, TESTBANK FOR
Health Assessment for Nursing Practice, 8th Edition Wilson
Important Notes
The file includes the complete test bank, organized chapter by chapter.
A sample of selected pages has been provided for preview.
All available appendices and Excel files (if included in the original resources) are
provided.
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editions.
New editions are added regularly – stay connected for updates!
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will gladly replace it with the correct version.
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, Test Bank - Chapter 1
Q1. A patient comes to the emergency department and tells the triage nurse that he is “having a
heart attack.” What is the nurse’s top priority at this time?
1. Determine the patient’s personal data and insurance coverage.
2. Ask the patient to take a seat in the waiting room until his name is called.
3. Request that a nurse collect data for a comprehensive history.
4. Ask a nurse to start a focused assessment of this patient now.
Q2. Which situation illustrates a screening assessment?
1. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and
physical examination.
2. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure
checks to mall patrons.
3. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg
pain.
4. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
Q3. For which person is a screening assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q4. For which person is a shift assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q5. For which person is a comprehensive assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q6. For which person is an episodic or follow-up assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q7. Which is an example of data a nurse collects during a physical examination?
1. The patient’s lack of hair and shiny skin over both shins
2. The patient’s stated concern about lack of money for prescriptions
3. The patient’s complaints of tingling sensations in the feet
4. The patient’s mother’s statements that the patient is very nervous lately
Q8. The nurse documents which information in the patient’s history?
1. The patient’s skin feels warm to the touch.
2. The patient is scratching his arm.
,3. The patient’s temperature is 100° F.
4. The patient complains of itching.
Q9. Which patient information does the nurse document in the patient’s physical assessment?
1. Slurred speech
2. Immunizations
3. Smoking habit
4. Allergies
Q10. After collecting the data, the nurse begins data analysis with which action?
1. Organizing data
2. Documenting subjective data
3. Reporting information to other health team members
4. Documenting objective information
Q11. Which activity illustrates the concept of primary prevention?
1. Monthly breast self-examination
2. Annual cervical (Papanicolaou test) examination
3. Education about living with asthma
4. Exercising three times a week
Q12. A nurse is teaching a patient how to manage chronic obstructive pulmonary disease (COPD).
This intervention is an example of which level of health promotion?
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. Risk factor prevention
Q13. Which activity illustrates the concept of secondary prevention?
1. Annual mammogram
2. Nutrition classes on low-fat cooking
3. Education on living with diabetes mellitus
4. Cardiac rehabilitation after coronary artery bypass surgery
Q14. A community organization sponsors a health fair to increase awareness of colon cancer. At
the health fair, colorectal cancer screening kits are distributed, and health care professionals
answer questions, take blood pressure, and distribute literature. What level of health prevention is
being implemented by this community organization?
1. Primary
2. Secondary
3. Tertiary
4. Risk factor
, Test Bank - Chapter 2
Q1. Which statement or question does the nurse use during the introduction phase of the interview?
1. “I’m here to learn more about the pain you’re experiencing.”
2. “Can you describe the pain that you’re experiencing?”
3. “I heard you say that the pain is ‘all over’ your body.”
4. “What relieves the pain you are having?”
Q2. Which statement is appropriate to use when beginning an interview with a new patient?
1. “Have you ever been a patient in this clinic before?”
2. “What is your purpose for coming to the clinic today?”
3. “Tell me a little about yourself and your family.”
4. “Did you have any difficulty finding the clinic?”
Q3. Which statement by the nurse demonstrates a patient-centered interview?
1. “I need to complete this questionnaire about your medical and family history.”
2. “The hospital requires me to complete this assessment as soon as possible.”
3. “Tell me about the symptoms you’ve been having.”
4. “I’ve had the same symptoms that you’ve described.”
Q4. Which question is an example of an open-ended question?
1. “Have you experienced this pain before?”
2. “Do you have someone to help you at home?”
3. “How many times a day do you use your inhaler?”
4. “What were you doing when you felt the pain?”
Q5. A nurse suspects a female patient is a victim of physical abuse. Which response is most likely
to encourage the patient to confide in the nurse?
1. “You’ve got a huge bruise on your face. Did your husband hit you?”
2. “That bruise looks tender. I don’t know how people can do that to one another.”
3. “If your boyfriend hit you, you can get a restraining order against him.”
4. “I’ve seen women who have been hurt by boyfriends or husbands. Does anyone hit you?”
Q6. Which technique used by the nurse encourages a patient to continue talking during an
interview?
1. Laughing and smiling during conversation
2. Using phrases such as “Go on,” and “Then?”
3. Repeating what the patient said, but using different words
4. Asking the patient to clarify a point
Q7. During the history, the patient states that she does not use many drugs. What is the nurse’s
appropriate response to this statement?
1. “Tell me about the drugs you are using currently.”
2. “To some people six or seven is not many.”
3. “Do you mean prescription drugs or illicit drugs?”
4. “How often are you using these drugs?”
Q8. A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months
ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The
nurse suspects that the patient is noncompliant with her diet. Which response by the nurse
enhances data collection in this situation?
,1. “Tell me about what foods you eat and the frequency of your meals.”
2. “What symptoms do you notice when your blood sugar levels are high?”
3. “You need to follow what the doctor has prescribed to manage your disease.”
4. “Tell me what you know about the cause of type 2 diabetes.”
Q9. A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not
experienced any problems because of the lack of sleep. Which response by the nurse is most
appropriate?
1. “That is interesting.”
2. “Only 4 hours of sleep? How do you stay awake during the day?”
3. “Really? Everyone needs more sleep than that.”
4. “Did I understand that you sleep 4 hours every night?”
Q10. Which technique should the nurse use to obtain more data about a patient’s vague or
ambiguous statement?
1. Laughing and smiling during conversation
2. Using phrases such as “Go on,” and “Then?”
3. Repeating what the patient has said, but using different words
4. Asking the patient to explain a point
Q11. What does the nurse say to obtain more data about a patient’s vague statement about diet
such as, “My diet’s okay”?
1. “Eating a variety of meats, fruits, and vegetables each day is important.”
2. “Give me an example of the foods you eat in a typical day.”
3. “Go on.”
4. “Does your diet meet your needs or does it need improvement?”
Q12. While giving a history, a male patient describes several events out of order that occurred in
different decades in his life. What technique does the nurse use to understand the timeline of these
events?
1. State the order of events as understood and ask the patient to verify the order.
2. Draw conclusions about the order of events from data given.
3. Ask the patient to elaborate about these events.
4. Ask the patient to repeat what he said about these events.
Q13. A male patient is very talkative and shares much information that is not relevant to his history
or the reason for his admission. Which action by the nurse improves data collection in this
situation?
1. Terminate the interview.
2. Use closed-ended questions.
3. Ask the patient to stay on the subject.
4. Ask another nurse to complete the interview.
Q14. A patient answers questions quietly and appears sad. While answering questions about her
marriage, she begins to cry. Which response by the nurse is appropriate in this situation?
1. “Don’t cry! I’ll come back when you’ve settled down.”
2. “I only have a few more questions to ask, and then I’ll leave you alone for a while.”
3. “Everyone has ups and downs in their marriage. What problems are you having?”
4. “I see that you are upset. Is there something you’d like to discuss?”
Q15. During an interview, a patient begins to cry and appears angry. Which response by the nurse
is most therapeutic?
1. “This topic prompted an emotional response, tell me what you are feeling.”
,2. “This topic does not usually cause such an emotional response.”
3. “Calm down and tell me what is wrong.”
4. “I will leave you alone for a few minutes so you can pull yourself together.”
Q16. In which situation is the nurse’s use of closed-ended questions most appropriate?
1. When clarifying vague or conflicting data
2. When obtaining a history from an overly talkative patient
3. When encouraging a patient to elaborate on details of his or her history
4. When collecting data about the current health problem
Q17. The nurse is interviewing a woman with her husband present. The husband answers the
questions for the wife most of the time. What is the most appropriate therapeutic nursing action to
hear the patient’s viewpoint?
1. Continue the interview.
2. Ask the husband to step out of the room.
3. Ask another nurse to complete the interview.
4. Tell the woman to speak up for herself.
Q18. A female Korean patient accompanied by her husband and son comes to the emergency
department (ED) complaining of abdominal pain. The patient speaks and understands Korean only.
Which person is the appropriate choice for the nurse to use to get a history from this patient?
1. The patient’s husband who speaks Korean and English
2. The patient’s son who speaks Korean and English
3. A male technician who works in the ED who speaks Korean and English
4. A female interpreter who speaks Korean and English and is available by phone
Q19. Which nurse demonstrates culturally competent care for a female patient from Russia?
1. Nurse A who asks the patient about cultural factors that influence health care
2. Nurse B who interacts with every patient from Russia in the same manner
3. Nurse C who learns the cultural variables of every culture, including Russia
4. Nurse D who relies on her previous experience with patients from Russia
Q20. For which patient is a focused health history most appropriate?
1. A new patient at the health clinic for an annual examination
2. A patient admitted to the hospital with vomiting and abdominal pain
3. A patient at the health care provider’s office for a sport physical
4. A patient discharged 11 months ago who is being readmitted today
Q21. A patient tells the nurse at the clinic, “I can never seem to get warm lately and feel tired all the
time.” The nurse records these data under which section of the health history?
1. Past health history
2. Present health status
3. Reason for seeking care (chief complaint)
4. Subjective assessment data
Q22. A patient comes to the ambulatory surgery center for an elective procedure this morning.
While giving the admission history, the patient states she is allergic to latex. What is the most
appropriate response by the nurse at this time?
1. Removing all latex products from the patient’s room
2. Using powdered gloves when providing care to this patient
3. Informing the surgeon that the patient has type I hypersensitivity to latex
4. Questioning the patient about symptoms experienced in the past with latex
,Q23. A nurse is interviewing a male patient who reports he has not had a tetanus immunization in
about 15 years because he had a “bad reaction” to the last tetanus immunization. What is the most
appropriate response by the nurse in this case?
1. Notify the health care provider that this immunization cannot be given.
2. Document that the patient is allergic to the tetanus vaccine.
3. Give the vaccine after explaining that adverse reactions are rare.
4. Ask the patient to describe the “bad reaction” to the vaccine in more detail.
Q24. A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In
which section of the history does the nurse document the insulin and diabetes?
1. Past health history
2. Present health status
3. Reason for seeking care (chief complaint)
4. History of present illness
Q25. A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which
question will provide data about this patient’s functional ability?
1. “When did your arthritis symptoms begin?”
2. “How has your arthritis affected your daily life?”
3. “Why did you come to the clinic today?”
4. “How do you feel about your diagnosis of rheumatoid arthritis?”
Q26. An example of a health promotion question included in the health history is:
1. “Do you have any allergies?”
2. “How often are you exercising?”
3. “What are you doing to relieve your leg pain?”
4. “What kind of herbs are you using?”
Q27. The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts
sleep and has not been helped by over-the-counter cough medicines. Which question is most
appropriate for the nurse to ask next?
1. “So what do you think is causing this persistent cough?”
2. “Have you tried taking sleeping pills to help you sleep?”
3. “Did you think this will just go away on its own?”
4. “What other symptoms have you noticed related to this cough?”
Q28. Which data do nurses document under the heading of Past Health History? (Select all that
apply.)
1. Father has Alzheimer disease.
2. Last tetanus in 2009
3. Had chicken pox as a child
4. Drinks three to four beers each day
5. Had a dental examination 6 months ago
Q29. Which data do nurses document under the heading of Personal and Psychosocial History?
(Select all that apply.)
1. Walks for 45 minutes each day
2. Eats meats, vegetables, and fruit at two meals daily
3. Is allergic to milk and milk products
4. Is married and has two daughters whom he is close to
5. Smokes marijuana once a week
6. Grandfather died from prostate cancer
,Q30. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who
reports breathing problems? (Select all that apply.)
1. How long have you had this problem with your breathing?
2. Do you have a family history of breathing problems?
3. Does this breathing problem come and go or is it constant?
4. What do you do to make your breathing better?
5. How does this breathing problem affect your work or daily activities?
6. How many packs of cigarettes do you smoke a day?
Q31. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who
reports a headache? (Select all that apply.)
1. Describe what the headache feels like.
2. When was your last eye examination?
3. What makes the headaches worse?
4. How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain
ever)?
5. Do you have any symptoms with the headaches, such as nausea?
6. When did you first notice the headaches?
Q32. Which questions are pertinent for a nurse to ask a patient while performing a review of the
cardiovascular system? (Select all that apply.)
1. Do you remember what your last cholesterol value was?
2. Have you had chest pain or shortness of breath?
3. Do you have trouble breathing when you lie down?
4. Are your feet cold, numb, or do they change color?
5. How much do you weigh?
6. Have you noticed edema in your ankles at the end of the day?
, Test Bank - Chapter 3
Q1. What is the most important nursing action to reduce transmission of microorganisms prior to
initiation of the physical assessment?
1. Clean the bell and diaphragm of the stethoscope between patients.
2. Perform hand hygiene.
3. Wear gloves when anticipating exposure to body fluids.
4. Wear eye protection when anticipating spatter of body fluids.
Q2. When examining a patient, the nurse remembers to follow which principle of Standard
Precautions?
1. Wear gloves throughout the entire examination of the patient.
2. Wear gloves when in contact with the patient’s mucous membranes.
3. Wear gloves to reduce the need for handwashing.
4. Wear eye protection and a gown during the examination of the patient.
Q3. Which explanation is most appropriate for a nurse preparing to palpate a patient’s neck?
1. “I need to feel for tumors in your neck.”
2. “I’m going to feel your neck for any abnormalities.”
3. “I need to press deeply on your neck so please hold still.”
4. “Is there any tenderness in your neck?”
Q4. Which nurse is performing the technique of light palpation appropriately?
1. Nurse A applies the bimanual technique to determine size and location of the patient’s heart.
2. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs.
3. Nurse C places the ulnar surface of the hands on the patient’s thorax to detect vibrations.
4. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations.
Q5. How does the nurse perform the bimanual technique of palpation to assess organs?
1. Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm
2. Holding a light source in one hand while stroking the skin lightly with the dominant hand
3. Using the ulnar surfaces of both hands to press inward 4 to 5 cm
4. Using both hands, one anterior and one posterior, to entrap an organ between the fingertips
Q6. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel
cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the
temperatures of the lower extremities with the upper extremities?
1. Using the backs (dorsum) of the hands to detect differences
2. Using the ulnar surface of the hands to detect differences
3. Using the pads of the fingers to detect differences
4. Using the palmar surface (underside) of the hands to detect differences
Q7. How does a nurse assess for fluid in a patient’s abdomen?
1. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index
finger of the pleximeter with the pad of the middle finger of the dominant hand
2. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor
3. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed,
and striking that finger with the tip of the middle finger of the dominant hand
4. Using direct percussion by placing one hand over the abdomen and striking lightly with the other
hand
Health Assessment for Nursing Practice, 8th Edition Wilson
Important Notes
The file includes the complete test bank, organized chapter by chapter.
A sample of selected pages has been provided for preview.
All available appendices and Excel files (if included in the original resources) are
provided.
We continuously update our files to ensure you receive the latest and most accurate
editions.
New editions are added regularly – stay connected for updates!
Purchase Guarantee
If you believe you have purchased the wrong file, don’t worry. Contact us anytime and we
will gladly replace it with the correct version.
Contact Email:
, Test Bank - Chapter 1
Q1. A patient comes to the emergency department and tells the triage nurse that he is “having a
heart attack.” What is the nurse’s top priority at this time?
1. Determine the patient’s personal data and insurance coverage.
2. Ask the patient to take a seat in the waiting room until his name is called.
3. Request that a nurse collect data for a comprehensive history.
4. Ask a nurse to start a focused assessment of this patient now.
Q2. Which situation illustrates a screening assessment?
1. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and
physical examination.
2. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pressure
checks to mall patrons.
3. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg
pain.
4. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
Q3. For which person is a screening assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q4. For which person is a shift assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q5. For which person is a comprehensive assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q6. For which person is an episodic or follow-up assessment indicated?
1. The person who had abdominal surgery yesterday
2. The person who is unaware of his high serum glucose levels
3. The person who is being admitted to a long-term care facility
4. The person who is beginning rehabilitation after a knee replacement
Q7. Which is an example of data a nurse collects during a physical examination?
1. The patient’s lack of hair and shiny skin over both shins
2. The patient’s stated concern about lack of money for prescriptions
3. The patient’s complaints of tingling sensations in the feet
4. The patient’s mother’s statements that the patient is very nervous lately
Q8. The nurse documents which information in the patient’s history?
1. The patient’s skin feels warm to the touch.
2. The patient is scratching his arm.
,3. The patient’s temperature is 100° F.
4. The patient complains of itching.
Q9. Which patient information does the nurse document in the patient’s physical assessment?
1. Slurred speech
2. Immunizations
3. Smoking habit
4. Allergies
Q10. After collecting the data, the nurse begins data analysis with which action?
1. Organizing data
2. Documenting subjective data
3. Reporting information to other health team members
4. Documenting objective information
Q11. Which activity illustrates the concept of primary prevention?
1. Monthly breast self-examination
2. Annual cervical (Papanicolaou test) examination
3. Education about living with asthma
4. Exercising three times a week
Q12. A nurse is teaching a patient how to manage chronic obstructive pulmonary disease (COPD).
This intervention is an example of which level of health promotion?
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. Risk factor prevention
Q13. Which activity illustrates the concept of secondary prevention?
1. Annual mammogram
2. Nutrition classes on low-fat cooking
3. Education on living with diabetes mellitus
4. Cardiac rehabilitation after coronary artery bypass surgery
Q14. A community organization sponsors a health fair to increase awareness of colon cancer. At
the health fair, colorectal cancer screening kits are distributed, and health care professionals
answer questions, take blood pressure, and distribute literature. What level of health prevention is
being implemented by this community organization?
1. Primary
2. Secondary
3. Tertiary
4. Risk factor
, Test Bank - Chapter 2
Q1. Which statement or question does the nurse use during the introduction phase of the interview?
1. “I’m here to learn more about the pain you’re experiencing.”
2. “Can you describe the pain that you’re experiencing?”
3. “I heard you say that the pain is ‘all over’ your body.”
4. “What relieves the pain you are having?”
Q2. Which statement is appropriate to use when beginning an interview with a new patient?
1. “Have you ever been a patient in this clinic before?”
2. “What is your purpose for coming to the clinic today?”
3. “Tell me a little about yourself and your family.”
4. “Did you have any difficulty finding the clinic?”
Q3. Which statement by the nurse demonstrates a patient-centered interview?
1. “I need to complete this questionnaire about your medical and family history.”
2. “The hospital requires me to complete this assessment as soon as possible.”
3. “Tell me about the symptoms you’ve been having.”
4. “I’ve had the same symptoms that you’ve described.”
Q4. Which question is an example of an open-ended question?
1. “Have you experienced this pain before?”
2. “Do you have someone to help you at home?”
3. “How many times a day do you use your inhaler?”
4. “What were you doing when you felt the pain?”
Q5. A nurse suspects a female patient is a victim of physical abuse. Which response is most likely
to encourage the patient to confide in the nurse?
1. “You’ve got a huge bruise on your face. Did your husband hit you?”
2. “That bruise looks tender. I don’t know how people can do that to one another.”
3. “If your boyfriend hit you, you can get a restraining order against him.”
4. “I’ve seen women who have been hurt by boyfriends or husbands. Does anyone hit you?”
Q6. Which technique used by the nurse encourages a patient to continue talking during an
interview?
1. Laughing and smiling during conversation
2. Using phrases such as “Go on,” and “Then?”
3. Repeating what the patient said, but using different words
4. Asking the patient to clarify a point
Q7. During the history, the patient states that she does not use many drugs. What is the nurse’s
appropriate response to this statement?
1. “Tell me about the drugs you are using currently.”
2. “To some people six or seven is not many.”
3. “Do you mean prescription drugs or illicit drugs?”
4. “How often are you using these drugs?”
Q8. A nurse is interviewing a patient who was diagnosed with type 2 diabetes mellitus 6 months
ago. Since that time, the patient has gained weight and her blood glucose levels remain high. The
nurse suspects that the patient is noncompliant with her diet. Which response by the nurse
enhances data collection in this situation?
,1. “Tell me about what foods you eat and the frequency of your meals.”
2. “What symptoms do you notice when your blood sugar levels are high?”
3. “You need to follow what the doctor has prescribed to manage your disease.”
4. “Tell me what you know about the cause of type 2 diabetes.”
Q9. A male patient tells the nurse that he rarely sleeps more than 4 hours a night and has not
experienced any problems because of the lack of sleep. Which response by the nurse is most
appropriate?
1. “That is interesting.”
2. “Only 4 hours of sleep? How do you stay awake during the day?”
3. “Really? Everyone needs more sleep than that.”
4. “Did I understand that you sleep 4 hours every night?”
Q10. Which technique should the nurse use to obtain more data about a patient’s vague or
ambiguous statement?
1. Laughing and smiling during conversation
2. Using phrases such as “Go on,” and “Then?”
3. Repeating what the patient has said, but using different words
4. Asking the patient to explain a point
Q11. What does the nurse say to obtain more data about a patient’s vague statement about diet
such as, “My diet’s okay”?
1. “Eating a variety of meats, fruits, and vegetables each day is important.”
2. “Give me an example of the foods you eat in a typical day.”
3. “Go on.”
4. “Does your diet meet your needs or does it need improvement?”
Q12. While giving a history, a male patient describes several events out of order that occurred in
different decades in his life. What technique does the nurse use to understand the timeline of these
events?
1. State the order of events as understood and ask the patient to verify the order.
2. Draw conclusions about the order of events from data given.
3. Ask the patient to elaborate about these events.
4. Ask the patient to repeat what he said about these events.
Q13. A male patient is very talkative and shares much information that is not relevant to his history
or the reason for his admission. Which action by the nurse improves data collection in this
situation?
1. Terminate the interview.
2. Use closed-ended questions.
3. Ask the patient to stay on the subject.
4. Ask another nurse to complete the interview.
Q14. A patient answers questions quietly and appears sad. While answering questions about her
marriage, she begins to cry. Which response by the nurse is appropriate in this situation?
1. “Don’t cry! I’ll come back when you’ve settled down.”
2. “I only have a few more questions to ask, and then I’ll leave you alone for a while.”
3. “Everyone has ups and downs in their marriage. What problems are you having?”
4. “I see that you are upset. Is there something you’d like to discuss?”
Q15. During an interview, a patient begins to cry and appears angry. Which response by the nurse
is most therapeutic?
1. “This topic prompted an emotional response, tell me what you are feeling.”
,2. “This topic does not usually cause such an emotional response.”
3. “Calm down and tell me what is wrong.”
4. “I will leave you alone for a few minutes so you can pull yourself together.”
Q16. In which situation is the nurse’s use of closed-ended questions most appropriate?
1. When clarifying vague or conflicting data
2. When obtaining a history from an overly talkative patient
3. When encouraging a patient to elaborate on details of his or her history
4. When collecting data about the current health problem
Q17. The nurse is interviewing a woman with her husband present. The husband answers the
questions for the wife most of the time. What is the most appropriate therapeutic nursing action to
hear the patient’s viewpoint?
1. Continue the interview.
2. Ask the husband to step out of the room.
3. Ask another nurse to complete the interview.
4. Tell the woman to speak up for herself.
Q18. A female Korean patient accompanied by her husband and son comes to the emergency
department (ED) complaining of abdominal pain. The patient speaks and understands Korean only.
Which person is the appropriate choice for the nurse to use to get a history from this patient?
1. The patient’s husband who speaks Korean and English
2. The patient’s son who speaks Korean and English
3. A male technician who works in the ED who speaks Korean and English
4. A female interpreter who speaks Korean and English and is available by phone
Q19. Which nurse demonstrates culturally competent care for a female patient from Russia?
1. Nurse A who asks the patient about cultural factors that influence health care
2. Nurse B who interacts with every patient from Russia in the same manner
3. Nurse C who learns the cultural variables of every culture, including Russia
4. Nurse D who relies on her previous experience with patients from Russia
Q20. For which patient is a focused health history most appropriate?
1. A new patient at the health clinic for an annual examination
2. A patient admitted to the hospital with vomiting and abdominal pain
3. A patient at the health care provider’s office for a sport physical
4. A patient discharged 11 months ago who is being readmitted today
Q21. A patient tells the nurse at the clinic, “I can never seem to get warm lately and feel tired all the
time.” The nurse records these data under which section of the health history?
1. Past health history
2. Present health status
3. Reason for seeking care (chief complaint)
4. Subjective assessment data
Q22. A patient comes to the ambulatory surgery center for an elective procedure this morning.
While giving the admission history, the patient states she is allergic to latex. What is the most
appropriate response by the nurse at this time?
1. Removing all latex products from the patient’s room
2. Using powdered gloves when providing care to this patient
3. Informing the surgeon that the patient has type I hypersensitivity to latex
4. Questioning the patient about symptoms experienced in the past with latex
,Q23. A nurse is interviewing a male patient who reports he has not had a tetanus immunization in
about 15 years because he had a “bad reaction” to the last tetanus immunization. What is the most
appropriate response by the nurse in this case?
1. Notify the health care provider that this immunization cannot be given.
2. Document that the patient is allergic to the tetanus vaccine.
3. Give the vaccine after explaining that adverse reactions are rare.
4. Ask the patient to describe the “bad reaction” to the vaccine in more detail.
Q24. A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In
which section of the history does the nurse document the insulin and diabetes?
1. Past health history
2. Present health status
3. Reason for seeking care (chief complaint)
4. History of present illness
Q25. A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which
question will provide data about this patient’s functional ability?
1. “When did your arthritis symptoms begin?”
2. “How has your arthritis affected your daily life?”
3. “Why did you come to the clinic today?”
4. “How do you feel about your diagnosis of rheumatoid arthritis?”
Q26. An example of a health promotion question included in the health history is:
1. “Do you have any allergies?”
2. “How often are you exercising?”
3. “What are you doing to relieve your leg pain?”
4. “What kind of herbs are you using?”
Q27. The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts
sleep and has not been helped by over-the-counter cough medicines. Which question is most
appropriate for the nurse to ask next?
1. “So what do you think is causing this persistent cough?”
2. “Have you tried taking sleeping pills to help you sleep?”
3. “Did you think this will just go away on its own?”
4. “What other symptoms have you noticed related to this cough?”
Q28. Which data do nurses document under the heading of Past Health History? (Select all that
apply.)
1. Father has Alzheimer disease.
2. Last tetanus in 2009
3. Had chicken pox as a child
4. Drinks three to four beers each day
5. Had a dental examination 6 months ago
Q29. Which data do nurses document under the heading of Personal and Psychosocial History?
(Select all that apply.)
1. Walks for 45 minutes each day
2. Eats meats, vegetables, and fruit at two meals daily
3. Is allergic to milk and milk products
4. Is married and has two daughters whom he is close to
5. Smokes marijuana once a week
6. Grandfather died from prostate cancer
,Q30. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who
reports breathing problems? (Select all that apply.)
1. How long have you had this problem with your breathing?
2. Do you have a family history of breathing problems?
3. Does this breathing problem come and go or is it constant?
4. What do you do to make your breathing better?
5. How does this breathing problem affect your work or daily activities?
6. How many packs of cigarettes do you smoke a day?
Q31. Which questions are pertinent to ask when obtaining a symptom analysis from a patient who
reports a headache? (Select all that apply.)
1. Describe what the headache feels like.
2. When was your last eye examination?
3. What makes the headaches worse?
4. How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain
ever)?
5. Do you have any symptoms with the headaches, such as nausea?
6. When did you first notice the headaches?
Q32. Which questions are pertinent for a nurse to ask a patient while performing a review of the
cardiovascular system? (Select all that apply.)
1. Do you remember what your last cholesterol value was?
2. Have you had chest pain or shortness of breath?
3. Do you have trouble breathing when you lie down?
4. Are your feet cold, numb, or do they change color?
5. How much do you weigh?
6. Have you noticed edema in your ankles at the end of the day?
, Test Bank - Chapter 3
Q1. What is the most important nursing action to reduce transmission of microorganisms prior to
initiation of the physical assessment?
1. Clean the bell and diaphragm of the stethoscope between patients.
2. Perform hand hygiene.
3. Wear gloves when anticipating exposure to body fluids.
4. Wear eye protection when anticipating spatter of body fluids.
Q2. When examining a patient, the nurse remembers to follow which principle of Standard
Precautions?
1. Wear gloves throughout the entire examination of the patient.
2. Wear gloves when in contact with the patient’s mucous membranes.
3. Wear gloves to reduce the need for handwashing.
4. Wear eye protection and a gown during the examination of the patient.
Q3. Which explanation is most appropriate for a nurse preparing to palpate a patient’s neck?
1. “I need to feel for tumors in your neck.”
2. “I’m going to feel your neck for any abnormalities.”
3. “I need to press deeply on your neck so please hold still.”
4. “Is there any tenderness in your neck?”
Q4. Which nurse is performing the technique of light palpation appropriately?
1. Nurse A applies the bimanual technique to determine size and location of the patient’s heart.
2. Nurse B uses the fingertips to feel for temperature differences on the patient’s legs.
3. Nurse C places the ulnar surface of the hands on the patient’s thorax to detect vibrations.
4. Nurse D depresses the patient’s abdomen approximately 4 cm to assess pulsations.
Q5. How does the nurse perform the bimanual technique of palpation to assess organs?
1. Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm
2. Holding a light source in one hand while stroking the skin lightly with the dominant hand
3. Using the ulnar surfaces of both hands to press inward 4 to 5 cm
4. Using both hands, one anterior and one posterior, to entrap an organ between the fingertips
Q6. While assessing a patient’s lower extremities, the nurse suspects the lower extremities feel
cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the
temperatures of the lower extremities with the upper extremities?
1. Using the backs (dorsum) of the hands to detect differences
2. Using the ulnar surface of the hands to detect differences
3. Using the pads of the fingers to detect differences
4. Using the palmar surface (underside) of the hands to detect differences
Q7. How does a nurse assess for fluid in a patient’s abdomen?
1. Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index
finger of the pleximeter with the pad of the middle finger of the dominant hand
2. Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor
3. Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed,
and striking that finger with the tip of the middle finger of the dominant hand
4. Using direct percussion by placing one hand over the abdomen and striking lightly with the other
hand
