Nursing Health Assessment: The Foundation of Clinical Practice, 3rd Edition by Patricia M. Dillon

Chapter 01: The Complete Health Assessment

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. Which critical thinking skill allows the nurse to think outside of the box when assessing a patient?
1) Divergent thinking
2) Reasoning
3) Creativity
4) Reflection

____ 2. The primary level of preventive health care focuses on which topic?
1) Health promotion
2) Early detection
3) Promotion intervention
4) End-of-life care

____ 3. The nurse is prioritizing data collected during the health assessment. Which data is primary?
1) Pain rating of 4 on a 1 to 10 numeric scale
2) New diagnosis of type 2 diabetes mellitus (DM)
3) Blood pressure of 130/90 mmHg
4) Pulse oximetry reading of 73%

____ 4. Which type of skill is most important when performing a physical assessment?
1) Psychomotor
2) Interpersonal
3) Ethical
4) Affective

____ 5. Which activity is an example of secondary prevention?
1) Wound débridement
2) Immunization
3) Preoperative teaching
4) Long-term nasogastric feedings

____ 6. Which assessment data is considered a symptom?
1) Rapid respirations
2) Sweaty palms
3) Belching
4) Feelings of anxiety

____ 7. Who or what is considered the primary data source for a toddler-age patient?
1) The toddler
2) A parent
3) The medical record
4) Other healthcare providers

____ 8. Which part of the assessment provides the most subjective data?
1) Health history
2) Physical assessment
3) Review of medical records

, 4) Medication record

____ 9. 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?
1) The patient's chart
2) A physical assessment
3) Laboratory tests
4) A discussion with the patient

____ 10. 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?
1) “What problem brought you here today?”
2) “How old are you?”
3) “Have you had any difficulty breathing?”
4) “What childhood illnesses have you had?”

____ 11. Which is the reason for asking the patient about family history of diseases when conducting a health history
interview?
1) To identify functional or dysfunctional family dynamics
2) To identify support systems
3) To identify familial or genetically linked health disorders
4) To identify rehabilitation needs

____ 12. Which data are part of the past health history?
1) Health beliefs
2) Surgeries
3) Genetically linked diseases
4) Age of siblings

____ 13. Which is the purpose of the nursing health history?
1) To determine the patient's response to the health problem
2) To determine the extent of the health problem
3) To determine which medications are appropriate to alleviate the health problem
4) All of the above

____ 14. Which setting is the best place to gather data for a health history?
1) Waiting room
2) Hallway
3) Patient's room
4) On the way to surgery

____ 15. 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?
1) Leaning over the bed
2) Standing at the bedside
3) Sitting on the bed
4) Sitting on a chair at the bedside

____ 16. 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?
1) Psychosocial profile
2) Current health problems

, 3) Past health problems
4) Developmental considerations

____ 17. 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?
1) Past health history
2) Present health status
3) Reason for seeking care
4) Objective assessment data

____ 18. When is it appropriate for the nurse to conduct the focused physical assessment?
1) During the initial assessment for a yearly exam
2) On admission to the hospital for surgery
3) On admission of a patient in acute respiratory distress
4) All of the above

____ 19. Glass thermometers and sphygmomanometers have been replaced by other equipment in many healthcare
settings. Which is the rationale for this change?
1) Difficulty with calibration
2) Difficulty with sterilization
3) Mercury toxicity
4) Poor results

____ 20. The bell of the stethoscope is best for detecting which type of sounds?
1) High pitch
2) Low pitch
3) Medium pitch
4) All of the above

____ 21. The nurse is unable to palpate pedal pulses bilaterally on an obese patient. Which is the priority action for the
nurse to take?
1) Document that pedal pulses are absent
2) Auscultate heart tones
3) Assess gait
4) Assess pulses with a Doppler

____ 22. Which is the best assessment tool to use when testing far vision in 2-year-old children?
1) Snellen alphabet chart
2) Stycar chart
3) Allen cards
4) Pocket vision screener

____ 23. Which is the best method for the nurse to use when documenting a patient’s physical exam?
1) In order of the assessment
2) By the patient's main complaint
3) By system
4) With all normal and abnormal data clustered

____ 24. Which part of the hand does the nurse use to detect vibrations?
1) Fingertips
2) Fingerpads
3) Ball of hand