Test Bank for
Nursing Health Assessment The Foundation of Clinical Practice,
3rd Edition, Patricia M. Dillon
,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
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
,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
, 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
, 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
Nursing Health Assessment The Foundation of Clinical Practice,
3rd Edition, Patricia M. Dillon
,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
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
,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
, 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
, 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
