Deck 1: The Complete Health Assessment

Question 1

Which part of the assessment provides the most subjective data?

A) Health history
B) Physical assessment
C) Review of medical records
D) Medication record

Answer 1

Health history

Question 2

The nurse is preparing to begin a health history for a new patient. Which question is most appropriate for the nurse to begin the process?

A) "What problem brought you here today?"
B) "How old are you?"
C) "Have you had any difficulty breathing?"
D) "What childhood illnesses have you had?"

Answer 2

"What problem brought you here today?"

Question 3

The patient tells the nurse, "I can never seem to get warm lately and decided to come to the clinic." The nurse records this under which section of the health history?

A) Past health history
B) Present health status
C) Reason for seeking care
D) Objective assessment data

Answer 3

Reason for seeking care

Question 4

The nurse is preparing to conduct a health history interview with a patient. Which is the best position for the nurse to assume during this process?

A) Leaning over the bed
B) Standing at the bedside
C) Sitting on the bed
D) Sitting on a chair at the bedside

Question 5

Which setting is the best place to gather data for a health history?

A) Waiting room
B) Hallway
C) Patient's room
D) On the way to surgery

Question 6

The bell of the stethoscope is best for detecting which type of sounds?

A) High pitch
B) Low pitch
C) Medium pitch
D) All of the above

Question 7

Which is the purpose of the nursing health history?

A) To determine the patient's response to the health problem
B) To determine the extent of the health problem
C) To determine which medications are appropriate to alleviate the health problem
D) All of the above

Question 8

Glass thermometers and sphygmomanometers have been replaced by other equipment in many healthcare settings. Which is the rationale for this change?

A) Difficulty with calibration
B) Difficulty with sterilization
C) Mercury toxicity
D) Poor results

Question 9

Which activity is an example of secondary prevention?

A) Wound débridement
B) Immunization
C) Preoperative teaching
D) Long-term nasogastric feedings

Question 10

The nurse is preparing to conduct a health history for a new patient. Where would the nurse gather data for this portion of the assessment?

A) The patient's chart
B) A physical assessment
C) Laboratory tests
D) A discussion with the patient

Question 11

The nurse is prioritizing data collected during the health assessment. Which data is primary?

A) Pain rating of 4 on a 1 to 10 numeric scale
B) New diagnosis of type 2 diabetes mellitus (DM)
C) Blood pressure of 130/90 mmHg
D) Pulse oximetry reading of 73%

Question 12

Which data are part of the past health history?

A) Health beliefs
B) Surgeries
C) Genetically linked diseases
D) Age of siblings

Question 13

The nurse is asking a patient questions about health practices and beliefs. In which portion of the health history will the nurse document these findings?

A) Psychosocial profile
B) Current health problems
C) Past health problems
D) Developmental considerations

Question 14

Which assessment data is considered a symptom?

A) Rapid respirations
B) Sweaty palms
C) Belching
D) Feelings of anxiety

Question 15

Which type of skill is most important when performing a physical assessment?

A) Psychomotor
B) Interpersonal
C) Ethical
D) Affective

Question 16

Who or what is considered the primary data source for a toddler-age patient?

A) The toddler
B) A parent
C) The medical record
D) Other healthcare providers

Question 17

Which critical thinking skill allows the nurse to think outside of the box when assessing a patient?

A) Divergent thinking
B) Reasoning
C) Creativity
D) Reflection

Question 18

The primary level of preventive health care focuses on which topic?

A) Health promotion
B) Early detection
C) Promotion intervention
D) End-of-life care

Question 19

Which is the reason for asking the patient about family history of diseases when conducting a health history interview?

A) To identify functional or dysfunctional family dynamics
B) To identify support systems
C) To identify familial or genetically linked health disorders
D) To identify rehabilitation needs

Question 20

When is it appropriate for the nurse to conduct the focused physical assessment?

A) During the initial assessment for a yearly exam
B) On admission to the hospital for surgery
C) On admission of a patient in acute respiratory distress
D) All of the above

Question 21

The nurse is assisting the healthcare provider during a pelvic examination. Which action by the nurse is appropriate?

A) Preparing the hemoccult test
B) Placing the patient in Sims' position
C) Preparing the speculum
D) Placing sterile gloves on the provider

Question 22

The nurse is unable to palpate pedal pulses bilaterally on an obese patient. Which is the priority action for the nurse to take?

A) Document that pedal pulses are absent
B) Auscultate heart tones
C) Assess gait
D) Assess pulses with a Doppler

Question 23

Which is the correct technique for using the bell portion of the stethoscope?

A) Avoid touching the bell during auscultation
B) Hold the bell lightly on the chest wall
C) Apply light pressure with the bell slightly tilted up
D) Hold the bell firmly against the chest wall

Question 24

The nurse is using an ophthalmoscope during a routine head-to-toe assessment. Which is the nurse assessing?

A) External ear canal
B) Tympanic membrane
C) Red light reflex
D) Cranial nerves

Question 25

The nurse is conducting a neurologic assessment. Which items are needed? Select all that apply.

A) Cotton balls
B) Test tubes
C) Scents
D) Salts
E) Latex gloves

Question 26

The nurse is assessing the patient's range of motion. Which tool is a requirement for this assessment?

A) Stethoscope
B) Otoscope
C) Ophthalmoscope
D) Ganiometer

Question 27

The nurse is preparing to assess the fetal heart rate during the 32nd week of gestation. Which action is appropriate?

A) Using the bell of the stethoscope
B) Using the diaphragm of the stethoscope
C) Using palpation to feel the fetal heart rate
D) Using a fetoscope

Question 28

Which part of the hand does the nurse use to detect vibrations?

A) Fingertips
B) Fingerpads
C) Ball of hand
D) Dorsal surface

Question 29

Which action by the nurse is appropriate when using an otoscope to assess the tympanic membrane of an adult?

A) Pulling the earlobe up and back
B) Pulling the earlobe down and back
C) Pulling the earlobe horizontally to straighten the ear canal
D) Avoiding moving the canal out of the normal anatomic position

Question 30

The nurse is assessing the circumference of a patient's abdomen. Which will the nurse use when documenting the findings?

A) Millimeters
B) Centimeters
C) Inches
D) Kilograms

Question 31

The nurse is using a nasoscope during a head-to-toe assessment. Which assessments require the use of this tool? Select all that apply.

A) Nostrils
B) Nasal mucosa
C) Scrotum
D) Fontanels
E) Septum

Question 32

The nurse uses a tongue depressor to assess the gag reflex. Which action is appropriate by the nurse?

A) Sending the depressor for sterilization
B) Discarding the depressor in one piece
C) Breaking the depressor and then discarding it
D) Using the depressor for another patient

Question 33

Which is the best assessment tool to use when testing far vision in 2-year-old children?

A) Snellen alphabet chart
B) Stycar chart
C) Allen cards
D) Pocket vision screener

Question 34

The nurse is preparing to assess the patient's thyroid gland. Which action is appropriate?

A) Asking the patient to identify a scent
B) Asking the patient to swallow water
C) Asking the patient to identify a taste
D) Asking the person to repeat "99"

Question 35

The nurse is preparing to weigh a patient on a medical-surgical unit. Which is the priority action?

A) Asking the patient to remove his or her shoes for the weight assessment
B) Asking the patient to refrain from eating or drinking before the weight assessment
C) Calibrating the scale
D) Cleaning the scale

Question 36

Which is the best method for the nurse to use when documenting a patient's physical exam?

A) In order of the assessment
B) By the patient's main complaint
C) By system
D) With all normal and abnormal data clustered

Question 37

The nurse is planning to use percussion during the physical examination of a patient. Which is the reason for using percussion?

A) To assess areas of tenderness
B) To assess organ and tissue density
C) To assess areas of inflammation
D) To assess consistency