Test Bank for Nursing Health Assessment The Foundation of Clinical Practice, 3rd Edition, Patricia M. Dillon DR ERIC DR ERIC Table of Contents 1. Introduction to Assessment 2. Assessing the Integumentary System 3. Assessing the Head, Face and Neck 4. Ass

Test Bank for Nursing Health Assessment The Foundation of Clinical Practice, 3rd Edition, Patricia M. Dillon DR ERIC DR ERIC Table of Contents 1. Introduction to Assessment 2. Assessing the Integumentary System 3. Assessing the Head, Face and Neck 4. Assessing Eyes and the Ears 5. Assessing the Respiratory System 6. Assessing the Cardiovascular System 7. Assessing the Peripheral -Vascular and Lymphatic Systems 8. Assessing the Breasts 9. Assessing the Abdomen 10. Assessing the Female Genitourinary 11. Assessing the Male Genitourinary 12. Assessing the Motor Musculoskeletal System 13. Assessing the Sensory Neurological System 14. Assessing the Mother to Be 15. Assessing the Newborn and Infant 16. Assessing the Toddler and Preschooler 17. Assessing the School-Age Child and Adolescent 18. Assessing the Older Adult 19. Assessing the Homeless Person 20. Assessing Pain DR ERIC DR ERIC 21. Approach to the Mental Health Assessment 22. Assessing Nutrition 23. Assessing Spirituality 24. Assessing Culture 25. Assessing the Patient’s Environment 26. Assessing Abuse 27. Assessing the Dying Patient—new DR ERIC DR ERIC Chapter 01: The Complete Health Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which critical thinking skill allows the nurse to think outside of the box when assessing a patient? 1) Divergent thinking 2) Reasoning 3) Creativity 4) Reflection 2. The primary level of preventive health care focuses on which topic? 1) Health promotion 2) Early detection 3) Promotion intervention 4) End-of-life care 3. The nurse is prioritizing data collected during the health assessment. Which data is primary? 1) Pain rating of 4 on a 1 to 10 numeric scale 2) New diagnosis of type 2 diabetes mellitus (DM) 3) Blood pressure of 130/90 mmHg 4) Pulse oximetry reading of 73% 4. Which type of skill is most important when performing a physical assessment? 1) Psychomotor 2) Interpersonal 3) Ethical 4) Affective 5. Which activity is an example of secondary prevention? 1) Wound débridement 2) Immunization 3) Preoperative teaching 4) Long-term nasogastric feedings 6. Which assessment data is considered a symptom? 1) Rapid respirations 2) Sweaty palms 3) Belching 4) Feelings of anxiety 7. Who or what is considered the primary data source for a toddler-age patient? 1) The toddler 2) A parent 3) The medical record 4) Other healthcare providers 8. Which part of the assessment provides the most subjective data? 1) Health history 2) Physical assessment 3) Review of medical records 4) Medication record DR ERIC DR ERIC 9. The nurse is preparing to conduct a health history for a new patient. Where would the nurse gather data for this portion of the assessment? 1) The patient's chart 2) A physical assessment 3) Laboratory tests 4) A discussion with the patient 10. The nurse is preparing to begin a health history for a new patient. Which question is most appropriate for the nurse to begin the process? 1) “What problem brought you here today?” 2) “How old are you?” 3) “Have you had any difficulty breathing?” 4) “What childhood illnesses have you had?” 11. Which is the reason for asking the patient about family history of diseases when conducting a health history interview? 1) To identify functional or dysfunctional family dynamics 2) To identify support systems 3) To identify familial or genetically linked health disorders 4) To identify rehabilitation needs 12. Which data are part of the past health history? 1) Health beliefs 2) Surgeries 3) Genetically linked diseases 4) Age of siblings 13. Which is the purpose of the nursing health history? 1) To determine the patient's response to the health problem 2) To determine the extent of the health problem 3) To determine which medications are appropriate to alleviate the health problem 4) All of the above 14. Which setting is the best place to gather data for a health history? 1) Waiting room 2) Hallway 3) Patient's room 4) On the way to surgery 15. The nurse is preparing to conduct a health history interview with a patient. Which is the best position for the nurse to assume during this process? 1) Leaning over the bed 2) Standing at the bedside 3) Sitting on the bed 4) Sitting on a chair at the bedside 16. The nurse is asking a patient questions about health practices and beliefs. In which portion of the health history will the nurse document these findings? 1) Psychosocial profile 2) Current health problems 3) Past health problems 4) Developmental considerations DR ERIC DR ERIC 17. The patient tells the nurse, “I can never seem to get warm lately and decided to come to the clinic.” The nurse records this under which section of the health history? 1) Past health history 2) Present health status 3) Reason for seeking care 4) Objective assessment data 18. When is it appropriate for the nurse to conduct the focused physical assessment? 1) During the initial assessment for a yearly exam 2) On admission to the hospital for surgery 3) On admission of a patient in acute respiratory distress 4) All of the above 19. Glass thermometers and sphygmomanometers have been replaced by other equipment in many healthcare settings. Which is the rationale for this change? 1) Difficulty with calibration 2) Difficulty with sterilization 3) Mercury toxicity 4) Poor results 20. The bell of the stethoscope is best for detecting which type of sounds? 1) High pitch 2) Low pitch 3) Medium pitch 4) All of the above 21. The nurse is unable to palpate pedal pulses bilaterally on an obese patient. Which is the priority action for the nurse to take? 1) Document that pedal pulses are absent 2) Auscultate heart tones 3) Assess gait 4) Assess pulses with a Doppler 22. Which is the best assessment tool to use when testing far vision in 2-year-old children? 1) Snellen alphabet chart 2) Stycar chart 3) Allen cards 4) Pocket vision screener 23. Which is the best method for the nurse to use when documenting a patient’s physical exam? 1) In order of the assessment 2) By the patient's main complaint 3) By system 4) With all normal and abnormal data clustered 24. Which part of the hand does the nurse use to detect vibrations? 1) Fingertips 2) Fingerpads 3) Ball of hand 4) Dorsal surface DR ERIC DR ERIC 25. The nurse is planning to use percussion during the physical examination of a patient. Which is the reason for using percussion? 1) To assess areas of tenderness 2) To assess organ and tissue density 3) To assess areas of inflammation 4) To assess consistency 26. Which action by the nurse is appropriate when using an otoscope to assess the tympanic membrane of an adult? 1) Pulling the earlobe up and back 2) Pulling the earlobe down and back 3) Pulling the earlobe horizontally to straighten the ear canal 4) Avoiding moving the canal out of the normal anatomic position 27. The nurse is preparing to assess the fetal heart rate during the 32nd week of gestation. Which action is appropriate? 1) Using the bell of the stethoscope 2) Using the diaphragm of the stethoscope 3) Using palpation to feel the fetal heart rate 4) Using a fetoscope 28. The nurse is using an ophthalmoscope during a routine head-to-toe assessment. Which is the nurse assessing? 1) External ear canal 2) Tympanic membrane 3) Red light reflex 4) Cranial nerves 29. Which is the correct technique for using the bell portion of the stethoscope? 1) Avoid touching the bell during auscultation 2) Hold the bell lightly on the chest wall 3) Apply light pressure with the bell slightly tilted up 4) Hold the bell firmly against the chest wall 30. The nurse is preparing to assess the patient’s thyroid gland. Which action is appropriate? 1) Asking the patient to identify a scent 2) Asking the patient to swallow water 3) Asking the patient to identify a taste 4) Asking the person to repeat “99” 31. The nurse uses a tongue depressor to assess the gag reflex. Which action is appropriate by the nurse? 1) Sending the depressor for sterilization 2) Discarding the depressor in one piece 3) Breaking the depressor and then discarding it 4) Using the depressor for another patient 32. The nurse is assessing the patient’s range of motion. Which tool is a requirement for this assessment? 1) Stethoscope 2) Otoscope 3) Ophthalmoscope 4) Ganiometer 33. The nurse is assisting the healthcare provider during a pelvic examination. Which action by the nurse is appropriate?