Health Assessment Final Test Bank Questions AND ANSWERS
Rationale: 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 expert to listen.
The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base
b. Admitting data
c. Financial statement
d. Discharge summary - ANSWER- a. Data base
Rationale: With orchitis, the testis is swollen, with a feeling of weight, and is tender or
painful. The mass does not transilluminate, and the scrotal skin is reddened.
Transillumination of a mass occurs with a hydrocele, not orchitis.
During an examination, the nurse observes a female patients vestibule and expects to see the:
a. Urethral meatus and vaginal orifice.
b. Vaginal orifice and vestibular (Bartholin) glands.
c. Urethral meatus and paraurethral (Skene) glands.
d. Paraurethral (Skene) and vestibular (Bartholin) glands. - ANSWER- a. Urethral meatus
and vaginal orifice.
,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 - ANSWER- a. Objective
Rationale: 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.
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 - ANSWER- c. Subjective
Rationale: 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.
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 - ANSWER- c.
Validate the data by asking a coworker to listen to the breath sounds
,Rationale: Together with the patients record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patients record,
laboratory studies, or data.
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 -
ANSWER- d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
Rationale: The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation.
Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills - ANSWER- a. Nurses lack of research skills in
evaluating the quality of research studies
, Rationale: As individuals, nurses lack research skills in evaluating the quality of research
studies, are isolated from other colleagues who are knowledgeable in research, and often lack
the time to visit the library to read research. The other responses are not considered barriers.
The nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis?
Select all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - ANSWER- a. Inspiratory wheezes noted in left
lower lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
Rationale: Clustering related cues help the nurse recognize relationships among the data. The
cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea,
respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are
not related to the respiratory cues.
The nurse is conducting an interview. Which of these statements is true regarding open-ended
questions? Select all that apply.
a. Open-ended questions elicit cold facts
Rationale: 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 expert to listen.
The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base
b. Admitting data
c. Financial statement
d. Discharge summary - ANSWER- a. Data base
Rationale: With orchitis, the testis is swollen, with a feeling of weight, and is tender or
painful. The mass does not transilluminate, and the scrotal skin is reddened.
Transillumination of a mass occurs with a hydrocele, not orchitis.
During an examination, the nurse observes a female patients vestibule and expects to see the:
a. Urethral meatus and vaginal orifice.
b. Vaginal orifice and vestibular (Bartholin) glands.
c. Urethral meatus and paraurethral (Skene) glands.
d. Paraurethral (Skene) and vestibular (Bartholin) glands. - ANSWER- a. Urethral meatus
and vaginal orifice.
,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 - ANSWER- a. Objective
Rationale: 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.
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 - ANSWER- c. Subjective
Rationale: 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.
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 - ANSWER- c.
Validate the data by asking a coworker to listen to the breath sounds
,Rationale: Together with the patients record and laboratory studies, the objective and
subjective data form the data base. The other items are not part of the patients record,
laboratory studies, or data.
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 -
ANSWER- d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
Rationale: The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation.
Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills - ANSWER- a. Nurses lack of research skills in
evaluating the quality of research studies
, Rationale: As individuals, nurses lack research skills in evaluating the quality of research
studies, are isolated from other colleagues who are knowledgeable in research, and often lack
the time to visit the library to read research. The other responses are not considered barriers.
The nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis?
Select all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - ANSWER- a. Inspiratory wheezes noted in left
lower lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
Rationale: Clustering related cues help the nurse recognize relationships among the data. The
cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea,
respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are
not related to the respiratory cues.
The nurse is conducting an interview. Which of these statements is true regarding open-ended
questions? Select all that apply.
a. Open-ended questions elicit cold facts
