TEST BANK
Nursing Health Assessment: A Best Practice Approach
Sharon Jensen
3rd Edition
,Table of Contents
Chapter 01 The Nurse's Role in Health Assessment 1
Chapter 02 The Health History and Interview 10
Chapter 03 Techniques of Assessment and Safety 27
Chapter 04 Documentation and Interprofessional Communication 35
Chapter 05 Vital Signs and General Survey 43
Chapter 06 Pain Assessment 51
Chapter 07 Nutritional Assessment 60
Chapter 08 Assessment of Developmental Stages 68
Chapter 09 Mental Health, Violence, and Drug Abuse 76
Chapter 10 Cultural Assessment 91
Chapter 11 Skin, Hair, and Nails Assessment 105
Chapter 12 Head and Neck, with Vision and Hearing Basics 114
Chapter 13 Eye Assessment for Advanced and Specialty Practice 123
Chapter 14 Ear Assessment for Advanced and Specialty Practice 132
Chapter 15 Nose, Sinuses, Mouth, and Throat 141
Chapter 16 Thorax and Lung Assessment 149
Chapter 17 Heart and Neck Vessels Assessment 158
Chapter 18 Peripheral Vascular and Lymphatic Assessment 167
Chapter 19 Breasts and Axillae Assessment 176
Chapter 20 Abdominal Assessment 185
Chapter 21 Musculoskeletal Assessment 193
Chapter 22 Neurological and Mental Status 202
Chapter 23 Male Genitalia and Rectal Assessment 211
Chapter 24 Female Genitalia and Rectal Assessment 220
Chapter 25 Pregnant Women 228
Chapter 26 Newborns and Infants 237
Chapter 27 Children and Adolescents 246
Chapter 28 Older Adults 255
Chapter 29 Assessment of the Hospitalized Adult 264
Chapter 30 Head-to-Toe Assessment of the Adult 273
,______________________________________________________________________________________________
Test Bank - Nursing Health Assessment: A Best Practice Approach, 3rd Edition (Jensen, 2019)
Chapter 1, The Nurse's Role in Health Assessment
MULTIPLE CHOICE
1. Which is one of the broad goals within nursing?
A) To provide cost-effective care
B) To form broad nursing diagnoses
C) To promote self-care
D) To treat human responses
ANS: D
Feedback: Four broad goals are within nursing: (1) to promote health (state of optimal
functioning or well-being with physical, social, and mental components); (2) to prevent
illness; (3) to treat human responses to health or illness; and (4) to advocate for
individuals, families, communities, and populations. The other options listed are not
broad goals. Nursing focuses on promoting health; while cost-effective care is strived
for, it is not a part of the broad goal, and therefore this is not a broad goal within nursing.
Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is
important, but does not correctly answer the question.
PTS: 1 REF: Page: 4 | Header: Roles of the Professional Nurse
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Remember
2. The nurse is conducting a physical assessment. The data the nurse would collect vary
depending on what?
A) How much time the nurse has
B) The client's acuity
C) The client's cooperation
D) Onset of current symptoms
ANS: B
Feedback: Data that nurses collect during a physical assessment vary depending on a
client's acuity (condition), health history, and current symptoms. The data collected
during a physical assessment do not depend on how much time the nurse has, how
cooperative the client is, or the onset of the current symptoms.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
3. A nursing instructor is discussing the purposes of health assessment. Which is one
purpose of health assessment?
A) To establish a database against which subsequent assessments can be measured
B) To establish rapport with the client and family
______________________________________________________________________________________________
1|Page
, ______________________________________________________________________________________________
Test Bank - Nursing Health Assessment: A Best Practice Approach, 3rd Edition (Jensen, 2019)
C) To gather information for specialists to whom the client might be referred
D) To quantify the degree of pain a client may be experiencing
ANS: A
Feedback: A health assessment is performed to gain further insight into the current
condition and to establish a database that subsequent assessments can be measured
against.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
4. How do nurses facilitate the achievement of high-level wellness with a client?
A) Encouraging the client to keep appointments
B) Providing the client information on alternative treatments
C) Promoting health in the client
D) Providing good client care
ANS: C
Feedback: High-level wellness is a process by which people maintain balance and
direction in the most favorable environment. The role of nurses is to facilitate this
achievement through health promotion and teaching. Nurses do not facilitate the
achievement of high-level wellness by encouraging clients to keep appointments,
providing information on alternative treatments, or providing “good” patient care.
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
5. The nurse is caring for a client who, on the continuum between wellness and illness, is
moving toward illness and premature death. How would the nurse know this to be true?
A) The client stops doing wellness-promoting activities.
B) The client develops signs and symptoms.
C) The client begins exercising.
D) The client verbalizes anxiety over the cost of medications.
ANS: B
Feedback: The person who moves toward illness and premature death develops signs,
symptoms, and disability, which, unfortunately, is when most treatment occurs in the
current health care system. The client may stop doing wellness-promoting activities and
not tell the nurse of this fact, which makes “The client stops doing wellness-promoting
activities” incorrect. “The client begins exercising” is incorrect because a client who
begins exercising is moving toward wellness, not illness. “The client verbalizes anxiety
over the cost of medications” is incorrect because the verbalization of anxiety over
financial matters is not an indication of illness.
______________________________________________________________________________________________
2|Page
Nursing Health Assessment: A Best Practice Approach
Sharon Jensen
3rd Edition
,Table of Contents
Chapter 01 The Nurse's Role in Health Assessment 1
Chapter 02 The Health History and Interview 10
Chapter 03 Techniques of Assessment and Safety 27
Chapter 04 Documentation and Interprofessional Communication 35
Chapter 05 Vital Signs and General Survey 43
Chapter 06 Pain Assessment 51
Chapter 07 Nutritional Assessment 60
Chapter 08 Assessment of Developmental Stages 68
Chapter 09 Mental Health, Violence, and Drug Abuse 76
Chapter 10 Cultural Assessment 91
Chapter 11 Skin, Hair, and Nails Assessment 105
Chapter 12 Head and Neck, with Vision and Hearing Basics 114
Chapter 13 Eye Assessment for Advanced and Specialty Practice 123
Chapter 14 Ear Assessment for Advanced and Specialty Practice 132
Chapter 15 Nose, Sinuses, Mouth, and Throat 141
Chapter 16 Thorax and Lung Assessment 149
Chapter 17 Heart and Neck Vessels Assessment 158
Chapter 18 Peripheral Vascular and Lymphatic Assessment 167
Chapter 19 Breasts and Axillae Assessment 176
Chapter 20 Abdominal Assessment 185
Chapter 21 Musculoskeletal Assessment 193
Chapter 22 Neurological and Mental Status 202
Chapter 23 Male Genitalia and Rectal Assessment 211
Chapter 24 Female Genitalia and Rectal Assessment 220
Chapter 25 Pregnant Women 228
Chapter 26 Newborns and Infants 237
Chapter 27 Children and Adolescents 246
Chapter 28 Older Adults 255
Chapter 29 Assessment of the Hospitalized Adult 264
Chapter 30 Head-to-Toe Assessment of the Adult 273
,______________________________________________________________________________________________
Test Bank - Nursing Health Assessment: A Best Practice Approach, 3rd Edition (Jensen, 2019)
Chapter 1, The Nurse's Role in Health Assessment
MULTIPLE CHOICE
1. Which is one of the broad goals within nursing?
A) To provide cost-effective care
B) To form broad nursing diagnoses
C) To promote self-care
D) To treat human responses
ANS: D
Feedback: Four broad goals are within nursing: (1) to promote health (state of optimal
functioning or well-being with physical, social, and mental components); (2) to prevent
illness; (3) to treat human responses to health or illness; and (4) to advocate for
individuals, families, communities, and populations. The other options listed are not
broad goals. Nursing focuses on promoting health; while cost-effective care is strived
for, it is not a part of the broad goal, and therefore this is not a broad goal within nursing.
Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is
important, but does not correctly answer the question.
PTS: 1 REF: Page: 4 | Header: Roles of the Professional Nurse
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Remember
2. The nurse is conducting a physical assessment. The data the nurse would collect vary
depending on what?
A) How much time the nurse has
B) The client's acuity
C) The client's cooperation
D) Onset of current symptoms
ANS: B
Feedback: Data that nurses collect during a physical assessment vary depending on a
client's acuity (condition), health history, and current symptoms. The data collected
during a physical assessment do not depend on how much time the nurse has, how
cooperative the client is, or the onset of the current symptoms.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
3. A nursing instructor is discussing the purposes of health assessment. Which is one
purpose of health assessment?
A) To establish a database against which subsequent assessments can be measured
B) To establish rapport with the client and family
______________________________________________________________________________________________
1|Page
, ______________________________________________________________________________________________
Test Bank - Nursing Health Assessment: A Best Practice Approach, 3rd Edition (Jensen, 2019)
C) To gather information for specialists to whom the client might be referred
D) To quantify the degree of pain a client may be experiencing
ANS: A
Feedback: A health assessment is performed to gain further insight into the current
condition and to establish a database that subsequent assessments can be measured
against.
PTS: 1 REF: Page: 6 | Header: What is health assessment?
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply
4. How do nurses facilitate the achievement of high-level wellness with a client?
A) Encouraging the client to keep appointments
B) Providing the client information on alternative treatments
C) Promoting health in the client
D) Providing good client care
ANS: C
Feedback: High-level wellness is a process by which people maintain balance and
direction in the most favorable environment. The role of nurses is to facilitate this
achievement through health promotion and teaching. Nurses do not facilitate the
achievement of high-level wellness by encouraging clients to keep appointments,
providing information on alternative treatments, or providing “good” patient care.
PTS: 1 REF: Page: 6 | Header: Wellness and Illness
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Caring
BLM: Cognitive Level: Understand
5. The nurse is caring for a client who, on the continuum between wellness and illness, is
moving toward illness and premature death. How would the nurse know this to be true?
A) The client stops doing wellness-promoting activities.
B) The client develops signs and symptoms.
C) The client begins exercising.
D) The client verbalizes anxiety over the cost of medications.
ANS: B
Feedback: The person who moves toward illness and premature death develops signs,
symptoms, and disability, which, unfortunately, is when most treatment occurs in the
current health care system. The client may stop doing wellness-promoting activities and
not tell the nurse of this fact, which makes “The client stops doing wellness-promoting
activities” incorrect. “The client begins exercising” is incorrect because a client who
begins exercising is moving toward wellness, not illness. “The client verbalizes anxiety
over the cost of medications” is incorrect because the verbalization of anxiety over
financial matters is not an indication of illness.
______________________________________________________________________________________________
2|Page
