Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
Chapter 1, The Nurse's Role in Health Assessment
MULTIPLE CHOICE
1. Which is one of the broad goals within nursing?
A) To provide cost-effective care
B) To form broad nursing diagnoses
C) To promote self-care
D) To treat human responses
ANS: D
Feedback: Four broad goals are within nursing: (1) to promote health
(state of optimal functioning or well-being with physical, social, and
mental components); (2) to prevent illness; (3) to treat human responses
to health or illness; and (4) to advocate for individuals, families,
communities, and populations. The other options listed are not broad
goals. Nursing focuses on promoting health; while cost-effective care is strived for, it is not a
part of the broad goal, and therefore this is not a broad goal within nursing. Nursing looks to
develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not
correctly answer the question.
PTS: 1 REF: Page: 4 | Header: Roles of the Professional Nurse
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Remember
2. The nurse is conducting a physical assessment. The data the nurse would collect vary
depending on what?
A) How much time the nurse has
B) The client's acuity
C) The client's cooperation
D) Onset of current symptoms
ANS: B
Feedback: Data that nurses collect during a physical assessment vary depending on a client's
acuity (condition), health history, and current symptoms. The data collected during a physical
assessment do not depend on how much time the nurse has, how cooperative the client is, or
the onset of the current symptoms.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
3. A nursing instructor is discussing the purposes of health assessment. Which is one purpose of
health assessment?
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
A) To establish a database against which subsequent assessments can be measured
B) To establish rapport with the client and family
C) To gather information for specialists to whom the client might be referred
D) To quantify the degree of pain a client may be experiencing
ANS: A
Feedback: A health assessment is performed to gain further insight into the current condition
and to establish a database that subsequent assessments can be measured against.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
4. How do nurses facilitate the achievement of high-level wellness with a client?
A) Encouraging the client to keep appointments
B) Providing the client information on alternative treatments
C) Promoting health in the client
D) Providing good client care
ANS: C
Feedback: High-level wellness is a process by which people maintain balance and direction in
the most favorable environment. The role of nurses is to facilitate this achievement through
health promotion and teaching. Nurses do not facilitate the achievement of high-level
wellness by encouraging clients to keep appointments, providing information on alternative
treatments, or providing “good” patient care.
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
5. The nurse is caring for a client who, on the continuum between wellness and illness, is
moving toward illness and premature death. How would the nurse know this to be true?
A) The client stops doing wellness-promoting activities.
B) The client develops signs and symptoms.
C) The client begins exercising.
D) The client verbalizes anxiety over the cost of medications.
ANS: B
Feedback: The person who moves toward illness and premature death develops signs,
symptoms, and disability, which, unfortunately, is when most treatment occurs in the current
health care system. The client may stop doing wellness-promoting activities and not tell the
nurse of this fact, which makes “The client stops doing wellness-promoting activities”
incorrect. “The client begins exercising” is incorrect because a client who begins exercising is
moving toward wellness, not illness. “The client verbalizes anxiety over the cost of
medications” is incorrect because the verbalization of anxiety over financial matters is not an
indication of illness.
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
6. A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic
statements in the care plan, what would the nurse use?
A) Rationale
B) American Nurses Association recommendations
C) Physical assessment skills
D) Diagnostic reasoning
ANS: D
Feedback: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic
statements. Rationale, ANA recommendations, and physical assessment skills are not part of
formulating diagnostic statements. Rationale supports the nursing interventions of the nursing
care plan. The American Nurses Association does not have recommendations regarding
formulation of diagnostic statements for the care plan. Physical assessment skills are
important in the assessment step of the nursing process, not the formulation of the diagnostic
statements.
PTS: 1 REF: Page: 9 | Header: Diagnostic Reasoning
OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Apply
7. A nurse is caring for three clients whose care involves complex situations and multiple
responsibilities. What is the key to resolving problems for this nurse?
A) Diagnostic reasoning
B) Physical assessment
C) Critical thinking
D) Nursing care plan
ANS: C
Feedback: Nurses are frequently involved in complex situations with multiple responsibilities.
They are required to think through the analysis, develop alternatives, and implement the best
interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is
important in developing diagnostic statements, not in caring for multiple clients with complex
care needs. Physical assessment is important in building the foundation of the nursing care
plan. The nursing care plan directs the care that will be provided for the individual client, but
does not address the needs of caring for multiple clients.
PTS: 1 REF: Page: 8 | Header: Critical Thinking OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
8. A community health nurse is planning individualized care for a community. What does the
nurse use as a framework for this plan?
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
A) Nursing process
B) Diagnostic reasoning
C) Critical thinking
D) Community care map
ANS: A
Feedback: The nursing process serves as a framework for providing individualized care not
only to individuals but also to families and communities. Diagnostic reasoning, critical
thinking, and community care maps are not frameworks for providing individualized care to a
community.
PTS: 1 REF: Page: 7 | Header: Nursing Process OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze
9. A nurse performs a comprehensive assessment on a client. Which is included only in a
comprehensive assessment?
A) Circulatory assessment
B) Assessment of the airway
C) Complete health history
D) Disability assessment
ANS: C
Feedback: The comprehensive assessment includes a complete health history and physical
assessment. It is done annually on an outpatient basis, following admission to a hospital or
long-term care facility, or as defined in a facility's standards of care in the acute care setting.
Circulatory assessment, assessment of the airway, and disability assessment are part of an
emergency assessment.
PTS: 1 REF: Page: 9 | Header: Comprehensive Assessment
OBJ: 6
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand
10. The nurse is admitting a client to the clinic and performs a focused assessment. What makes a
focused assessment different from a comprehensive assessment?
A) A focused assessment covers the body head to toe, unlike a comprehensive
assessment.
B) A focused assessment occurs only in the clinic area, unlike a comprehensive
assessment.
C) A focused assessment involves all body systems, unlike a comprehensive
assessment.
D) A focused assessment is more in-depth on specific issues, unlike a comprehensive
assessment.
ANS: D
Jensen
Chapter 1, The Nurse's Role in Health Assessment
MULTIPLE CHOICE
1. Which is one of the broad goals within nursing?
A) To provide cost-effective care
B) To form broad nursing diagnoses
C) To promote self-care
D) To treat human responses
ANS: D
Feedback: Four broad goals are within nursing: (1) to promote health
(state of optimal functioning or well-being with physical, social, and
mental components); (2) to prevent illness; (3) to treat human responses
to health or illness; and (4) to advocate for individuals, families,
communities, and populations. The other options listed are not broad
goals. Nursing focuses on promoting health; while cost-effective care is strived for, it is not a
part of the broad goal, and therefore this is not a broad goal within nursing. Nursing looks to
develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not
correctly answer the question.
PTS: 1 REF: Page: 4 | Header: Roles of the Professional Nurse
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Remember
2. The nurse is conducting a physical assessment. The data the nurse would collect vary
depending on what?
A) How much time the nurse has
B) The client's acuity
C) The client's cooperation
D) Onset of current symptoms
ANS: B
Feedback: Data that nurses collect during a physical assessment vary depending on a client's
acuity (condition), health history, and current symptoms. The data collected during a physical
assessment do not depend on how much time the nurse has, how cooperative the client is, or
the onset of the current symptoms.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
3. A nursing instructor is discussing the purposes of health assessment. Which is one purpose of
health assessment?
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
A) To establish a database against which subsequent assessments can be measured
B) To establish rapport with the client and family
C) To gather information for specialists to whom the client might be referred
D) To quantify the degree of pain a client may be experiencing
ANS: A
Feedback: A health assessment is performed to gain further insight into the current condition
and to establish a database that subsequent assessments can be measured against.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
4. How do nurses facilitate the achievement of high-level wellness with a client?
A) Encouraging the client to keep appointments
B) Providing the client information on alternative treatments
C) Promoting health in the client
D) Providing good client care
ANS: C
Feedback: High-level wellness is a process by which people maintain balance and direction in
the most favorable environment. The role of nurses is to facilitate this achievement through
health promotion and teaching. Nurses do not facilitate the achievement of high-level
wellness by encouraging clients to keep appointments, providing information on alternative
treatments, or providing “good” patient care.
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
5. The nurse is caring for a client who, on the continuum between wellness and illness, is
moving toward illness and premature death. How would the nurse know this to be true?
A) The client stops doing wellness-promoting activities.
B) The client develops signs and symptoms.
C) The client begins exercising.
D) The client verbalizes anxiety over the cost of medications.
ANS: B
Feedback: The person who moves toward illness and premature death develops signs,
symptoms, and disability, which, unfortunately, is when most treatment occurs in the current
health care system. The client may stop doing wellness-promoting activities and not tell the
nurse of this fact, which makes “The client stops doing wellness-promoting activities”
incorrect. “The client begins exercising” is incorrect because a client who begins exercising is
moving toward wellness, not illness. “The client verbalizes anxiety over the cost of
medications” is incorrect because the verbalization of anxiety over financial matters is not an
indication of illness.
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
6. A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic
statements in the care plan, what would the nurse use?
A) Rationale
B) American Nurses Association recommendations
C) Physical assessment skills
D) Diagnostic reasoning
ANS: D
Feedback: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic
statements. Rationale, ANA recommendations, and physical assessment skills are not part of
formulating diagnostic statements. Rationale supports the nursing interventions of the nursing
care plan. The American Nurses Association does not have recommendations regarding
formulation of diagnostic statements for the care plan. Physical assessment skills are
important in the assessment step of the nursing process, not the formulation of the diagnostic
statements.
PTS: 1 REF: Page: 9 | Header: Diagnostic Reasoning
OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Apply
7. A nurse is caring for three clients whose care involves complex situations and multiple
responsibilities. What is the key to resolving problems for this nurse?
A) Diagnostic reasoning
B) Physical assessment
C) Critical thinking
D) Nursing care plan
ANS: C
Feedback: Nurses are frequently involved in complex situations with multiple responsibilities.
They are required to think through the analysis, develop alternatives, and implement the best
interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is
important in developing diagnostic statements, not in caring for multiple clients with complex
care needs. Physical assessment is important in building the foundation of the nursing care
plan. The nursing care plan directs the care that will be provided for the individual client, but
does not address the needs of caring for multiple clients.
PTS: 1 REF: Page: 8 | Header: Critical Thinking OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
8. A community health nurse is planning individualized care for a community. What does the
nurse use as a framework for this plan?
, Test Bank For Nursing Health Assessment A Best Practice Approach, 3rd Edition Sharon
Jensen
A) Nursing process
B) Diagnostic reasoning
C) Critical thinking
D) Community care map
ANS: A
Feedback: The nursing process serves as a framework for providing individualized care not
only to individuals but also to families and communities. Diagnostic reasoning, critical
thinking, and community care maps are not frameworks for providing individualized care to a
community.
PTS: 1 REF: Page: 7 | Header: Nursing Process OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze
9. A nurse performs a comprehensive assessment on a client. Which is included only in a
comprehensive assessment?
A) Circulatory assessment
B) Assessment of the airway
C) Complete health history
D) Disability assessment
ANS: C
Feedback: The comprehensive assessment includes a complete health history and physical
assessment. It is done annually on an outpatient basis, following admission to a hospital or
long-term care facility, or as defined in a facility's standards of care in the acute care setting.
Circulatory assessment, assessment of the airway, and disability assessment are part of an
emergency assessment.
PTS: 1 REF: Page: 9 | Header: Comprehensive Assessment
OBJ: 6
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand
10. The nurse is admitting a client to the clinic and performs a focused assessment. What makes a
focused assessment different from a comprehensive assessment?
A) A focused assessment covers the body head to toe, unlike a comprehensive
assessment.
B) A focused assessment occurs only in the clinic area, unlike a comprehensive
assessment.
C) A focused assessment involves all body systems, unlike a comprehensive
assessment.
D) A focused assessment is more in-depth on specific issues, unlike a comprehensive
assessment.
ANS: D
