1/18/23, 8:05 AM Medical-Surgical Nursing 13th Edition Test Bank Chapter 5
1. A school nurse is teaching a 14-year-old girl of normal weight some of the key factors
necessary to maintain good nutrition in this stage of her growth and development. What
interventions should the nurse most likely prioritize?
A) Decreasing her calorie intake and encouraging her to maintain her weight to
avoid obesity
B) Increasing her BMI, taking a multivitamin, and discussing body image
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
D) Obtaining a food diary along with providing close monitoring for anorexia
Ans: C
Feedback:
Adolescent girls are considered to be at high risk for nutritional disorders. Increasing
calcium intake and promoting a balanced diet will provide the necessary vitamins and
minerals. If adolescents are diagnosed with eating disorders early, the recovery chances
are increased. The question presents no information that indicates a need for decreasing
her calories. There is no apparent need for an increase in BMI. A food diary is used for
assessing eating habits, but the question asks for teaching factors related to good
nutrition.
2. A nurse is conducting a health assessment of an adult patient when the patient asks,
“Why do you need all this health information and who is going to see it?” What is the
nurse's best response?
A) “Please do not worry. It is safe and will be used only to help us with your care.
It's accessible to a wide variety of people who are invested in your health.”
B) “It is good you asked and you have a right to know; your information helps us to
provide you with the best possible care, and your records are in a secure place.”
C) “Your health information is placed on secure Web sites to provide easy access to
anyone wishing to see your medical records. This ensures continuity of care.”
D) “Health information becomes the property of the hospital and we will make sure
that no one sees it. Then, in 2 years, we destroy all records and the process starts
over.”
Ans: B
Feedback:
Whenever information is elicited from a person through a health history or physical
examination, the person has the right to know why the information is sought and how it
will be used. For this reason, it is important to explain what the history and physical
examination are, how the information will be obtained, and how it will be used.
Medical records allow access to health care providers who need the information to
provide patients with the best possible care, and the records are always held in a secure
environment. Telling the patient “not to worry” minimizes the patient's concern
regarding the safety of his or her health information and “a wide variety of people”
should not have access to patients' health information. Health information should not be
placed on Web sites and health records are not destroyed every 2 years.
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,1/18/23, 8:05 AM Medical-Surgical Nursing 13th Edition Test Bank Chapter 5
3. The nurse is performing an admission assessment of a 72-year-old female patient who
understands minimal English. An interpreter who speaks the patient's language is
unavailable and no members of the care team speak the language. How should the nurse
best perform data collection?
A) Have a family member provide the data.
B) Obtain the data from the old chart and physician's assessment.
C) Obtain the data only from the patient, prioritizing aspects that the patient
understands.
D) Collect all possible data from the patient and have the family supplement missing
details.
Ans: D
Feedback:
The informant, or the person providing the information, may not always be the patient.
The nurse can gain information from the patient and have the family provide any
missing details. The nurse should always obtain as much information as possible
directly from the patient. In this case, it is not likely possible to get all the information
needed only from the patient.
4. You are the nurse assessing a 28-year-old woman who has presented to the emergency
department with vague complaints of malaise. You note bruising to the patient's upper
arm that correspond to the outline of fingers as well as yellow bruising around her left
eye. The patient makes minimal eye contact during the assessment. How might you best
inquire about the bruising?
A) “Is anyone physically hurting you?”
B) “Tell me about your relationships.”
C) “Do you want to see a social worker?”
D) “Is there something you want to tell me?”
Ans: A
Feedback:
Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it
is important to ask direct questions, such as, “Is anyone physically hurting you?” The
other options are incorrect because they are not the best way to illicit information about
possible abuse in a direct and appropriate manner.
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, 1/18/23, 8:05 AM Medical-Surgical Nursing 13th Edition Test Bank Chapter 5
5. You are the nurse performing a health assessment of an adult male patient. The man
states, “The doctor has already asked me all these questions. Why are you asking them
all over again?” What is your best response?
A) “This history helps us determine what your needs may be for nursing care.”
B) “You are right; this may seem redundant and I'm sure that it's frustrating for
you.”
C) “I want to make sure your doctor has covered everything that's important for your
treatment.”
D) “I am a member of your health care team and we want to make sure that nothing
falls through the cracks.”
Ans: A
Feedback:
Regardless of the assessment format used, the focus of nurses during data collection is
different from that of physicians and other health team members. Explaining to the
patient the purpose of the nursing assessment creates a better understanding of what the
nurse does. It also gives the patient an opportunity to add his or her own input into the
patient's care plan. The nurse should address the patient's concerns directly and avoid
casting doubt on the thoroughness of the physician.
6. You are taking a health history on an adult patient who is new to the clinic. While
performing your assessment, the patient informs you that her mother has type 1
diabetes. What is the primary significance of this information to the health history?
A) The patient may be at risk for developing diabetes.
B) The patient may need teaching on the effects of diabetes.
C) The patient may need to attend a support group for individuals with diabetes.
D) The patient may benefit from a dietary regimen that tracks glucose intake.
Ans: A
Feedback:
Nurses incorporate a genetics focus into the health assessments of family history to
assess for genetics-related risk factors. The information aids the nurse in determining if
the patient may be predisposed to diseases that are genetic in origin. The results of
diabetes testing would determine whether dietary changes, support groups or health
education would be needed.
Page 3
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1. A school nurse is teaching a 14-year-old girl of normal weight some of the key factors
necessary to maintain good nutrition in this stage of her growth and development. What
interventions should the nurse most likely prioritize?
A) Decreasing her calorie intake and encouraging her to maintain her weight to
avoid obesity
B) Increasing her BMI, taking a multivitamin, and discussing body image
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
D) Obtaining a food diary along with providing close monitoring for anorexia
Ans: C
Feedback:
Adolescent girls are considered to be at high risk for nutritional disorders. Increasing
calcium intake and promoting a balanced diet will provide the necessary vitamins and
minerals. If adolescents are diagnosed with eating disorders early, the recovery chances
are increased. The question presents no information that indicates a need for decreasing
her calories. There is no apparent need for an increase in BMI. A food diary is used for
assessing eating habits, but the question asks for teaching factors related to good
nutrition.
2. A nurse is conducting a health assessment of an adult patient when the patient asks,
“Why do you need all this health information and who is going to see it?” What is the
nurse's best response?
A) “Please do not worry. It is safe and will be used only to help us with your care.
It's accessible to a wide variety of people who are invested in your health.”
B) “It is good you asked and you have a right to know; your information helps us to
provide you with the best possible care, and your records are in a secure place.”
C) “Your health information is placed on secure Web sites to provide easy access to
anyone wishing to see your medical records. This ensures continuity of care.”
D) “Health information becomes the property of the hospital and we will make sure
that no one sees it. Then, in 2 years, we destroy all records and the process starts
over.”
Ans: B
Feedback:
Whenever information is elicited from a person through a health history or physical
examination, the person has the right to know why the information is sought and how it
will be used. For this reason, it is important to explain what the history and physical
examination are, how the information will be obtained, and how it will be used.
Medical records allow access to health care providers who need the information to
provide patients with the best possible care, and the records are always held in a secure
environment. Telling the patient “not to worry” minimizes the patient's concern
regarding the safety of his or her health information and “a wide variety of people”
should not have access to patients' health information. Health information should not be
placed on Web sites and health records are not destroyed every 2 years.
Page 1
about:blank 1/21
,1/18/23, 8:05 AM Medical-Surgical Nursing 13th Edition Test Bank Chapter 5
3. The nurse is performing an admission assessment of a 72-year-old female patient who
understands minimal English. An interpreter who speaks the patient's language is
unavailable and no members of the care team speak the language. How should the nurse
best perform data collection?
A) Have a family member provide the data.
B) Obtain the data from the old chart and physician's assessment.
C) Obtain the data only from the patient, prioritizing aspects that the patient
understands.
D) Collect all possible data from the patient and have the family supplement missing
details.
Ans: D
Feedback:
The informant, or the person providing the information, may not always be the patient.
The nurse can gain information from the patient and have the family provide any
missing details. The nurse should always obtain as much information as possible
directly from the patient. In this case, it is not likely possible to get all the information
needed only from the patient.
4. You are the nurse assessing a 28-year-old woman who has presented to the emergency
department with vague complaints of malaise. You note bruising to the patient's upper
arm that correspond to the outline of fingers as well as yellow bruising around her left
eye. The patient makes minimal eye contact during the assessment. How might you best
inquire about the bruising?
A) “Is anyone physically hurting you?”
B) “Tell me about your relationships.”
C) “Do you want to see a social worker?”
D) “Is there something you want to tell me?”
Ans: A
Feedback:
Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it
is important to ask direct questions, such as, “Is anyone physically hurting you?” The
other options are incorrect because they are not the best way to illicit information about
possible abuse in a direct and appropriate manner.
Page 2
about:blank 2/21
, 1/18/23, 8:05 AM Medical-Surgical Nursing 13th Edition Test Bank Chapter 5
5. You are the nurse performing a health assessment of an adult male patient. The man
states, “The doctor has already asked me all these questions. Why are you asking them
all over again?” What is your best response?
A) “This history helps us determine what your needs may be for nursing care.”
B) “You are right; this may seem redundant and I'm sure that it's frustrating for
you.”
C) “I want to make sure your doctor has covered everything that's important for your
treatment.”
D) “I am a member of your health care team and we want to make sure that nothing
falls through the cracks.”
Ans: A
Feedback:
Regardless of the assessment format used, the focus of nurses during data collection is
different from that of physicians and other health team members. Explaining to the
patient the purpose of the nursing assessment creates a better understanding of what the
nurse does. It also gives the patient an opportunity to add his or her own input into the
patient's care plan. The nurse should address the patient's concerns directly and avoid
casting doubt on the thoroughness of the physician.
6. You are taking a health history on an adult patient who is new to the clinic. While
performing your assessment, the patient informs you that her mother has type 1
diabetes. What is the primary significance of this information to the health history?
A) The patient may be at risk for developing diabetes.
B) The patient may need teaching on the effects of diabetes.
C) The patient may need to attend a support group for individuals with diabetes.
D) The patient may benefit from a dietary regimen that tracks glucose intake.
Ans: A
Feedback:
Nurses incorporate a genetics focus into the health assessments of family history to
assess for genetics-related risk factors. The information aids the nurse in determining if
the patient may be predisposed to diseases that are genetic in origin. The results of
diabetes testing would determine whether dietary changes, support groups or health
education would be needed.
Page 3
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