EXAM 2 HEALTH ASSESSMENT STUDY QUESTIONS
CHAPTER 1
MULTIPLE CHOICE
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.
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 about
him or herself during history taking. The terms reflective and introspective are not used to
describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 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 of data
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 used
to describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. 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.
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patient’s record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
, MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8.The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an
example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes
who needs diabetic teaching
c. Individual with a small laceration on the
sole of the foot
d. Individual with shortness of breath and
respiratory distress
ANS: D
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority
problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS: C
Second-level priority problems are those that require prompt intervention to forestall further
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety
or security) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the
appropriateness of the __________ diagnosis.
, a. Nursing
b. Medical
c. Admission
d. Collaborative
ANS: A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to
achieve outcomes for which the nurse is accountable. The other items do not contribute to the
development of appropriate nursing interventions.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. The nursing process is a sequential method of problem solving that nurses use and includes
which steps?
a. Assessment, treatment, planning,
evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis,
treatment, and discharge planning
c. Admission, diagnosis, treatment,
evaluation, and discharge planning
d. Assessment, diagnosis, outcome
identification, planning, implementation,
and evaluation
ANS: D
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18.When reviewing the concepts of health, the nurse recalls that the components of holistic health
include which of these?
a. Disease originates from the external
environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient’s
health state.
d. Holistic health views the mind, body, and
spirit as interdependent.
ANS: D
Consideration of the whole person is the essence of holistic health, which views the mind, body,
and spirit as interdependent. The basis of disease originates from both the external environment
and from within the person. Both the individual human and the external environment are open
, systems, continually changing and adapting, and each person is responsible for his or her own
personal health state.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
CHAPTER 5
MULTIPLE CHOICE
1. During an examination, the nurse can assess mental status by which activity?
a. Examining the patient’s
electroencephalogram
b. Observing the patient as he or she
performs an intelligence quotient (IQ) test
c. Observing the patient and inferring health
or dysfunction
d. Examining the patient’s response to a
specific set of questions
ANS: C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its
functioning is inferred through an assessment of an individual’s behaviors, such as
consciousness, language, mood and affect, and other aspects.
PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 67 MSC: Client Needs: Psychosocial Integrity
2. The nurse is assessing the mental status of a child. Which statement about children and mental
status is true?
a. All aspects of mental status in children are
interdependent.
b. Children are highly labile and unstable
until the age of 2 years.
c. Children’s mental status is largely a
function of their parents’ level of
functioning until the age of 7 years.
d. A child’s mental status is impossible to
assess until the child develops the ability
to concentrate.
ANS: A
Separating and tracing the development of only one aspect of mental status is difficult. All
aspects are interdependent. For example, consciousness is rudimentary at birth because the
cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s
body. The other statements are not true.
CHAPTER 1
MULTIPLE CHOICE
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.
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 about
him or herself during history taking. The terms reflective and introspective are not used to
describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 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 of data
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 used
to describe data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. 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.
ANS: A
Together with the patient’s record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patient’s record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 2
, MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8.The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an
example of a first-level priority problem?
a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes
who needs diabetic teaching
c. Individual with a small laceration on the
sole of the foot
d. Individual with shortness of breath and
respiratory distress
ANS: D
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital
signs) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority
problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
ANS: C
Second-level priority problems are those that require prompt intervention to forestall further
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety
or security) (see Table 1-1).
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 4
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
10. Which critical thinking skill helps the nurse see relationships among the data?
a. Validation
b. Clustering related cues
c. Identifying gaps in data
d. Distinguishing relevant from irrelevant
ANS: B
Clustering related cues helps the nurse see relationships among the data.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the
appropriateness of the __________ diagnosis.
, a. Nursing
b. Medical
c. Admission
d. Collaborative
ANS: A
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to
achieve outcomes for which the nurse is accountable. The other items do not contribute to the
development of appropriate nursing interventions.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 6
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. The nursing process is a sequential method of problem solving that nurses use and includes
which steps?
a. Assessment, treatment, planning,
evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis,
treatment, and discharge planning
c. Admission, diagnosis, treatment,
evaluation, and discharge planning
d. Assessment, diagnosis, outcome
identification, planning, implementation,
and evaluation
ANS: D
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18.When reviewing the concepts of health, the nurse recalls that the components of holistic health
include which of these?
a. Disease originates from the external
environment.
b. The individual human is a closed system.
c. Nurses are responsible for a patient’s
health state.
d. Holistic health views the mind, body, and
spirit as interdependent.
ANS: D
Consideration of the whole person is the essence of holistic health, which views the mind, body,
and spirit as interdependent. The basis of disease originates from both the external environment
and from within the person. Both the individual human and the external environment are open
, systems, continually changing and adapting, and each person is responsible for his or her own
personal health state.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 7
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
CHAPTER 5
MULTIPLE CHOICE
1. During an examination, the nurse can assess mental status by which activity?
a. Examining the patient’s
electroencephalogram
b. Observing the patient as he or she
performs an intelligence quotient (IQ) test
c. Observing the patient and inferring health
or dysfunction
d. Examining the patient’s response to a
specific set of questions
ANS: C
Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its
functioning is inferred through an assessment of an individual’s behaviors, such as
consciousness, language, mood and affect, and other aspects.
PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)
REF: p. 67 MSC: Client Needs: Psychosocial Integrity
2. The nurse is assessing the mental status of a child. Which statement about children and mental
status is true?
a. All aspects of mental status in children are
interdependent.
b. Children are highly labile and unstable
until the age of 2 years.
c. Children’s mental status is largely a
function of their parents’ level of
functioning until the age of 7 years.
d. A child’s mental status is impossible to
assess until the child develops the ability
to concentrate.
ANS: A
Separating and tracing the development of only one aspect of mental status is difficult. All
aspects are interdependent. For example, consciousness is rudimentary at birth because the
cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother’s
body. The other statements are not true.
