Health Assessment Exam1: Study Guide
Chapter 1
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.
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.
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.
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.
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.
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.
,4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.
The nurse’s next action should be to:
a. Immediately notify the patient’s 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.
When unsure of a sound heard while listening to a patient’s 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.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, without a background of skills and
experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
Intuition is characterized by pattern recognition—expert nurses learn to attend to a
pattern of assessment data and act without consciously labeling it. The other options are
not correct.
7. The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
, a. EBP relies on tradition for support of best
practices.
b. EBP is simply the use of best practice
techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence
with the clinician’s experience.
d. The patient’s own preferences are not
important with EBP.
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinician’s experience, as well as patient preferences and values,
when making decisions about care and treatment. EBP is more than simply using the best
practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
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
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).
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
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).
, 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
Clustering related cues helps the nurse see relationships among the data.
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
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.
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
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems?
Chapter 1
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.
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.
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.
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.
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.
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.
,4. When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard.
The nurse’s next action should be to:
a. Immediately notify the patient’s 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.
When unsure of a sound heard while listening to a patient’s 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.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the
nurse should keep in mind that novice nurses, without a background of skills and
experience from which to draw, are more likely to make their decisions using:
a. Intuition.
b. A set of rules.
c. Articles in journals.
d. Advice from supervisors.
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously
labeling it. These responses are referred to as:
a. Intuition.
b. The nursing process.
c. Clinical knowledge.
d. Diagnostic reasoning.
Intuition is characterized by pattern recognition—expert nurses learn to attend to a
pattern of assessment data and act without consciously labeling it. The other options are
not correct.
7. The nurse is reviewing information about evidence-based practice (EBP). Which
statement best reflects EBP?
, a. EBP relies on tradition for support of best
practices.
b. EBP is simply the use of best practice
techniques for the treatment of patients.
c. EBP emphasizes the use of best evidence
with the clinician’s experience.
d. The patient’s own preferences are not
important with EBP.
EBP is a systematic approach to practice that emphasizes the use of best evidence in
combination with the clinician’s experience, as well as patient preferences and values,
when making decisions about care and treatment. EBP is more than simply using the best
practice techniques to treat patients, and questioning tradition is important when no
compelling and supportive research evidence exists.
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
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).
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
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).
, 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
Clustering related cues helps the nurse see relationships among the data.
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
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.
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
The nursing process is a method of problem solving that includes assessment, diagnosis,
outcome identification, planning, implementation, and evaluation.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems?
