2nd Health Promotion and Disease Prevention
Question 1
pts
A nurse performing a physical assessment of a client gathers both subjective and
objective data. Which finding would the nurse document as subjective data?
Blood pressure is 170/80 mm Hg.
The client appears anxious.
The client has diminished reflexes in the legs.
Correct!
The client states that he has a rash.
Rationale: The purpose of a physical assessment is to collect both subjective and
objective data. Subjective data, collected during the health history, consist of
information that the client gives about himself or herself. Objective data are obtained
through physical examination and vital signs measurements, what the nurse observes,
and laboratory study and diagnostic test results.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include
data that the nurse would obtain during the physical examination. Review: the difference
between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp.
2, 55). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
Question 2
, pts
A nurse is reviewing the findings of a physical examination that have been documented
in a client's record. Which piece of information does the nurse recognize as objective
data?
The last menstrual period was 30 days ago.
The client is allergic to strawberries.
The client takes acetaminophen (Tylenol) for headaches.
Correct!
A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.
Rationale: Subjective data, collected during the health history, consist of information
that the client gives about himself or herself. Objective data are obtained through
physical examination and vital signs measurements, what the nurse observes, and
laboratory study and diagnostic test results. Allergies, the date of the client’s last
menstrual period, and the reported use of medication for headaches are all subjective
data.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include
data that the nurse would obtain from the client during the health history. Review: the
difference between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp.
2, 55). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
Question 3
pts
A nurse is making an initial home visit to a client with chronic obstructive pulmonary
disease who was recently discharged from the hospital. Which type of database does
the nurse use to obtain information from the client?
,Episodic
Correct!
Complete
Follow-up
Emergency
Rationale: A complete database includes a complete health history and a full physical
examination. It describes the client’s current and past state of health and forms a
baseline against which all future changes can be measured. The complete database is
collected in a primary care setting such as a pediatric or family practice clinic, an
independent or group private practice, a college health service, a women’s healthcare
agency, a visiting nurse agency, or a community health agency. An episodic database is
compiled for a limited or short-term problem and is focused mainly on one problem or
one body system. A follow-up database is used to evaluate an identified problem at
regular and appropriate intervals. An emergency database involves the rapid collection
of the data that are often compiled as lifesaving measures are being performed.
Test-Taking Strategy: Noting the words “initial home visit” in the question will direct you
to the correct option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed.,
p.8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Technology and Informatics
HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology
Question 4
pts
A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for
symptoms of a cold and is now complaining of chest congestion and cough. The nurse
should proceed with the examination by collecting which?
A complete (total health) database
, Correct!
Data related to the respiratory system
Data related to follow-up care
Data related to the treatment for the cold
Rationale: An episodic database is compiled for a limited or short-term problem and is
focused mainly on one problem or body system. The history and examination will be
focused primarily on the respiratory system in this client. A complete database includes
a complete health history and a full physical examination. It describes the client’s
current and past state of health and forms a baseline against which all future changes
can be measured. A follow-up database is used to evaluate an identified problem at
regular and appropriate intervals.
Test-Taking Strategy: Focusing on the data in the question and noting the words “now
complaining of chest congestion and cough” will direct you to the correct option.
Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.
8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Gas Exchange
HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas Exchange
Question 5
pts
A client is brought to the emergency department after a motor vehicle accident. The
client is alert and cooperative but has sustained multiple fractures of the legs. How
should the nurse proceed with data collection?
Correct!
Ask health history questions while performing the examination and initiating emergency
measures
Question 1
pts
A nurse performing a physical assessment of a client gathers both subjective and
objective data. Which finding would the nurse document as subjective data?
Blood pressure is 170/80 mm Hg.
The client appears anxious.
The client has diminished reflexes in the legs.
Correct!
The client states that he has a rash.
Rationale: The purpose of a physical assessment is to collect both subjective and
objective data. Subjective data, collected during the health history, consist of
information that the client gives about himself or herself. Objective data are obtained
through physical examination and vital signs measurements, what the nurse observes,
and laboratory study and diagnostic test results.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include
data that the nurse would obtain during the physical examination. Review: the difference
between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp.
2, 55). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
Question 2
, pts
A nurse is reviewing the findings of a physical examination that have been documented
in a client's record. Which piece of information does the nurse recognize as objective
data?
The last menstrual period was 30 days ago.
The client is allergic to strawberries.
The client takes acetaminophen (Tylenol) for headaches.
Correct!
A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen.
Rationale: Subjective data, collected during the health history, consist of information
that the client gives about himself or herself. Objective data are obtained through
physical examination and vital signs measurements, what the nurse observes, and
laboratory study and diagnostic test results. Allergies, the date of the client’s last
menstrual period, and the reported use of medication for headaches are all subjective
data.
Test-Taking Strategy: Eliminate the options that are comparable or alike and include
data that the nurse would obtain from the client during the health history. Review: the
difference between subjective and objective data .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp.
2, 55). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
Question 3
pts
A nurse is making an initial home visit to a client with chronic obstructive pulmonary
disease who was recently discharged from the hospital. Which type of database does
the nurse use to obtain information from the client?
,Episodic
Correct!
Complete
Follow-up
Emergency
Rationale: A complete database includes a complete health history and a full physical
examination. It describes the client’s current and past state of health and forms a
baseline against which all future changes can be measured. The complete database is
collected in a primary care setting such as a pediatric or family practice clinic, an
independent or group private practice, a college health service, a women’s healthcare
agency, a visiting nurse agency, or a community health agency. An episodic database is
compiled for a limited or short-term problem and is focused mainly on one problem or
one body system. A follow-up database is used to evaluate an identified problem at
regular and appropriate intervals. An emergency database involves the rapid collection
of the data that are often compiled as lifesaving measures are being performed.
Test-Taking Strategy: Noting the words “initial home visit” in the question will direct you
to the correct option. Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed.,
p.8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Technology and Informatics
HESI Concepts: Evidence-Based Practice/Evidence, Informatics/Technology
Question 4
pts
A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for
symptoms of a cold and is now complaining of chest congestion and cough. The nurse
should proceed with the examination by collecting which?
A complete (total health) database
, Correct!
Data related to the respiratory system
Data related to follow-up care
Data related to the treatment for the cold
Rationale: An episodic database is compiled for a limited or short-term problem and is
focused mainly on one problem or body system. The history and examination will be
focused primarily on the respiratory system in this client. A complete database includes
a complete health history and a full physical examination. It describes the client’s
current and past state of health and forms a baseline against which all future changes
can be measured. A follow-up database is used to evaluate an identified problem at
regular and appropriate intervals.
Test-Taking Strategy: Focusing on the data in the question and noting the words “now
complaining of chest congestion and cough” will direct you to the correct option.
Review: the different types of databases .
Reference: Jarvis, C. (2008). Physical examination and health assessment (5th ed., p.
8). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Health Assessment/Physical Exam
Priority Concepts: Evidence, Gas Exchange
HESI Concepts: Evidence-Based Practice/Evidence, Oxygenation/Gas Exchange
Question 5
pts
A client is brought to the emergency department after a motor vehicle accident. The
client is alert and cooperative but has sustained multiple fractures of the legs. How
should the nurse proceed with data collection?
Correct!
Ask health history questions while performing the examination and initiating emergency
measures
