Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen
Test Bank
Chapter 1. Nurse’s Role in Health Assessment
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.
ANS: A
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: C
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
ANS: A
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,Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a. Immediately notify the patients 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.
ANS: C
When unsure of a sound heard while listening to a patients 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.
DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 3
MSC: Client Needs: General
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.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP?
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, a. EBP relies on tradition for support of best practices.
mn mn mn mn mn mn mn mn
b. EBP is simply the use of best practice techniques for the treatment of patients.
mn mn mn mn mn mn mn mn mn mn mn mn mn
c. EBP emphasizes the use of best evidence with the clinicians experience.
mn mn mn mn mn mn mn mn mn mn
d. The patients own preferences are not important with EBP
mn mn mn mn mn mn mn mn
. ANS: C
mn mn
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
with the clinicians experience, as well as patient preferences and values, when making decision
mn mn mn mn mn mn mn mn mn mn mn mn mn
s about care and treatment. EBP is more than simply using the best practice techniques to trea
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
t patients, and questioning tradition is important when no compelling and supportive research
mn mn mn mn mn mn mn mn mn mn mn mn mn
evidence exists. mn
DIF: Cognitive Level: Applying (Application) REF: dm. 5
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Whi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
ch is an example of a first-level priority problem?
mn mn mn mn mn mn mn mn
a. Patient with postoperative pain mn mn mn
b. Newly diagnosed patient with diabetes who needs diabetic teaching
mn mn mn mn mn mn mn mn
c. Individual with a small laceration on the sole of the foot
mn mn mn mn mn mn mn mn mn mn
d. Individual with shortness of breath and respiratory distres mn mn mn mn mn mn mn
s ANS: D
mn mn
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
mn mn mn mn mn mn mn mn mn mn mn mn
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vita
mn mn mn mn mn mn mn mn mn
l signs) (see Table 1-1).
mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
9. When considering priority setting of problems, the nurse keeps in mind that second-
mn mn mn mn mn mn mn mn mn mn mn mn
level priority problems include which of these aspects?
mn mn mn mn mn mn mn
a. Low self-esteem mn
b. Lack of knowledge mn mn
c. Abnormal laboratory values mn mn
d. Severely abnormal vital signs mn mn mn
ANS: C
mn mn
Second-level priority problems are those that require prompt intervention to forestall further
mn mn mn mn mn mn mn mn mn mn mn
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety
mn mn mn mn mn mn mn mn mn mn mn mn
or security) (see Table 1-1).
mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
10. Which critical thinking skill helps the nurse see relationships among the data?
mn mn mn mn mn mn mn mn mn mn mn
a. Validation
b. Clustering related cues mn mn
c. Identifying gaps in data mn mn mn
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, d. Distinguishing relevant from irrelevant mn mn mn
ANS: B
mn mn
Clustering related cues helps the nurse see relationships among the data.
mn mn mn mn mn mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
11. The nurse knows that developing appropriate nursing interventions for a patient relies on t
mn mn mn mn mn mn mn mn mn mn mn mn mn
he appropriateness of the
mn diagnosis. mn mn
a. Nursing
b. Medical
c. Admission
d. Collaborative
ANS: A
mn mn
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to
mn mn mn mn mn mn mn mn mn mn mn mn mn
achieve outcomes for which the nurse is accountable. The other items do not contribute to the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
development of appropriate nursing interventions. mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 6
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
12. The nursing process is a sequential method of problem solving that nurses use and includ
mn mn mn mn mn mn mn mn mn mn mn mn mn mn
es which steps?
mn mn
a. Assessment, treatment, planning, evaluation, discharge, and follow-up mn mn mn mn mn mn
b. Admission, assessment, diagnosis, treatment, and discharge planning
mn mn mn mn mn mn
c. Admission, diagnosis, treatment, evaluation, and discharge planning
mn mn mn mn mn mn
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluatio mn mn mn mn mn mn mn
n ANS: D
mn mn
The nursing process is a method of problem solving that includes assessment, diagnosis,
mn mn mn mn mn mn mn mn mn mn mn mn
outcome identification, planning, implementation, and evaluation.
mn mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm.
mn mn mn mn mn mn mn
3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is havi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
ng difficulty breathing. How should the nurse prioritize these problems?
mn mn mn mn mn mn mn mn mn
a. Breathing, pain, and sleep mn mn mn
b. Breathing, sleep, and pain mn mn mn
c. Sleep, breathing, and pain
mn mn mn
d. Sleep, pain, and breathing mn mn mn
ANS: A
mn mn
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing,
mn mn mn mn mn mn mn mn mn mn
and circulation), followed by second-level problems, and then third-
mn mn mn mn mn mn mn mn
level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 4
mn mn mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
14. Which of these would be formulated by a nurse using diagnostic reasoning?
mn mn mn mn mn mn mn mn mn mn mn
a. Nursing diagnosis mn
WWW.THENURSINGMASTERY.COM
Test Bank
Chapter 1. Nurse’s Role in Health Assessment
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.
ANS: A
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: C
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.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The patients record, laboratory studies, objective data, and subjective data combine to form
the:
a. Data base.
b. Admitting data.
c. Financial statement.
d. Discharge summary.
ANS: A
WWW.THENURSINGMASTERY.COM
,Together with the patients record and laboratory studies, the objective and subjective data form
the data base. The other items are not part of the patients record, laboratory studies, or data.
DIF: Cognitive Level: Remembering (Knowledge) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a. Immediately notify the patients 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.
ANS: C
When unsure of a sound heard while listening to a patients 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.
DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 2
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
ANS: B
Novice nurses operate from a set of defined, structured rules. The expert practitioner uses
intuitive links.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 3
MSC: Client Needs: General
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.
ANS: A
Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it. The other options are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
MSC: Client Needs: General
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement
best reflects EBP?
WWW.THENURSINGMASTERY.COM
, a. EBP relies on tradition for support of best practices.
mn mn mn mn mn mn mn mn
b. EBP is simply the use of best practice techniques for the treatment of patients.
mn mn mn mn mn mn mn mn mn mn mn mn mn
c. EBP emphasizes the use of best evidence with the clinicians experience.
mn mn mn mn mn mn mn mn mn mn
d. The patients own preferences are not important with EBP
mn mn mn mn mn mn mn mn
. ANS: C
mn mn
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
with the clinicians experience, as well as patient preferences and values, when making decision
mn mn mn mn mn mn mn mn mn mn mn mn mn
s about care and treatment. EBP is more than simply using the best practice techniques to trea
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
t patients, and questioning tradition is important when no compelling and supportive research
mn mn mn mn mn mn mn mn mn mn mn mn mn
evidence exists. mn
DIF: Cognitive Level: Applying (Application) REF: dm. 5
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Whi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
ch is an example of a first-level priority problem?
mn mn mn mn mn mn mn mn
a. Patient with postoperative pain mn mn mn
b. Newly diagnosed patient with diabetes who needs diabetic teaching
mn mn mn mn mn mn mn mn
c. Individual with a small laceration on the sole of the foot
mn mn mn mn mn mn mn mn mn mn
d. Individual with shortness of breath and respiratory distres mn mn mn mn mn mn mn
s ANS: D
mn mn
First-level priority problems are those that are emergent, life threatening, and immediate (e.g.,
mn mn mn mn mn mn mn mn mn mn mn mn
establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vita
mn mn mn mn mn mn mn mn mn
l signs) (see Table 1-1).
mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
9. When considering priority setting of problems, the nurse keeps in mind that second-
mn mn mn mn mn mn mn mn mn mn mn mn
level priority problems include which of these aspects?
mn mn mn mn mn mn mn
a. Low self-esteem mn
b. Lack of knowledge mn mn
c. Abnormal laboratory values mn mn
d. Severely abnormal vital signs mn mn mn
ANS: C
mn mn
Second-level priority problems are those that require prompt intervention to forestall further
mn mn mn mn mn mn mn mn mn mn mn
deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety
mn mn mn mn mn mn mn mn mn mn mn mn
or security) (see Table 1-1).
mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 4
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
10. Which critical thinking skill helps the nurse see relationships among the data?
mn mn mn mn mn mn mn mn mn mn mn
a. Validation
b. Clustering related cues mn mn
c. Identifying gaps in data mn mn mn
WWW.THENURSINGMASTERY.COM
, d. Distinguishing relevant from irrelevant mn mn mn
ANS: B
mn mn
Clustering related cues helps the nurse see relationships among the data.
mn mn mn mn mn mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 2
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
11. The nurse knows that developing appropriate nursing interventions for a patient relies on t
mn mn mn mn mn mn mn mn mn mn mn mn mn
he appropriateness of the
mn diagnosis. mn mn
a. Nursing
b. Medical
c. Admission
d. Collaborative
ANS: A
mn mn
An accurate nursing diagnosis provides the basis for the selection of nursing interventions to
mn mn mn mn mn mn mn mn mn mn mn mn mn
achieve outcomes for which the nurse is accountable. The other items do not contribute to the
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
development of appropriate nursing interventions. mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm. 6
mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
12. The nursing process is a sequential method of problem solving that nurses use and includ
mn mn mn mn mn mn mn mn mn mn mn mn mn mn
es which steps?
mn mn
a. Assessment, treatment, planning, evaluation, discharge, and follow-up mn mn mn mn mn mn
b. Admission, assessment, diagnosis, treatment, and discharge planning
mn mn mn mn mn mn
c. Admission, diagnosis, treatment, evaluation, and discharge planning
mn mn mn mn mn mn
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluatio mn mn mn mn mn mn mn
n ANS: D
mn mn
The nursing process is a method of problem solving that includes assessment, diagnosis,
mn mn mn mn mn mn mn mn mn mn mn mn
outcome identification, planning, implementation, and evaluation.
mn mn mn mn mn mn
DIF: Cognitive Level: Understanding (Comprehension) REF: dm.
mn mn mn mn mn mn mn
3
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is havi
mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn mn
ng difficulty breathing. How should the nurse prioritize these problems?
mn mn mn mn mn mn mn mn mn
a. Breathing, pain, and sleep mn mn mn
b. Breathing, sleep, and pain mn mn mn
c. Sleep, breathing, and pain
mn mn mn
d. Sleep, pain, and breathing mn mn mn
ANS: A
mn mn
First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing,
mn mn mn mn mn mn mn mn mn mn
and circulation), followed by second-level problems, and then third-
mn mn mn mn mn mn mn mn
level problems. DIF: Cognitive Level: Analyzing (Analysis) REF: dm. 4
mn mn mn mn mn mn mn mn mn
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
mn mn mn mn mn mn mn mn mn mn
14. Which of these would be formulated by a nurse using diagnostic reasoning?
mn mn mn mn mn mn mn mn mn mn mn
a. Nursing diagnosis mn
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