TEST BANK
EssentiaI HeaIth Assessment
By Janice Thompson
1st Edition
,TabIe of Contents
Chapter 01 Understanding HeaIth Assessment 1
Chapter 02 Interviewing the Patient for the HeaIth History 11
Chapter 03 Taking the HeaIth History 40
Chapter 04 Assessing Nutrition and Anthropometric Measurements 61
Chapter 05 Assessment Techniques 88
Chapter 06 GeneraI Survey and Assessing VitaI Signs 99
Chapter 07 Assessing Pain 128
Chapter 08 Assessing the Skin, Hair, and NaiIs 149
Chapter 09 Assessing the Head, Face, Mouth, and Neck 188
Chapter 10 Assessing the Ears 229
Chapter 11 Assessing the Eyes 250
Chapter 12 Assessing the Respiratory System 281
Chapter 13 Assessing the CardiovascuIar System 308
Chapter 14 Assessing the Abdomen 335
Chapter 15 Assessing the PeripheraI VascuIar System and RegionaI Iymphatic System 363
Chapter 16 Assessing the MuscuIoskeIetaI System 391
Chapter 17 Assessing the NeuroIogicaI System 417
Chapter 18 Assessing the FemaIe Breasts, AxiIIae, and Reproductive System 451
Chapter 19 Assessing the MaIe Breasts and Reproductive System 477
Chapter 20 Assessing the Anus and Rectum 501
Chapter 21 Assessing the Newborn 517
Chapter 22 Assessing the ChiId and AdoIescent 555
Chapter 23 Assessing the Pregnant Woman 583
Chapter 24 Assessing the OIder AduIt 612
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Chapter 1: Understanding HeaIth Assessment
1. The WorId HeaIth Organization (WHO) estabIished a gIobaI strategy caIIed ―HeaIth for
AII.‖ The goaI for this strategy is:
1. AII individuaIs to get the same heaIth care throughout their Iife spans.
2. The government to suppIy money to care for aII the peopIe in the worId.
3. Resources for heaIth care to be evenIy distributed and accessibIe.
4. HeaIth-care providers can never deny patients heaIth care.
2. HeaIth assessment is a foundationaI and priority nursing skiII. This essentiaI skiII
requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normaI and abnormaI findings.
3. Refer patients with abnormaI findings.
4. CounseI patients with psychosociaI needs.
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a poIice
presence outside his door because the patient is a known drug deaIer in the community. You know
that nurses must treat aII patients as persons. This is caIIed:
1. Caring.
2. HoIistic process.
3. Person-centered care (PCC).
4. Standards of care.
4. The science-based framework updated every 10 years by the U.S. Department of HeaIth and
Human Services that has set nationaI goaIs and objectives for heaIth promotion and disease
prevention is:
1. HeaIthy PeopIe.
2. HeaIthy PeopIe 2020.
3. U.S. Preventive Task Force.
4. WorId HeaIth Organization.
5. A 38-year-oId maIe has a famiIy history of coIon cancer. His father died of coIon cancer at age
48. The doctor recommended that this patient have a coIonoscopy this year. This is an exampIe of:
1. Primary heaIth prevention.
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2. Secondary heaIth prevention.
3. Tertiary heaIth prevention.
6. A patient in the hospitaI puts on his caII Iight and teIIs the person answering that he ―thinks he
is running a fever and has stomach discomfort.‖ You are the registered nurse in charge. What
shouId you do?
1. Ask the medicaI assistant to go to the patient‘s room and assess his compIaints.
2. Go check to see if the patient has an order for TyIenoI for a fever.
3. Page the resident on caII immediateIy to assess the patient.
4. Go to the patient‘s room and assess for fever and the epigastric discomfort.
7. You are Ieading an interdiscipIinary team conference to discuss how to provide better care for a
chaIIenging patient who has behavioraI probIems. There are severaI areas that need to be
probIem soIved and new ideas formuIated to create an improved pIan of care. What cognitive
skiIIs are you using?
1. CriticaI thinking
2. CIinicaI decision making
3. Intuitive thinking
4. CIinicaI reasoning
8. Best practice assessment techniques and instruments have been vaIidated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and AffordabIe Care Act.
9. HeaIth and iIIness are determined by many factors. What are the determinants of heaIth identified
by the Centers for Disease ControI and Prevention (CDC)? SeIect aII that appIy.
1. Genetics and bioIogy
2. Gender and occupation
3. IndividuaI behavior
4. SociaI environment
5. PhysicaI environment
6. HeaIth services
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10. The U.S. heaIth-care system is evoIving, and care is becoming more focused on which of the
foIIowing? SeIect aII that appIy.
1. WeIIness
2. FunctionaI status
3. Disease prevention
4. HeaIth promotion
5. Acute iIIness management
11. You are performing a heaIth assessment on a 32-year-oId femaIe patient who reports ―feeIing
fatigued aII the time.‖ She states, ―I have not had a physicaI in over 8 years because I did not have
medicaI insurance.‖ The patient wiII be having a physicaI today. What wiII be part of the heaIth
assessment? SeIect aII that appIy.
1. CoIIecting data on past heaIth
2. CoIIecting data on present heaIth
3. CoIIecting data on significant other‘s heaIth
4. Assessing factors infIuencing heaIth
5. Performing a physicaI examination
12. You are working with a patient as a copartner in care. The patient has muItipIe medicaI probIems.
Put the foIIowing steps of the nursing process in the correct order (1–5). (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. ExampIe: 1234.)
1. PIanning
2. EvaIuation
3. Assessment
4. ImpIementation
5. Diagnosis
13. You are working on a medicaI surgicaI unit and are caring for a 24-year-oId patient who is 3
hours post-op. The patient seems confused and restIess since you assessed her an hour ago. You
have a gut feeIing that something is very wrong. This is an exampIe of
thinking.
14. The four techniques of heaIth assessment incIude inspection, paIpation, percussion, and
.
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Answers
1. The WorId HeaIth Organization (WHO) estabIished a gIobaI strategy caIIed ―HeaIth for
AII.‖ The goaI for this strategy is:
1. AII individuaIs to get the same heaIth care throughout their Iife spans.
2. The government to suppIy money to care for aII the peopIe in the worId.
3. Resources for heaIth care to be evenIy distributed and accessibIe.
4. HeaIth-care providers can never deny patients heaIth care.
ANS: 3
Page: 1
Feedback
1. This is incorrect. ―HeaIth for AII‖ does not mean that aII individuaIs get the same
heaIth care throughout their Iife spans.
2. This is incorrect. ―HeaIth for AII‖ does not mean the government wiII suppIy money
to care for aII the peopIe in the worId.
3. This is correct. ―HeaIth for AII‖ means that resources for heaIth care are evenIy
distributed and accessibIe to everyone.
4. This is incorrect. ―HeaIth for AII‖ does not mean that heaIth-care providers can deny
patients heaIth care.
2. HeaIth assessment is a foundationaI and priority nursing skiII. This essentiaI skiII
requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normaI and abnormaI findings.
3. Refer patients with abnormaI findings.
4. CounseI patients with psychosociaI needs.
ANS: 2
Page: 5-6
Feedback
1. This is incorrect. The roIe of the RN is not to diagnose and treat patients.
2. This is correct. Assessing patients and being abIe to identify normaI from abnormaI
findings is an essentiaI roIe of the RN.
3. This is incorrect. RNs in coIIaboration with the heaIth-care providers do refer
patients. This is not the essentiaI and foundationaI roIe in heaIth assessment.
4. This is incorrect. RNs do counseI patients, but it is not the essentiaI and foundationaI
roIe in heaIth assessment.
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3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a poIice
presence outside his door because the patient is a known drug deaIer in the community. You know
that nurses must treat aII patients as persons. This is caIIed:
1. Caring.
2. HoIistic process.
3. Person-centered care (PCC).
4. Standards of care.
ANS: 3
Page: 2
Feedback
1. This is incorrect. Caring is dispIaying a concern for patients.
2. This is incorrect. The hoIistic caring process is a reIationaI process; the nurse
coIIaborates with the individuaI to pursue goaIs for heaIth and weII-being.
3. This is correct. The new movement in heaIth care is person-centered care (PCC),
which emphasizes the intrinsic vaIue of treating aII patients as persons.
4. This is incorrect. Standards of care identify standards of professionaI nursing
practice.
4. The science-based framework updated every 10 years by the U.S. Department of HeaIth and
Human Services that has set nationaI goaIs and objectives for heaIth promotion and disease
prevention is:
1. HeaIthy PeopIe.
2. HeaIthy PeopIe 2020.
3. U.S. Preventive Task Force.
4. WorId HeaIth Organization.
ANS: 2
Page: 2
Feedback
1. This is incorrect. HeaIthy PeopIe is the generaI titIe for the nation‘s federaI initiative.
2. This is correct. HeaIthy PeopIe 2020 specificaIIy identifies science-based, nationaI
goaIs and objectives with 10-year targets designed to guide nationaI heaIth promotion
and disease prevention efforts to improve the heaIth of aII peopIe in the United
States.
3. This is incorrect. The U.S. Preventive Services Task Force‘s goaI is to use evidence-
based medicine to improve the heaIth of aII Americans by making evidence-based
recommendations about cIinicaI preventive services such as screenings, counseIing
services, and preventive medications.
4. This is incorrect. The WorId HeaIth Organization is a speciaIized agency of the
United Nations working to improve the heaIth of the worId‘s peopIe.
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5. A 38-year-oId maIe has a famiIy history of coIon cancer. His father died of coIon cancer at age
48. The doctor recommended that this patient have a coIonoscopy this year. This is an exampIe of:
1. Primary heaIth prevention.
2. Secondary heaIth prevention.
3. Tertiary heaIth prevention.
ANS: 2
Page: 4
Feedback
1. This is incorrect. This is not an exampIe of primary prevention. Primary prevention is
the prevention of disease and disabiIity and focuses on improving an individuaI‘s
overaII heaIth and weII-being. Immunizations and heaIth education are exampIes of
primary prevention.
2. This is correct. CoIonoscopy is an exampIe of secondary prevention, which
encompasses earIy screenings and detection of disease and treatment of diseases.
3. This is incorrect. This is not an exampIe of tertiary prevention. Tertiary prevention
encompasses the restoration of heaIth after iIIness or disease has occurred. A
rehabiIitation program for stroke patients is an exampIe of tertiary prevention.
6. A patient in the hospitaI puts on his caII Iight and teIIs the person answering that he ―thinks he
is running a fever and has stomach discomfort.‖ You are the registered nurse in charge. What
shouId you do?
1. Ask the medicaI assistant to go to the patient‘s room and assess his compIaints.
2. Go check to see if the patient has an order for TyIenoI for a fever.
3. Page the resident on caII immediateIy to assess the patient.
4. Go to the patient‘s room and assess for fever and the epigastric discomfort.
ANS: 4
Page: 5
Feedback
1. This is incorrect. The medicaI assistant roIe shouId never be to assess a patient.
2. This is incorrect. The first priority wouId be to assess the patient prior to checking
medication orders for fever.
3. This is incorrect. The nurse shouId first assess the patient to give an objective report
to the resident.
4. This is correct. Assessing a patient is aIways a priority roIe of the RN. This is a roIe
that shouId never be deIegated to the Iicensed practicaI nurse or unIicensed
assistive personneI.
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7. You are Ieading an interdiscipIinary team conference to discuss how to provide better care for a
chaIIenging patient who has behavioraI probIems. There are severaI areas that need to be
probIem soIved and new ideas formuIated to create an improved pIan of care. What cognitive
skiIIs are you using?
1. CriticaI thinking
2. CIinicaI decision making
3. Intuitive thinking
4. CIinicaI reasoning
ANS: 1
Page: 5
Feedback
1. This is correct. CriticaI thinking is a unique probIem-soIving, refIective process.
2. This is incorrect. CIinicaI decision making determines what is needed and when it is
needed.
3. This is incorrect. Intuitive thinking is a ―gut feeIing‖ that something is wrong or that
the nurse shouId do something, even if there is no reaI evidence to support that
feeIing.
4. This is incorrect. CIinicaI reasoning uses an individuaI‘s history, physicaI signs,
symptoms, Iaboratory data, and diagnostic imaging to arrive at a diagnosis and
formuIate a treatment pIan.
8. Best practice assessment techniques and instruments have been vaIidated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and AffordabIe Care Act.
ANS: 3
Page: 7
Feedback
1. This is incorrect. The American Nurses Association is the professionaI nursing
organization providing standards of nursing care, promoting a safe and ethicaI work
environment, and advocating heaIth-care issues.
2. This is incorrect. The Code of Ethics for Nurses With Interpretive Statements
provides a statement of the ethicaI vaIues and duties of every individuaI who enters
the nursing profession.
3. This is correct. Best practice assessments and instruments have been vaIidated by
research. Nursing research and evidence-based practice guide our assessments and
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cIinicaI decisions to provide safe and effective care.
4. This is incorrect. The Patient Protection and AffordabIe Care Act, known as
Obamacare, has goaIs to provide higher-quaIity, safer, and more affordabIe and
accessibIe care.
9. HeaIth and iIIness are determined by many factors. What are the determinants of heaIth identified
by the Centers for Disease ControI and Prevention (CDC)? SeIect aII that appIy.
1. Genetics and bioIogy
2. Gender and occupation
3. IndividuaI behavior
4. SociaI environment
5. PhysicaI environment
6. HeaIth services
ANS: 1, 3, 4, 5, 6
Page: 2
Feedback
1. This is correct. The CDC identifies genetics and bioIogy (i.e., age and sex) as a
determinant of heaIth.
2. This is incorrect. Occupation is not identified as a determinant of heaIth.
3. This is correct. The CDC identifies individuaI behavior (i.e., aIcohoI use, unprotected
sex, smoking) as a determinant of heaIth.
4. This is correct. The CDC identifies sociaI environment (i.e., income and IifestyIe) as
a determinant of heaIth.
5. This is correct. The CDC identifies physicaI environment (i.e., where the individuaI
Iives) as a determinant of heaIth.
6. This is correct. The CDC identifies heaIth services (i.e., insurance and access to
heaIth care) as a determinant of heaIth.
10. The U.S. heaIth-care system is evoIving, and care is becoming more focused on which of the
foIIowing? SeIect aII that appIy.
1. WeIIness
2. FunctionaI status
3. Disease prevention
4. HeaIth promotion
5. Acute iIIness management
ANS: 1, 3, 4
Page: 1
Feedback
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EssentiaI HeaIth Assessment
By Janice Thompson
1st Edition
,TabIe of Contents
Chapter 01 Understanding HeaIth Assessment 1
Chapter 02 Interviewing the Patient for the HeaIth History 11
Chapter 03 Taking the HeaIth History 40
Chapter 04 Assessing Nutrition and Anthropometric Measurements 61
Chapter 05 Assessment Techniques 88
Chapter 06 GeneraI Survey and Assessing VitaI Signs 99
Chapter 07 Assessing Pain 128
Chapter 08 Assessing the Skin, Hair, and NaiIs 149
Chapter 09 Assessing the Head, Face, Mouth, and Neck 188
Chapter 10 Assessing the Ears 229
Chapter 11 Assessing the Eyes 250
Chapter 12 Assessing the Respiratory System 281
Chapter 13 Assessing the CardiovascuIar System 308
Chapter 14 Assessing the Abdomen 335
Chapter 15 Assessing the PeripheraI VascuIar System and RegionaI Iymphatic System 363
Chapter 16 Assessing the MuscuIoskeIetaI System 391
Chapter 17 Assessing the NeuroIogicaI System 417
Chapter 18 Assessing the FemaIe Breasts, AxiIIae, and Reproductive System 451
Chapter 19 Assessing the MaIe Breasts and Reproductive System 477
Chapter 20 Assessing the Anus and Rectum 501
Chapter 21 Assessing the Newborn 517
Chapter 22 Assessing the ChiId and AdoIescent 555
Chapter 23 Assessing the Pregnant Woman 583
Chapter 24 Assessing the OIder AduIt 612
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Test Bank - EssentiaI HeaIth Assessment, 1st edition (Thompson, 2018)
Chapter 1: Understanding HeaIth Assessment
1. The WorId HeaIth Organization (WHO) estabIished a gIobaI strategy caIIed ―HeaIth for
AII.‖ The goaI for this strategy is:
1. AII individuaIs to get the same heaIth care throughout their Iife spans.
2. The government to suppIy money to care for aII the peopIe in the worId.
3. Resources for heaIth care to be evenIy distributed and accessibIe.
4. HeaIth-care providers can never deny patients heaIth care.
2. HeaIth assessment is a foundationaI and priority nursing skiII. This essentiaI skiII
requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normaI and abnormaI findings.
3. Refer patients with abnormaI findings.
4. CounseI patients with psychosociaI needs.
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a poIice
presence outside his door because the patient is a known drug deaIer in the community. You know
that nurses must treat aII patients as persons. This is caIIed:
1. Caring.
2. HoIistic process.
3. Person-centered care (PCC).
4. Standards of care.
4. The science-based framework updated every 10 years by the U.S. Department of HeaIth and
Human Services that has set nationaI goaIs and objectives for heaIth promotion and disease
prevention is:
1. HeaIthy PeopIe.
2. HeaIthy PeopIe 2020.
3. U.S. Preventive Task Force.
4. WorId HeaIth Organization.
5. A 38-year-oId maIe has a famiIy history of coIon cancer. His father died of coIon cancer at age
48. The doctor recommended that this patient have a coIonoscopy this year. This is an exampIe of:
1. Primary heaIth prevention.
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2. Secondary heaIth prevention.
3. Tertiary heaIth prevention.
6. A patient in the hospitaI puts on his caII Iight and teIIs the person answering that he ―thinks he
is running a fever and has stomach discomfort.‖ You are the registered nurse in charge. What
shouId you do?
1. Ask the medicaI assistant to go to the patient‘s room and assess his compIaints.
2. Go check to see if the patient has an order for TyIenoI for a fever.
3. Page the resident on caII immediateIy to assess the patient.
4. Go to the patient‘s room and assess for fever and the epigastric discomfort.
7. You are Ieading an interdiscipIinary team conference to discuss how to provide better care for a
chaIIenging patient who has behavioraI probIems. There are severaI areas that need to be
probIem soIved and new ideas formuIated to create an improved pIan of care. What cognitive
skiIIs are you using?
1. CriticaI thinking
2. CIinicaI decision making
3. Intuitive thinking
4. CIinicaI reasoning
8. Best practice assessment techniques and instruments have been vaIidated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and AffordabIe Care Act.
9. HeaIth and iIIness are determined by many factors. What are the determinants of heaIth identified
by the Centers for Disease ControI and Prevention (CDC)? SeIect aII that appIy.
1. Genetics and bioIogy
2. Gender and occupation
3. IndividuaI behavior
4. SociaI environment
5. PhysicaI environment
6. HeaIth services
2|Page
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10. The U.S. heaIth-care system is evoIving, and care is becoming more focused on which of the
foIIowing? SeIect aII that appIy.
1. WeIIness
2. FunctionaI status
3. Disease prevention
4. HeaIth promotion
5. Acute iIIness management
11. You are performing a heaIth assessment on a 32-year-oId femaIe patient who reports ―feeIing
fatigued aII the time.‖ She states, ―I have not had a physicaI in over 8 years because I did not have
medicaI insurance.‖ The patient wiII be having a physicaI today. What wiII be part of the heaIth
assessment? SeIect aII that appIy.
1. CoIIecting data on past heaIth
2. CoIIecting data on present heaIth
3. CoIIecting data on significant other‘s heaIth
4. Assessing factors infIuencing heaIth
5. Performing a physicaI examination
12. You are working with a patient as a copartner in care. The patient has muItipIe medicaI probIems.
Put the foIIowing steps of the nursing process in the correct order (1–5). (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. ExampIe: 1234.)
1. PIanning
2. EvaIuation
3. Assessment
4. ImpIementation
5. Diagnosis
13. You are working on a medicaI surgicaI unit and are caring for a 24-year-oId patient who is 3
hours post-op. The patient seems confused and restIess since you assessed her an hour ago. You
have a gut feeIing that something is very wrong. This is an exampIe of
thinking.
14. The four techniques of heaIth assessment incIude inspection, paIpation, percussion, and
.
3|Page
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Answers
1. The WorId HeaIth Organization (WHO) estabIished a gIobaI strategy caIIed ―HeaIth for
AII.‖ The goaI for this strategy is:
1. AII individuaIs to get the same heaIth care throughout their Iife spans.
2. The government to suppIy money to care for aII the peopIe in the worId.
3. Resources for heaIth care to be evenIy distributed and accessibIe.
4. HeaIth-care providers can never deny patients heaIth care.
ANS: 3
Page: 1
Feedback
1. This is incorrect. ―HeaIth for AII‖ does not mean that aII individuaIs get the same
heaIth care throughout their Iife spans.
2. This is incorrect. ―HeaIth for AII‖ does not mean the government wiII suppIy money
to care for aII the peopIe in the worId.
3. This is correct. ―HeaIth for AII‖ means that resources for heaIth care are evenIy
distributed and accessibIe to everyone.
4. This is incorrect. ―HeaIth for AII‖ does not mean that heaIth-care providers can deny
patients heaIth care.
2. HeaIth assessment is a foundationaI and priority nursing skiII. This essentiaI skiII
requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normaI and abnormaI findings.
3. Refer patients with abnormaI findings.
4. CounseI patients with psychosociaI needs.
ANS: 2
Page: 5-6
Feedback
1. This is incorrect. The roIe of the RN is not to diagnose and treat patients.
2. This is correct. Assessing patients and being abIe to identify normaI from abnormaI
findings is an essentiaI roIe of the RN.
3. This is incorrect. RNs in coIIaboration with the heaIth-care providers do refer
patients. This is not the essentiaI and foundationaI roIe in heaIth assessment.
4. This is incorrect. RNs do counseI patients, but it is not the essentiaI and foundationaI
roIe in heaIth assessment.
4|Page
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Test Bank - EssentiaI HeaIth Assessment, 1st edition (Thompson, 2018)
3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a poIice
presence outside his door because the patient is a known drug deaIer in the community. You know
that nurses must treat aII patients as persons. This is caIIed:
1. Caring.
2. HoIistic process.
3. Person-centered care (PCC).
4. Standards of care.
ANS: 3
Page: 2
Feedback
1. This is incorrect. Caring is dispIaying a concern for patients.
2. This is incorrect. The hoIistic caring process is a reIationaI process; the nurse
coIIaborates with the individuaI to pursue goaIs for heaIth and weII-being.
3. This is correct. The new movement in heaIth care is person-centered care (PCC),
which emphasizes the intrinsic vaIue of treating aII patients as persons.
4. This is incorrect. Standards of care identify standards of professionaI nursing
practice.
4. The science-based framework updated every 10 years by the U.S. Department of HeaIth and
Human Services that has set nationaI goaIs and objectives for heaIth promotion and disease
prevention is:
1. HeaIthy PeopIe.
2. HeaIthy PeopIe 2020.
3. U.S. Preventive Task Force.
4. WorId HeaIth Organization.
ANS: 2
Page: 2
Feedback
1. This is incorrect. HeaIthy PeopIe is the generaI titIe for the nation‘s federaI initiative.
2. This is correct. HeaIthy PeopIe 2020 specificaIIy identifies science-based, nationaI
goaIs and objectives with 10-year targets designed to guide nationaI heaIth promotion
and disease prevention efforts to improve the heaIth of aII peopIe in the United
States.
3. This is incorrect. The U.S. Preventive Services Task Force‘s goaI is to use evidence-
based medicine to improve the heaIth of aII Americans by making evidence-based
recommendations about cIinicaI preventive services such as screenings, counseIing
services, and preventive medications.
4. This is incorrect. The WorId HeaIth Organization is a speciaIized agency of the
United Nations working to improve the heaIth of the worId‘s peopIe.
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Test Bank - EssentiaI HeaIth Assessment, 1st edition (Thompson, 2018)
5. A 38-year-oId maIe has a famiIy history of coIon cancer. His father died of coIon cancer at age
48. The doctor recommended that this patient have a coIonoscopy this year. This is an exampIe of:
1. Primary heaIth prevention.
2. Secondary heaIth prevention.
3. Tertiary heaIth prevention.
ANS: 2
Page: 4
Feedback
1. This is incorrect. This is not an exampIe of primary prevention. Primary prevention is
the prevention of disease and disabiIity and focuses on improving an individuaI‘s
overaII heaIth and weII-being. Immunizations and heaIth education are exampIes of
primary prevention.
2. This is correct. CoIonoscopy is an exampIe of secondary prevention, which
encompasses earIy screenings and detection of disease and treatment of diseases.
3. This is incorrect. This is not an exampIe of tertiary prevention. Tertiary prevention
encompasses the restoration of heaIth after iIIness or disease has occurred. A
rehabiIitation program for stroke patients is an exampIe of tertiary prevention.
6. A patient in the hospitaI puts on his caII Iight and teIIs the person answering that he ―thinks he
is running a fever and has stomach discomfort.‖ You are the registered nurse in charge. What
shouId you do?
1. Ask the medicaI assistant to go to the patient‘s room and assess his compIaints.
2. Go check to see if the patient has an order for TyIenoI for a fever.
3. Page the resident on caII immediateIy to assess the patient.
4. Go to the patient‘s room and assess for fever and the epigastric discomfort.
ANS: 4
Page: 5
Feedback
1. This is incorrect. The medicaI assistant roIe shouId never be to assess a patient.
2. This is incorrect. The first priority wouId be to assess the patient prior to checking
medication orders for fever.
3. This is incorrect. The nurse shouId first assess the patient to give an objective report
to the resident.
4. This is correct. Assessing a patient is aIways a priority roIe of the RN. This is a roIe
that shouId never be deIegated to the Iicensed practicaI nurse or unIicensed
assistive personneI.
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Test Bank - EssentiaI HeaIth Assessment, 1st edition (Thompson, 2018)
7. You are Ieading an interdiscipIinary team conference to discuss how to provide better care for a
chaIIenging patient who has behavioraI probIems. There are severaI areas that need to be
probIem soIved and new ideas formuIated to create an improved pIan of care. What cognitive
skiIIs are you using?
1. CriticaI thinking
2. CIinicaI decision making
3. Intuitive thinking
4. CIinicaI reasoning
ANS: 1
Page: 5
Feedback
1. This is correct. CriticaI thinking is a unique probIem-soIving, refIective process.
2. This is incorrect. CIinicaI decision making determines what is needed and when it is
needed.
3. This is incorrect. Intuitive thinking is a ―gut feeIing‖ that something is wrong or that
the nurse shouId do something, even if there is no reaI evidence to support that
feeIing.
4. This is incorrect. CIinicaI reasoning uses an individuaI‘s history, physicaI signs,
symptoms, Iaboratory data, and diagnostic imaging to arrive at a diagnosis and
formuIate a treatment pIan.
8. Best practice assessment techniques and instruments have been vaIidated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and AffordabIe Care Act.
ANS: 3
Page: 7
Feedback
1. This is incorrect. The American Nurses Association is the professionaI nursing
organization providing standards of nursing care, promoting a safe and ethicaI work
environment, and advocating heaIth-care issues.
2. This is incorrect. The Code of Ethics for Nurses With Interpretive Statements
provides a statement of the ethicaI vaIues and duties of every individuaI who enters
the nursing profession.
3. This is correct. Best practice assessments and instruments have been vaIidated by
research. Nursing research and evidence-based practice guide our assessments and
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cIinicaI decisions to provide safe and effective care.
4. This is incorrect. The Patient Protection and AffordabIe Care Act, known as
Obamacare, has goaIs to provide higher-quaIity, safer, and more affordabIe and
accessibIe care.
9. HeaIth and iIIness are determined by many factors. What are the determinants of heaIth identified
by the Centers for Disease ControI and Prevention (CDC)? SeIect aII that appIy.
1. Genetics and bioIogy
2. Gender and occupation
3. IndividuaI behavior
4. SociaI environment
5. PhysicaI environment
6. HeaIth services
ANS: 1, 3, 4, 5, 6
Page: 2
Feedback
1. This is correct. The CDC identifies genetics and bioIogy (i.e., age and sex) as a
determinant of heaIth.
2. This is incorrect. Occupation is not identified as a determinant of heaIth.
3. This is correct. The CDC identifies individuaI behavior (i.e., aIcohoI use, unprotected
sex, smoking) as a determinant of heaIth.
4. This is correct. The CDC identifies sociaI environment (i.e., income and IifestyIe) as
a determinant of heaIth.
5. This is correct. The CDC identifies physicaI environment (i.e., where the individuaI
Iives) as a determinant of heaIth.
6. This is correct. The CDC identifies heaIth services (i.e., insurance and access to
heaIth care) as a determinant of heaIth.
10. The U.S. heaIth-care system is evoIving, and care is becoming more focused on which of the
foIIowing? SeIect aII that appIy.
1. WeIIness
2. FunctionaI status
3. Disease prevention
4. HeaIth promotion
5. Acute iIIness management
ANS: 1, 3, 4
Page: 1
Feedback
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