By Inspecting, Percussing,
Palpating, And Auscultating During The Physical Examination. Subjective Data Is What The
Person Says Abouthim Or Herself During History Taking. The Terms Reflective And
Introspective Are Not Used To Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
2. A Patient Tells The Nurse That He Is Very Nervous, Is Nauseated, And Feels Hot.
These Types Ofdata Would Be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective
.Ans: C
Subjective Data Are What The Person Says About Him Or Herself During History Taking.
Objective Data Are What The Health Professional Observes By Inspecting, Percussing,
Palpating, And Auscultating During The Physical Examination. The Terms Reflective And
Introspective Are Not Usedto Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
3. The Patients Record, Laboratory Studies, Objective Data, And Subjective Data
Combine To Formthe:
a. Data Base.
b. Admitting Data.
c. Financial Statement.
d. Discharge
Summary. Ans: A
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, Together With The Patients Record And Laboratory Studies, The Objective And Subjective
Data Formthe Data Base. The Other Items Are Not Part Of The Patients Record, Laboratory
Studies, Or Data.
Dif: Cognitive Level: Remembering (Knowledge) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
4. When Listening To A Patients Breath Sounds, The Nurse Is Unsure Of A Sound That Is
Heard. The Nurses Next Action Should Be To:
a. Immediately Notify The Patients 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. Ans: C
When Unsure Of A Sound Heard While Listening To A Patients Breath Sounds, The Nurse Validates The
Data To Ensure Accuracy. If The Nurse Has Less Experience In An Area, Then He Or She Asks
An Expertto Listen.
Dif: Cognitive Level: Analyzing (Analysis) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
5. The Nurse Is Conducting A Class For New Graduate Nurses. During The Teaching
Session, The Nurse Should Keep In Mind That Novice Nurses, Without A Background Of
Skills And Experiencefrom Which To Draw, Are More Likely To Make Their Decisions
Using:
a. Intuition.
b. A Set Of Rules.
c. Articles In Journals.
d. Advice
From Supervisors.Ans: B
Novice Nurses Operate From A Set Of Defined, Structured Rules. The Expert Practitioner Uses
Intuitive Links.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 3
Msc: Client Needs: General
6. Expert Nurses Learn To Attend To A Pattern Of Assessment Data And Act
Without Consciouslylabeling It. These Responses Are Referred To As:
a. Intuition.
b. The Nursing Process.
c. Clinical Knowledge.
d. Diagnostic
Reasoning. Ans: A
Intuition Is Characterized By Pattern Recognitionexpert Nurses Learn To Attend To A Pattern Of
Assessment Data And Act Without Consciously Labeling It. The Other Options
Are Not Correct.Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm.
4
Msc: Client Needs: General
7. The Nurse Is Reviewing Information About Evidence-Based Practice (Ebp). Which
Statement Best REFLECTS EBP?
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Nursing Health Assessment: A Best Practice
Approach 3rd Edition
By Sharon Jensen Latest Update.
WWW.THENURSINGMASTERY.COM
,Table Of Contents
Chapter 1. Nurse’s Role In Health Assessment ............................................................................................................................ 2
Chapter 2. The Interview And Health History............................................................................................................................ 12
Chapter 3. Techniques Of Physical Assessment ......................................................................................................................... 30
Chapter 4. Documentation And Interdisciplinary Communication ............................................................................................. 43
Chapter 5. Vital Signs And General Survey ............................................................................................................................... 54
Chapter 6. Pain Assessment....................................................................................................................................................... 72
Chapter 7. Nutrition Assessment ................................................................................................................................................ 77
Chapter 8. Assessment Of Developmental Stages ...................................................................................................................... 87
Chapter 9. Mental Health And Violence Assessment ................................................................................................................. 89
Chapter 10. Assessment Of Social, Spiritual, And Cultural Health.......................................................................................... 102
Chapter 11. Skin, Hair, And Nails ............................................................................................................................................ 114
Chapter 11. Skin, Hair, And Nails ............................................................................................................................................ 114
Chapter 12. Head And Neck With Lymphatics ........................................................................................................................ 128
Chapter 13. Eyes....................................................................................................................................................................... 142
Chapter 14. Ears ....................................................................................................................................................................... 154
Chapter 15. Nose, Mouth, And Throat ..................................................................................................................................... 166
Chapter 16. Thorax And Lungs ................................................................................................................................................ 179
Chapter 17. Heart And Neck Vessels ....................................................................................................................................... 189
Chapter 18. Peripheral Vascular With Lymphatics................................................................................................................... 202
Chapter 19. Breasts And Axillae .............................................................................................................................................. 213
Chapter 20. Abdominal ............................................................................................................................................................ 223
Chapter 21. Musculoskeletal..................................................................................................................................................... 236
Chapter 22. Neurological And Mental Status ........................................................................................................................... 248
Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen
Test Bank
Chapter 1. Nurse’s Role In Health Assessment
1. 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.
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, c. Subjective.
d. Introspective
.Ans: A
Objective Data Are What The Health Professional Observes By Inspecting, Percussing,
Palpating, And Auscultating During The Physical Examination. Subjective Data Is What The
Person Says Abouthim Or Herself During History Taking. The Terms Reflective And
Introspective Are Not Used To Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
2. A Patient Tells The Nurse That He Is Very Nervous, Is Nauseated, And Feels Hot.
These Types Ofdata Would Be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective
.Ans: C
Subjective Data Are What The Person Says About Him Or Herself During History Taking.
Objective Data Are What The Health Professional Observes By Inspecting, Percussing,
Palpating, And Auscultating During The Physical Examination. The Terms Reflective And
Introspective Are Not Usedto Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
3. The Patients Record, Laboratory Studies, Objective Data, And Subjective Data
Combine To Formthe:
a. Data Base.
b. Admitting Data.
c. Financial Statement.
d. Discharge
Summary. Ans: A
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, Together With The Patients Record And Laboratory Studies, The Objective And Subjective
Data Formthe Data Base. The Other Items Are Not Part Of The Patients Record, Laboratory
Studies, Or Data.
Dif: Cognitive Level: Remembering (Knowledge) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
4. When Listening To A Patients Breath Sounds, The Nurse Is Unsure Of A Sound That Is
Heard. The Nurses Next Action Should Be To:
a. Immediately Notify The Patients 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. Ans: C
When Unsure Of A Sound Heard While Listening To A Patients Breath Sounds, The Nurse Validates The
Data To Ensure Accuracy. If The Nurse Has Less Experience In An Area, Then He Or She Asks
An Expertto Listen.
Dif: Cognitive Level: Analyzing (Analysis) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
5. The Nurse Is Conducting A Class For New Graduate Nurses. During The Teaching
Session, The Nurse Should Keep In Mind That Novice Nurses, Without A Background Of
Skills And Experiencefrom Which To Draw, Are More Likely To Make Their Decisions
Using:
a. Intuition.
b. A Set Of Rules.
c. Articles In Journals.
d. Advice
From Supervisors.Ans: B
Novice Nurses Operate From A Set Of Defined, Structured Rules. The Expert Practitioner Uses
Intuitive Links.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 3
Msc: Client Needs: General
6. Expert Nurses Learn To Attend To A Pattern Of Assessment Data And Act
Without Consciouslylabeling It. These Responses Are Referred To As:
a. Intuition.
b. The Nursing Process.
c. Clinical Knowledge.
d. Diagnostic
Reasoning. Ans: A
Intuition Is Characterized By Pattern Recognitionexpert Nurses Learn To Attend To A Pattern Of
Assessment Data And Act Without Consciously Labeling It. The Other Options
Are Not Correct.Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm.
4
Msc: Client Needs: General
7. The Nurse Is Reviewing Information About Evidence-Based Practice (Ebp). Which
Statement Best REFLECTS EBP?
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