TEST BANK
Bates' Nursing Guide to Physical Examination and History
Taking
Beth Hogan-Quigley, and Mary Louis Palm
3rd Edition
,Table of Contents
Chapter 01 Introduction to Health Assessment and Social Determinants of Health 1
Chapter 02 Critical Thinking and Clinical Judgment in Health Assessment 10
Chapter 03 Interviewing and Communication 18
Chapter 04 The Health History 27
Chapter 05 Cultural and Spiritual Assessment 36
Chapter 06 Physical Examination-Getting Started 44
Chapter 07 General Survey Including Vital Signs and Pain 51
Chapter 08 Nutrition and Hydration 59
Chapter 09 The Integumentary System 68
Chapter 10 The Head and Neck 76
Chapter 11 The Eyes 85
Chapter 12 Ears, Nose, Mouth, and Throat 93
Chapter 13 The Respiratory System 103
Chapter 14 The Cardiovascular System 111
Chapter 15 The Peripheral Vascular System and Lymphatic System 119
Chapter 16 The Gastrointestinal and Renal Systems 127
Chapter 17 The Breasts and Axillae 136
Chapter 18 The Musculoskeletal System 144
Chapter 19 Mental Status and Mental Health Assessment 152
Chapter 20 The Nervous System 161
Chapter 21 Reproductive Systems 170
Chapter 22 Putting the Physical Examination All Together 176
Chapter 23 Assessing Children-Infancy Through Adolescence 185
Chapter 24 Assessing Older Adults 193
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Chapter 1, Introduction to Health Assessment and Social Determinants of Health
1. What is the nurse's focus while conducting a health assessment with a client? (Select all that
apply.)
A) Completing the health history.
B) Interpreting findings.
C) Formulating a plan of care
D) Implementing a plan of care.
E) Conducting a physical examination.
ANS: A, E
Feedback: A health assessment is comprised of the taking the client's health history then
followed by a physical examination. Interpreting findings, formulating a plan of care, and
implementing a plan of care are steps within the nursing process that use the data identified
by the health assessment.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
2. Before beginning a health assessment with a client, the nurse reviews Healthy People 2030
because of which of the following reasons.
A) It helps determine the client's plan of care.
B) It serves as a guide for the health assessment.
C) It identifies heath indicators, appropriate interventions, and resources.
D) It addresses most client health problems.
ANS: C
Feedback: Healthy People 2030 is a framework that identifies heath indicators, appropriate
interventions, and resources in the United States. The goals and objectives serve to improve
the health of individuals and communities, targeting the next 10 years. Its overall goal is to
increase quality of life by creating guidelines for a healthy lifestyle as well as educating
people and cultivating an awareness that will assist in the elimination of health disparities.
Healthy People 2030 does not help determine every client's plan of care. Healthy People
2030 does not serve as a guide for the health assessment nor does it list specific
interventions to address specific health problems. Instead, Healthy People 2030 indicators
pertinent to individuals are determined as the nurse completes the health assessment on each
patient.
PTS: 1 REF: Page and Header: 7–8, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
3. After completing a health history, the nurse determines that a client would benefit from
interventions to address the Healthy People 2030 indicator associated with the prevalence
and mortality of chronic disease. What assessment data would relate to this indicator?
(Select all that apply.)
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1|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
A) Client’s body mass index suggests obesity.
B) Client has been prescribed medication for hypertension.
C) Client is currently without health insurance.
D) Client was diagnosed with heart disease three years ago.
E) Client had a skin cancer lesion removed surgically four years ago.
ANS: B, D, E
Feedback: The Healthy People 2030 indicator "prevalence and mortality of chronic
disease" has the objectives of reducing coronary heart disease deaths, reducing the number
of people with hypertension, and reducing the overall cancer death rate. Because the client
has a history of hypertension, has been diagnosed with heart disease, and was previously
treated for skin cancer, the indicator "prevalence and mortality of chronic disease" would be
appropriate for this client. The Healthy People 2030 indicator of "healthy behaviors" would
be applicable for the body mass index of being overweight. The Healthy People 2030
indicator of "access to health services" would be applicable for the client currently without
health insurance.
PTS: 1 REF: Page and Header: 7–8, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Select
4. The nurse is following a structured head-to-toe approach to identify changes in a client's
body systems. Which component of the health assessment is the nurse completing with the
client?
A) Health history
B) Physical examination
C) Goal setting
D) Planning care
ANS: B
Feedback: In the physical examination, the nurse uses a structured head-to-toe approach to
identify changes in the client's body systems. The health history is when the nurse asks
pertinent questions to gather data from the client and/or family. Goal setting and planning
care are not parts of the health assessment.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. The nurse is conducting a health assessment on a client presenting to the emergency room
with a critical condition. The nurse should initially ask questions regarding which topic(s)
during the initial assessment? (Select all that apply.)
A) medications
B) allergies
C) adverse reactions
D) lifestyle changes
E) stress at work
______________________________________________________________________________________________
2|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
ANS: A, B, C
Feedback: The nurse should ask a client in critical condition brought into the emergency
department about topics concerning the event, including medications, allergies, and adverse
reactions. When a client has a professional relationship with the nurse and has had a
thorough health assessment at the initial meeting, the nurse may explore other assessment
topics such as lifestyle changes and stress at work. The thorough health history would be
completed when the patient was stable and able to answer further questions.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
6. What will be the nurse's initial role when conducting a health assessment with a client
reporting abdominal pain?
A) Teaching the client to draw knees to chest to help minimize the pain
B) Planning care to help minimize the client's pain
C) Collecting data regarding the nature of the pain
D) Identifying pain management interventions with input from the client
ANS: C
Feedback: The nurse's initial role in health assessment is to collect data. Teaching would
occur later in the process. Planning care and identifying interventions are parts of the
nursing process and not the health assessment.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change
in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife.
How did you get into my house?" Based upon the client's behavior, which assessment will
the nurse now focus upon?
A) Mental
B) Physical
C) Spiritual
D) Interpersonal
ANS: A
Feedback: The client is demonstrating confusion related to time and place. A change in
level of consciousness or confusion would be categorized as an alteration in the client's
mental status and would require further assessment. Such confusion would not be
categorized as being a physical, spiritual, or interpersonal change in the client's health status.
PTS: 1 REF: Page and Header: 9, Role of the Nurse in Assessment
NAT: Client Needs: Psychosocial Integrity TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
______________________________________________________________________________________________
3|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
8. During an adult client’s follow-up visit, the client asks the nurse about the overall goal of
Healthy People 2030. What should the nurse include in the response? (Select all that apply.)
A) Improve the health of individuals and communities.
B) Increase quality of life.
C) Create guidelines for healthy lifestyle.
D) Eliminate national health disparities.
E) Establish requirements for nursing assessment.
ANS: A, B, C, D
Feedback: The overall goal of Healthy People 2030 includes improving the health of
individuals and communities, increasing quality of life, creating guidelines for healthy
lifestyle, and eliminating national health disparities. The nurse should include these topics in
the response. Healthy People 2030 does not establish requirements for nursing assessment.
PTS: 1 REF: Page and Header: 6–7, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Remember NOT: Multiple Choice
9. When doing an overall assessment of a client, the nurse is able to use findings for which
primary purpose?
A) Identify conditions that the health care provider may have missed.
B) Identify in what areas the client can educate the family.
C) Identify in what areas the client needs the most care.
D) Identify the client's medical diagnosis.
ANS: C
Feedback: During the overall assessment of the client, the nurse is able to use the findings
and decide in which areas the client is in need of the most care. The nurse should not
identify conditions that the health care provider may have missed or identify the client’s
medical diagnosis, as making medical diagnoses are not within the nursing scope of
practice. The nurse may provide education to the client’s family throughout the client’s care;
however, the nurse should not delegate education of the family to the client, because this is
the nurse’s responsibility.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
10. During a health assessment, the client identifies having a 1 pack per day smoking habit.
What should the nurse initially focus upon when approaching the client about the benefits of
smoking cessation?
A) Determining whether the client wants to stop smoking
B) Educating the client on the detrimental effects smoking has on the entire body.
C) Identifying smoking as a modifiable risk factor for the client.
D) Sharing with the client that there are various smoking cessation methods available.
ANS: A
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4|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: Smoking cessation requires a dramatic change in behavior. The client must be
truly motivated in order for such a change to occur. The nurse should initially discuss with
the client if smoking cessation is a goal that the client may have. If the client is interested in
no longer smoking, the remaining options are less relevant. Explaining the detrimental
effects of smoking, identifying smoking as a modifiable risk factor and educating the client
to the various smoking cessation methods are beneficial when discussing the situation with a
client who has not yet made the decision to stop smoking.
PTS: 1 REF: Page and Header: 7, Role of the Nurse in Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
11. Which statement by the new nurse demonstrates an understanding of the nurse's
responsibility to conduct an effective health assessment of the client?
A) "A health assessment requires both a client history as well as a physical
examination."
B) "I always allow sufficient time to conduct the history portion of the assessment
effectively."
C) "I am always trying to improve my assessment skills."
D) "The health assessment is the foundation of quality client care."
ANS: C
Feedback: Health assessment is an integral part of nursing practice, and the need for
effective nursing assessment techniques is essential since the resulting information shapes
the plan of care in order to optimize each individual's health status throughout the lifespan.
Allowing sufficient time to conduct the various parts of the health assessment would be
considered an assessment skill. The remaining options focus on the description of what a
health assessment is rather than on the nursing responsibility to the assessment.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
12. The nurse is performing a health assessment with a client who presented to the emergency
department after falling as a result of feeling dizzy. Which questions demonstrates that the
nurse understands the initial purpose of effectively conducting a health assessment? (Select
all that apply.)
A) "Are you experiencing any pain at this time?"
B) "Are you feeling dizzy now?"
C) "Do you know what may have caused you to fall?"
D) "Do you know what your blood pressure is usually?"
E) "What do you think will help you from falling again?"
ANS: A, B, D
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5|Page
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: The initial purpose of the nursing health assessment is to determine a client's
health status, risk factors, and need for education as a basis for developing an immediate
nursing plan of care. Identifying the presence of pain, dizziness, and baseline blood pressure
are all relevant health assessment data. Knowing the cause of the dizziness and/or resulting
fall and identifying factors to help prevent injury in the future are information that will help
direct the future plan of care to help assure client safety.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Select
13. During a health assessment, a client shares, "I get a little dizzy when I get up from my chair
too quickly." Which question will the nurse ask the client first when attempting to identify
client needs and potential health risks?
A) "What do you mean by 'a little dizzy'?"
B) "Do you often feel dizzy?"
C) "Have you ever been dizzy enough to fall?"
D) Can you remember when you first started to feel dizzy?"
ANS: A
Feedback: Listening and understanding a client is key to discovering a client's needs. As
more details are acquired and collated, actual health risks emerge. The nurse should first
clarify what the client means by the statement. If is only then that the nurse can determine is
a health risk exists. While knowing the details of when the symptom started, how often it
occurs, and if falling has occurred is important, clarification of what the client means is the
initial focus of the nurse.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
14. A client is being admitted to the medical unit after being seen in the emergency department.
Which statement by the nurse indicates an understanding of the importance of the
appropriate timing of a health assessment?
A) "The client has been ordered a nutritional consult; I do the health assessment right
after that is finished."
B) "I'll do the health assessment when the client's family leaves so that distractions
will be minimal."
C) "I'm going to assess the client now so that I can begin formulating the care plan."
D) "The health assessment will be more thorough if I wait until the client is pain free."
ANS: C
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6|Page
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: Each person needs a complete health assessment. Ideally this is done on
admission, but extenuating circumstances may prohibit its completion in detail at this time.
The sooner the health assessment is completed fully, the better the nurse knows the client,
and more holistic care can be provided to ensure health promotion and quality of life. The
assessment should not be postponed until after the consult. The family should be informed
of the need for the assessment and asked to leave until it is completed, unless their input
with the history is needed. While pain may complicate the assessment process, it is not
advisable to wait until the client is pain free to complete the assessment.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
15. A client admitted with reports of nausea and vomiting has not reported any vomiting in the
last 6 hours. What initial response should the nurse have regarding this assessment
information and its effect on the client's nursing plan of care?
A) Request that the health care team revise the plan of care.
B) Notify the primary health care provider of the change in the client's health status.
C) Recognize the need to reevaluate the client's plan of care.
D) Monitor the client frequently for other changes in health status.
ANS: C
Feedback: The health assessment allows data to be collected that is specific to the client
and his or her nursing care needs. Initially, the nurse must be aware that any change to the
client's health status may require a change to this plan of care. If changes are required, the
health care team will be asked to consider and recommend them. Monitoring the client for
changes is always considered a nursing responsibility. Notifying the primary health care
provider is not directly related to the nursing plan of care.
PTS: 1 REF: Page and Header: 10, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
16. The nurse recognizes the goals and objectives of the Healthy People 2030 guidelines when
creating a plan of care that addresses which client-centered goals? (Select all that apply.)
A) living a healthy lifestyle
B) disease prevention
C) improving one's quality of life
D) providing affordable health care services
E) increasing the longevity of one's life
ANS: A, B, C, E
Feedback: The goals and objectives of Healthy People 2030 include promoting a healthy
lifestyle, disease prevention, improved quality of life, and length of a person's life. Although
important to the general wellness achieved by any individual, health care costs are not
addressed by the Healthy People 2030 guidelines.
PTS: 1 REF: Page and Header: 6–7, Health Assessment
______________________________________________________________________________________________
7|Page
, ______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
17. Consider the nurse's role in the health assessment of a client. What action will the nurse
perform initially when admitting a client to a long-term care facility?
A) collecting information regarding the client's health status
B) stabilizing the client's physical condition
C) developing an effective, respectful nurse–client relationship
D) creating an environment that encourages client autonomy
ANS: A
Feedback: Regardless of the care setting, the nurse's initial role in health assessment is to
collect data. While all the remaining options are relevant to quality client care, they are not
associated directly with the nurse's role concerning health assessment.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
18. The nurse has completed a health assessment on an older adult client being seen at a
neighborhood clinic. What client-specific information should the nurse identify as being a
priority?
A) lives alone
B) significantly impaired hearing
C) widowed 2 years ago
D) greatly concerned about cost of services
ANS: B
Feedback: As a nurse, it is vital to sift through all the client information and make decisions
on what information will impact client safety and quality of care. The ability to identify
what is important on a daily basis for each individual client is paramount for nursing care.
Of the data provided, the client's impaired hearing poses the greatest safety risk and has the
greatest impact on the client's quality of life and so has priority. While the other options
could be potential factors related to quality of life and safety, the nurse will need to assess
them further.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
19. Data being collected during a health assessment causes the nurse to believe there may be
additional issues that are possibly affecting the client's health and wellness. What action
should the nurse take to best address the suggestion of additional health concerns?
A) Concentrate first on planning care for the problem identified initially by the client.
B) Extend the time originally allotted for the completion of the initial health
assessment.
C) Plan to reassess the client with the focus on the possible additional health issues.
______________________________________________________________________________________________
8|Page
Bates' Nursing Guide to Physical Examination and History
Taking
Beth Hogan-Quigley, and Mary Louis Palm
3rd Edition
,Table of Contents
Chapter 01 Introduction to Health Assessment and Social Determinants of Health 1
Chapter 02 Critical Thinking and Clinical Judgment in Health Assessment 10
Chapter 03 Interviewing and Communication 18
Chapter 04 The Health History 27
Chapter 05 Cultural and Spiritual Assessment 36
Chapter 06 Physical Examination-Getting Started 44
Chapter 07 General Survey Including Vital Signs and Pain 51
Chapter 08 Nutrition and Hydration 59
Chapter 09 The Integumentary System 68
Chapter 10 The Head and Neck 76
Chapter 11 The Eyes 85
Chapter 12 Ears, Nose, Mouth, and Throat 93
Chapter 13 The Respiratory System 103
Chapter 14 The Cardiovascular System 111
Chapter 15 The Peripheral Vascular System and Lymphatic System 119
Chapter 16 The Gastrointestinal and Renal Systems 127
Chapter 17 The Breasts and Axillae 136
Chapter 18 The Musculoskeletal System 144
Chapter 19 Mental Status and Mental Health Assessment 152
Chapter 20 The Nervous System 161
Chapter 21 Reproductive Systems 170
Chapter 22 Putting the Physical Examination All Together 176
Chapter 23 Assessing Children-Infancy Through Adolescence 185
Chapter 24 Assessing Older Adults 193
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Chapter 1, Introduction to Health Assessment and Social Determinants of Health
1. What is the nurse's focus while conducting a health assessment with a client? (Select all that
apply.)
A) Completing the health history.
B) Interpreting findings.
C) Formulating a plan of care
D) Implementing a plan of care.
E) Conducting a physical examination.
ANS: A, E
Feedback: A health assessment is comprised of the taking the client's health history then
followed by a physical examination. Interpreting findings, formulating a plan of care, and
implementing a plan of care are steps within the nursing process that use the data identified
by the health assessment.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
2. Before beginning a health assessment with a client, the nurse reviews Healthy People 2030
because of which of the following reasons.
A) It helps determine the client's plan of care.
B) It serves as a guide for the health assessment.
C) It identifies heath indicators, appropriate interventions, and resources.
D) It addresses most client health problems.
ANS: C
Feedback: Healthy People 2030 is a framework that identifies heath indicators, appropriate
interventions, and resources in the United States. The goals and objectives serve to improve
the health of individuals and communities, targeting the next 10 years. Its overall goal is to
increase quality of life by creating guidelines for a healthy lifestyle as well as educating
people and cultivating an awareness that will assist in the elimination of health disparities.
Healthy People 2030 does not help determine every client's plan of care. Healthy People
2030 does not serve as a guide for the health assessment nor does it list specific
interventions to address specific health problems. Instead, Healthy People 2030 indicators
pertinent to individuals are determined as the nurse completes the health assessment on each
patient.
PTS: 1 REF: Page and Header: 7–8, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
3. After completing a health history, the nurse determines that a client would benefit from
interventions to address the Healthy People 2030 indicator associated with the prevalence
and mortality of chronic disease. What assessment data would relate to this indicator?
(Select all that apply.)
______________________________________________________________________________________________
1|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
A) Client’s body mass index suggests obesity.
B) Client has been prescribed medication for hypertension.
C) Client is currently without health insurance.
D) Client was diagnosed with heart disease three years ago.
E) Client had a skin cancer lesion removed surgically four years ago.
ANS: B, D, E
Feedback: The Healthy People 2030 indicator "prevalence and mortality of chronic
disease" has the objectives of reducing coronary heart disease deaths, reducing the number
of people with hypertension, and reducing the overall cancer death rate. Because the client
has a history of hypertension, has been diagnosed with heart disease, and was previously
treated for skin cancer, the indicator "prevalence and mortality of chronic disease" would be
appropriate for this client. The Healthy People 2030 indicator of "healthy behaviors" would
be applicable for the body mass index of being overweight. The Healthy People 2030
indicator of "access to health services" would be applicable for the client currently without
health insurance.
PTS: 1 REF: Page and Header: 7–8, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Select
4. The nurse is following a structured head-to-toe approach to identify changes in a client's
body systems. Which component of the health assessment is the nurse completing with the
client?
A) Health history
B) Physical examination
C) Goal setting
D) Planning care
ANS: B
Feedback: In the physical examination, the nurse uses a structured head-to-toe approach to
identify changes in the client's body systems. The health history is when the nurse asks
pertinent questions to gather data from the client and/or family. Goal setting and planning
care are not parts of the health assessment.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. The nurse is conducting a health assessment on a client presenting to the emergency room
with a critical condition. The nurse should initially ask questions regarding which topic(s)
during the initial assessment? (Select all that apply.)
A) medications
B) allergies
C) adverse reactions
D) lifestyle changes
E) stress at work
______________________________________________________________________________________________
2|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
ANS: A, B, C
Feedback: The nurse should ask a client in critical condition brought into the emergency
department about topics concerning the event, including medications, allergies, and adverse
reactions. When a client has a professional relationship with the nurse and has had a
thorough health assessment at the initial meeting, the nurse may explore other assessment
topics such as lifestyle changes and stress at work. The thorough health history would be
completed when the patient was stable and able to answer further questions.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
6. What will be the nurse's initial role when conducting a health assessment with a client
reporting abdominal pain?
A) Teaching the client to draw knees to chest to help minimize the pain
B) Planning care to help minimize the client's pain
C) Collecting data regarding the nature of the pain
D) Identifying pain management interventions with input from the client
ANS: C
Feedback: The nurse's initial role in health assessment is to collect data. Teaching would
occur later in the process. Planning care and identifying interventions are parts of the
nursing process and not the health assessment.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change
in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife.
How did you get into my house?" Based upon the client's behavior, which assessment will
the nurse now focus upon?
A) Mental
B) Physical
C) Spiritual
D) Interpersonal
ANS: A
Feedback: The client is demonstrating confusion related to time and place. A change in
level of consciousness or confusion would be categorized as an alteration in the client's
mental status and would require further assessment. Such confusion would not be
categorized as being a physical, spiritual, or interpersonal change in the client's health status.
PTS: 1 REF: Page and Header: 9, Role of the Nurse in Assessment
NAT: Client Needs: Psychosocial Integrity TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
______________________________________________________________________________________________
3|Page
,______________________________________________________________________________________________
Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
8. During an adult client’s follow-up visit, the client asks the nurse about the overall goal of
Healthy People 2030. What should the nurse include in the response? (Select all that apply.)
A) Improve the health of individuals and communities.
B) Increase quality of life.
C) Create guidelines for healthy lifestyle.
D) Eliminate national health disparities.
E) Establish requirements for nursing assessment.
ANS: A, B, C, D
Feedback: The overall goal of Healthy People 2030 includes improving the health of
individuals and communities, increasing quality of life, creating guidelines for healthy
lifestyle, and eliminating national health disparities. The nurse should include these topics in
the response. Healthy People 2030 does not establish requirements for nursing assessment.
PTS: 1 REF: Page and Header: 6–7, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Remember NOT: Multiple Choice
9. When doing an overall assessment of a client, the nurse is able to use findings for which
primary purpose?
A) Identify conditions that the health care provider may have missed.
B) Identify in what areas the client can educate the family.
C) Identify in what areas the client needs the most care.
D) Identify the client's medical diagnosis.
ANS: C
Feedback: During the overall assessment of the client, the nurse is able to use the findings
and decide in which areas the client is in need of the most care. The nurse should not
identify conditions that the health care provider may have missed or identify the client’s
medical diagnosis, as making medical diagnoses are not within the nursing scope of
practice. The nurse may provide education to the client’s family throughout the client’s care;
however, the nurse should not delegate education of the family to the client, because this is
the nurse’s responsibility.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
10. During a health assessment, the client identifies having a 1 pack per day smoking habit.
What should the nurse initially focus upon when approaching the client about the benefits of
smoking cessation?
A) Determining whether the client wants to stop smoking
B) Educating the client on the detrimental effects smoking has on the entire body.
C) Identifying smoking as a modifiable risk factor for the client.
D) Sharing with the client that there are various smoking cessation methods available.
ANS: A
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: Smoking cessation requires a dramatic change in behavior. The client must be
truly motivated in order for such a change to occur. The nurse should initially discuss with
the client if smoking cessation is a goal that the client may have. If the client is interested in
no longer smoking, the remaining options are less relevant. Explaining the detrimental
effects of smoking, identifying smoking as a modifiable risk factor and educating the client
to the various smoking cessation methods are beneficial when discussing the situation with a
client who has not yet made the decision to stop smoking.
PTS: 1 REF: Page and Header: 7, Role of the Nurse in Assessment
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
11. Which statement by the new nurse demonstrates an understanding of the nurse's
responsibility to conduct an effective health assessment of the client?
A) "A health assessment requires both a client history as well as a physical
examination."
B) "I always allow sufficient time to conduct the history portion of the assessment
effectively."
C) "I am always trying to improve my assessment skills."
D) "The health assessment is the foundation of quality client care."
ANS: C
Feedback: Health assessment is an integral part of nursing practice, and the need for
effective nursing assessment techniques is essential since the resulting information shapes
the plan of care in order to optimize each individual's health status throughout the lifespan.
Allowing sufficient time to conduct the various parts of the health assessment would be
considered an assessment skill. The remaining options focus on the description of what a
health assessment is rather than on the nursing responsibility to the assessment.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
12. The nurse is performing a health assessment with a client who presented to the emergency
department after falling as a result of feeling dizzy. Which questions demonstrates that the
nurse understands the initial purpose of effectively conducting a health assessment? (Select
all that apply.)
A) "Are you experiencing any pain at this time?"
B) "Are you feeling dizzy now?"
C) "Do you know what may have caused you to fall?"
D) "Do you know what your blood pressure is usually?"
E) "What do you think will help you from falling again?"
ANS: A, B, D
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: The initial purpose of the nursing health assessment is to determine a client's
health status, risk factors, and need for education as a basis for developing an immediate
nursing plan of care. Identifying the presence of pain, dizziness, and baseline blood pressure
are all relevant health assessment data. Knowing the cause of the dizziness and/or resulting
fall and identifying factors to help prevent injury in the future are information that will help
direct the future plan of care to help assure client safety.
PTS: 1 REF: Page and Header: 5, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Select
13. During a health assessment, a client shares, "I get a little dizzy when I get up from my chair
too quickly." Which question will the nurse ask the client first when attempting to identify
client needs and potential health risks?
A) "What do you mean by 'a little dizzy'?"
B) "Do you often feel dizzy?"
C) "Have you ever been dizzy enough to fall?"
D) Can you remember when you first started to feel dizzy?"
ANS: A
Feedback: Listening and understanding a client is key to discovering a client's needs. As
more details are acquired and collated, actual health risks emerge. The nurse should first
clarify what the client means by the statement. If is only then that the nurse can determine is
a health risk exists. While knowing the details of when the symptom started, how often it
occurs, and if falling has occurred is important, clarification of what the client means is the
initial focus of the nurse.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
14. A client is being admitted to the medical unit after being seen in the emergency department.
Which statement by the nurse indicates an understanding of the importance of the
appropriate timing of a health assessment?
A) "The client has been ordered a nutritional consult; I do the health assessment right
after that is finished."
B) "I'll do the health assessment when the client's family leaves so that distractions
will be minimal."
C) "I'm going to assess the client now so that I can begin formulating the care plan."
D) "The health assessment will be more thorough if I wait until the client is pain free."
ANS: C
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
Feedback: Each person needs a complete health assessment. Ideally this is done on
admission, but extenuating circumstances may prohibit its completion in detail at this time.
The sooner the health assessment is completed fully, the better the nurse knows the client,
and more holistic care can be provided to ensure health promotion and quality of life. The
assessment should not be postponed until after the consult. The family should be informed
of the need for the assessment and asked to leave until it is completed, unless their input
with the history is needed. While pain may complicate the assessment process, it is not
advisable to wait until the client is pain free to complete the assessment.
PTS: 1 REF: Page and Header: 6, Health Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
15. A client admitted with reports of nausea and vomiting has not reported any vomiting in the
last 6 hours. What initial response should the nurse have regarding this assessment
information and its effect on the client's nursing plan of care?
A) Request that the health care team revise the plan of care.
B) Notify the primary health care provider of the change in the client's health status.
C) Recognize the need to reevaluate the client's plan of care.
D) Monitor the client frequently for other changes in health status.
ANS: C
Feedback: The health assessment allows data to be collected that is specific to the client
and his or her nursing care needs. Initially, the nurse must be aware that any change to the
client's health status may require a change to this plan of care. If changes are required, the
health care team will be asked to consider and recommend them. Monitoring the client for
changes is always considered a nursing responsibility. Notifying the primary health care
provider is not directly related to the nursing plan of care.
PTS: 1 REF: Page and Header: 10, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
16. The nurse recognizes the goals and objectives of the Healthy People 2030 guidelines when
creating a plan of care that addresses which client-centered goals? (Select all that apply.)
A) living a healthy lifestyle
B) disease prevention
C) improving one's quality of life
D) providing affordable health care services
E) increasing the longevity of one's life
ANS: A, B, C, E
Feedback: The goals and objectives of Healthy People 2030 include promoting a healthy
lifestyle, disease prevention, improved quality of life, and length of a person's life. Although
important to the general wellness achieved by any individual, health care costs are not
addressed by the Healthy People 2030 guidelines.
PTS: 1 REF: Page and Header: 6–7, Health Assessment
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Test Bank - Bates Nursing Guide to Physical Examination and History Taking, 3rd Edition (Hogan-Quigley, 2022)
NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
17. Consider the nurse's role in the health assessment of a client. What action will the nurse
perform initially when admitting a client to a long-term care facility?
A) collecting information regarding the client's health status
B) stabilizing the client's physical condition
C) developing an effective, respectful nurse–client relationship
D) creating an environment that encourages client autonomy
ANS: A
Feedback: Regardless of the care setting, the nurse's initial role in health assessment is to
collect data. While all the remaining options are relevant to quality client care, they are not
associated directly with the nurse's role concerning health assessment.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
18. The nurse has completed a health assessment on an older adult client being seen at a
neighborhood clinic. What client-specific information should the nurse identify as being a
priority?
A) lives alone
B) significantly impaired hearing
C) widowed 2 years ago
D) greatly concerned about cost of services
ANS: B
Feedback: As a nurse, it is vital to sift through all the client information and make decisions
on what information will impact client safety and quality of care. The ability to identify
what is important on a daily basis for each individual client is paramount for nursing care.
Of the data provided, the client's impaired hearing poses the greatest safety risk and has the
greatest impact on the client's quality of life and so has priority. While the other options
could be potential factors related to quality of life and safety, the nurse will need to assess
them further.
PTS: 1 REF: Page and Header: 8, Role of the Nurse in Assessment
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
19. Data being collected during a health assessment causes the nurse to believe there may be
additional issues that are possibly affecting the client's health and wellness. What action
should the nurse take to best address the suggestion of additional health concerns?
A) Concentrate first on planning care for the problem identified initially by the client.
B) Extend the time originally allotted for the completion of the initial health
assessment.
C) Plan to reassess the client with the focus on the possible additional health issues.
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