FULL TEST BANK Nursing Health Assessment A Clinical Judgment
Approach 4rd Edition By Sharon Jensen (Author) Exam
1. Which action is most important when beginning a
comprehensive nursing health assessment?
,A. Obtain the patient's family history
B. Perform the physical examination
C. Establish rapport and explain the assessment
D. Review laboratory results
Answer: C. Establish rapport and explain the assessment
Rationale: Establishing rapport promotes trust, communication,
cooperation, and accurate information gathering.
2. Which source is considered the primary source of subjective
health information?
A. Spouse
B. Medical record
C. Patient
D. Previous nurse
Answer: C. Patient
Rationale: The patient is the primary source of subjective data
whenever the patient is able to communicate reliably.
3. Which finding is an example of objective data?
A. "I feel nauseated."
B. "My pain is 7 out of 10."
C. Temperature of 38.4°C (101.1°F)
D. "I have been tired all week."
Answer: C. Temperature of 38.4°C (101.1°F)
Rationale: Objective data are observable or measurable findings
obtained through examination, observation, or diagnostic
measurement.
,4. A patient states, "My chest feels like someone is sitting on it."
This information is classified as:
A. Objective data
B. Subjective data
C. Secondary data
D. Diagnostic data
Answer: B. Subjective data
Rationale: The patient's description of a sensation is subjective
information.
5. Which technique is generally performed first during a physical
examination?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D. Inspection
Rationale: Inspection involves systematic visual observation and
generally begins the physical examination.
6. Which assessment technique involves using the hands to
determine characteristics such as texture, temperature, tenderness,
and masses?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: B. Palpation
, Rationale: Palpation uses touch to assess physical characteristics of
body structures.
7. Which technique involves tapping the body surface to produce
sounds that provide information about underlying structures?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: C. Percussion
Rationale: Percussion produces characteristic sounds that help
identify air, fluid, or solid tissue beneath the surface.
8. Which technique requires a stethoscope?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: D. Auscultation
Rationale: Auscultation involves listening to internal body sounds,
commonly with a stethoscope.
9. A nurse asks a patient, "What brings you to the clinic today?"
This question primarily assesses the:
A. Past medical history
B. Chief concern
C. Family history
D. Review of systems
Approach 4rd Edition By Sharon Jensen (Author) Exam
1. Which action is most important when beginning a
comprehensive nursing health assessment?
,A. Obtain the patient's family history
B. Perform the physical examination
C. Establish rapport and explain the assessment
D. Review laboratory results
Answer: C. Establish rapport and explain the assessment
Rationale: Establishing rapport promotes trust, communication,
cooperation, and accurate information gathering.
2. Which source is considered the primary source of subjective
health information?
A. Spouse
B. Medical record
C. Patient
D. Previous nurse
Answer: C. Patient
Rationale: The patient is the primary source of subjective data
whenever the patient is able to communicate reliably.
3. Which finding is an example of objective data?
A. "I feel nauseated."
B. "My pain is 7 out of 10."
C. Temperature of 38.4°C (101.1°F)
D. "I have been tired all week."
Answer: C. Temperature of 38.4°C (101.1°F)
Rationale: Objective data are observable or measurable findings
obtained through examination, observation, or diagnostic
measurement.
,4. A patient states, "My chest feels like someone is sitting on it."
This information is classified as:
A. Objective data
B. Subjective data
C. Secondary data
D. Diagnostic data
Answer: B. Subjective data
Rationale: The patient's description of a sensation is subjective
information.
5. Which technique is generally performed first during a physical
examination?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D. Inspection
Rationale: Inspection involves systematic visual observation and
generally begins the physical examination.
6. Which assessment technique involves using the hands to
determine characteristics such as texture, temperature, tenderness,
and masses?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: B. Palpation
, Rationale: Palpation uses touch to assess physical characteristics of
body structures.
7. Which technique involves tapping the body surface to produce
sounds that provide information about underlying structures?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: C. Percussion
Rationale: Percussion produces characteristic sounds that help
identify air, fluid, or solid tissue beneath the surface.
8. Which technique requires a stethoscope?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: D. Auscultation
Rationale: Auscultation involves listening to internal body sounds,
commonly with a stethoscope.
9. A nurse asks a patient, "What brings you to the clinic today?"
This question primarily assesses the:
A. Past medical history
B. Chief concern
C. Family history
D. Review of systems
