Health Assessment Final Test Bank Questions and
answer 100% correct
Terms in this set (202)
After completing an initial assessment of a a. Objective
patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 Rationale: Objective data are what the health
professional beats per minute. These types of data would observes by inspecting, percussing,
palpating, and
be: auscultating during the physical examination. Subjective data
is what the person says about him or herself during
history
a.Objective taking. The terms reflective and introspective are not used to
b. Reflective describe data.
c. Subjective
d. Introspective
,A patient tells the nurse that he is very c. Subjective
nervous, is nauseated, and feels hot. These
types of data would be: Rationale: Subjective data are what the person says about him
or herself during history taking. Objective data are what
the
a.Objective health professional observes by inspecting, percussing,
b. Reflective palpating, and auscultating during the physical examination.
c. Subjective The terms reflective and introspective are not used to
d. Introspective describe data.
When listening to a patients breath sounds, c. Validate the data by asking a coworker to listen to
the the nurse is unsure of a sound that is heard. breath sounds
The nurses next action should be to:
Rationale: When unsure of a sound heard while listening to a
a.Immediately notify the patients physician patients breath sounds, the nurse validates the data to ensure
b. Document the sound exactly as it was accuracy. If the nurse has less experience in an area, then
he heard or she asks an expert to listen.
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
The patients record, laboratory studies, a. Data
base objective data, and subjective data combine
to form the: Rationale: Together with the patients record and
laboratory studies, the objective and subjective data form
the data base.
a.Data base The other items are not part of the patients record,
laboratory studies, or data.
b.Admitting data
c. Financial statement
d. Discharge summary
The nursing process is a sequential method d. Assessment, diagnosis, outcome identification, planning,
of problem solving that nurses use and implementation, and evaluation
includes which steps?
Rationale: The nursing process is a method of problem solving
a.Assessment, treatment, planning, that includes assessment, diagnosis, outcome identification,
evaluation, discharge, and follow-up planning, implementation, and evaluation.
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
,Barriers to incorporating EBP include: a.Nurses lack of research skills in evaluating the quality
of research studies
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
b. Lack of significant research studies other colleagues who are knowledgeable in research, and
often lack the time to visit the library to read research. The
c. Insufficient clinical skills of nurses other responses are not considered barriers.
d. Inadequate physical assessment skills
The nurse is reviewing data collected after a.Inspiratory wheezes noted in left lower lobes
an assessment. Of the data listed below, c. Nonproductive cough
which would be considered related cues e. Patient reports dyspnea upon exertion
that would be clustered together during f. Rate of respirations 16 breaths per minute
data analysis? Select all that apply.
Rationale: Clustering related cues help the nurse
a.Inspiratory wheezes noted in left lower recognize relationships among the data. The cues related to
lobes the patients respiratory status (e.g., wheezes, cough, report
of dyspnea, respiration rate and rhythm) are all related.
b. Hypoactive bowel sounds Cues related to bowels and peripheral edema are not
related to the
c. Nonproductive cough respiratory cues.
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
The nurse is conducting an interview. Which b. They allow for self-expression
of these statements is true regarding open-
ended questions? Select all that apply. c. Open-ended questions build and enhance rapport
a.Open-ended questions elicit cold facts f. They are used when narrative information is needed
b.They allow for self-expression Rationale: Open-ended questions allow for self-expression,
build and enhance rapport, and obtain narrative information.
c. Open-ended questions build and These features enhance communication during an interview.
enhance rapport The other statements are appropriate for closed or direct
questions.
d.They leave interactions neutral
e.Open-ended questions call for short one-
to two-word answers
f.They are used when narrative information
is needed
, The nurse is conducting an interview in an a.Collect the patients data in a direct, face-to-face manner.
outpatient clinic and is using a computer to
record data. Which are the best uses of the d. Type the data into the computer after the narrative is
computer in this situation? Select all that fully explored.
apply.
e. Allow the patient to see the monitor during typing.
a.Collect the patients data in a direct,
face-to-face manner. Rationale: The use of a computer can become a barrier.
The nurse should begin the interview as usual by
b. Enter all the data as the patient greeting the patient, establishing rapport, and
states them. collecting the patients
narrative story in a direct, face-to-face manner. Only after the
c.Ask the patient to wait as the nurse narrative is fully explored should the nurse type data into the
enters the data. computer. When typing, the nurse should position the monitor
so that the patient can see it.
d.Type the data into the computer after
the narrative is fully explored.
e.Allow the patient to see the monitor
during typing.
During an interview, the nurse would expect c. Social distance
that most of the interview will take place at
what distance? Rationale: Social distance, 4 to 12 feet, is usually the distance
category for most of the interview. Public distance, over 12
a.Intimate zone feet, is too much distance; the intimate zone is inappropriate,
and the personal distance will be used for the physical
b. Personal distance assessment.
c. Social distance
d. Public distance
During the interview portion of data d. Subjective
collection, the nurse collects_________data.
Rationale: The interview is the first, and really the most
a. Physical important, part of data collection. During the interview,
the nurse collects subjective data; that is, what the person
b. Historical says about him or herself.
c. Objective
d. Subjective
answer 100% correct
Terms in this set (202)
After completing an initial assessment of a a. Objective
patient, the nurse has charted that his
respirations are eupneic and his pulse is 58 Rationale: Objective data are what the health
professional beats per minute. These types of data would observes by inspecting, percussing,
palpating, and
be: auscultating during the physical examination. Subjective data
is what the person says about him or herself during
history
a.Objective taking. The terms reflective and introspective are not used to
b. Reflective describe data.
c. Subjective
d. Introspective
,A patient tells the nurse that he is very c. Subjective
nervous, is nauseated, and feels hot. These
types of data would be: Rationale: Subjective data are what the person says about him
or herself during history taking. Objective data are what
the
a.Objective health professional observes by inspecting, percussing,
b. Reflective palpating, and auscultating during the physical examination.
c. Subjective The terms reflective and introspective are not used to
d. Introspective describe data.
When listening to a patients breath sounds, c. Validate the data by asking a coworker to listen to
the the nurse is unsure of a sound that is heard. breath sounds
The nurses next action should be to:
Rationale: When unsure of a sound heard while listening to a
a.Immediately notify the patients physician patients breath sounds, the nurse validates the data to ensure
b. Document the sound exactly as it was accuracy. If the nurse has less experience in an area, then
he heard or she asks an expert to listen.
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
The patients record, laboratory studies, a. Data
base objective data, and subjective data combine
to form the: Rationale: Together with the patients record and
laboratory studies, the objective and subjective data form
the data base.
a.Data base The other items are not part of the patients record,
laboratory studies, or data.
b.Admitting data
c. Financial statement
d. Discharge summary
The nursing process is a sequential method d. Assessment, diagnosis, outcome identification, planning,
of problem solving that nurses use and implementation, and evaluation
includes which steps?
Rationale: The nursing process is a method of problem solving
a.Assessment, treatment, planning, that includes assessment, diagnosis, outcome identification,
evaluation, discharge, and follow-up planning, implementation, and evaluation.
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
,Barriers to incorporating EBP include: a.Nurses lack of research skills in evaluating the quality
of research studies
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
b. Lack of significant research studies other colleagues who are knowledgeable in research, and
often lack the time to visit the library to read research. The
c. Insufficient clinical skills of nurses other responses are not considered barriers.
d. Inadequate physical assessment skills
The nurse is reviewing data collected after a.Inspiratory wheezes noted in left lower lobes
an assessment. Of the data listed below, c. Nonproductive cough
which would be considered related cues e. Patient reports dyspnea upon exertion
that would be clustered together during f. Rate of respirations 16 breaths per minute
data analysis? Select all that apply.
Rationale: Clustering related cues help the nurse
a.Inspiratory wheezes noted in left lower recognize relationships among the data. The cues related to
lobes the patients respiratory status (e.g., wheezes, cough, report
of dyspnea, respiration rate and rhythm) are all related.
b. Hypoactive bowel sounds Cues related to bowels and peripheral edema are not
related to the
c. Nonproductive cough respiratory cues.
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
The nurse is conducting an interview. Which b. They allow for self-expression
of these statements is true regarding open-
ended questions? Select all that apply. c. Open-ended questions build and enhance rapport
a.Open-ended questions elicit cold facts f. They are used when narrative information is needed
b.They allow for self-expression Rationale: Open-ended questions allow for self-expression,
build and enhance rapport, and obtain narrative information.
c. Open-ended questions build and These features enhance communication during an interview.
enhance rapport The other statements are appropriate for closed or direct
questions.
d.They leave interactions neutral
e.Open-ended questions call for short one-
to two-word answers
f.They are used when narrative information
is needed
, The nurse is conducting an interview in an a.Collect the patients data in a direct, face-to-face manner.
outpatient clinic and is using a computer to
record data. Which are the best uses of the d. Type the data into the computer after the narrative is
computer in this situation? Select all that fully explored.
apply.
e. Allow the patient to see the monitor during typing.
a.Collect the patients data in a direct,
face-to-face manner. Rationale: The use of a computer can become a barrier.
The nurse should begin the interview as usual by
b. Enter all the data as the patient greeting the patient, establishing rapport, and
states them. collecting the patients
narrative story in a direct, face-to-face manner. Only after the
c.Ask the patient to wait as the nurse narrative is fully explored should the nurse type data into the
enters the data. computer. When typing, the nurse should position the monitor
so that the patient can see it.
d.Type the data into the computer after
the narrative is fully explored.
e.Allow the patient to see the monitor
during typing.
During an interview, the nurse would expect c. Social distance
that most of the interview will take place at
what distance? Rationale: Social distance, 4 to 12 feet, is usually the distance
category for most of the interview. Public distance, over 12
a.Intimate zone feet, is too much distance; the intimate zone is inappropriate,
and the personal distance will be used for the physical
b. Personal distance assessment.
c. Social distance
d. Public distance
During the interview portion of data d. Subjective
collection, the nurse collects_________data.
Rationale: The interview is the first, and really the most
a. Physical important, part of data collection. During the interview,
the nurse collects subjective data; that is, what the person
b. Historical says about him or herself.
c. Objective
d. Subjective
