Test Bank for
Nursing Health Assessment The Foundation of Clinical Practice,
3rd Edition, Patricia M. Dillon
,Table of Contents
1. Introduction to Assessment
2. Assessing the Integumentary System
3. Assessing the Head, Face and Neck
4. Assessing Eyes and the Ears
5. Assessing the Respiratory System
6. Assessing the Cardiovascular System
7. Assessing the Peripheral -Vascular and Lymphatic Systems
8. Assessing the Breasts
9. Assessing the Abdomen
10. Assessing the Female Genitourinary
11. Assessing the Male Genitourinary
12. Assessing the Motor Musculoskeletal System
13. Assessing the Sensory Neurological System
14. Assessing the Mother to Be
15. Assessing the Newborn and Infant
16. Assessing the Toddler and Preschooler
17. Assessing the School-Age Child and Adolescent
18. Assessing the Older Adult
19. Assessing the Homeless Person
20. Assessing Pain
,21. Approach to the Mental Health Assessment
22. Assessing Nutrition
23. Assessing Spirituality
24. Assessing Culture
25. Assessing the Patient’s Environment
26. Assessing Abuse
27. Assessing the Dying Patient—new
,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
4) Dorsal surface
,25. The nurse is planning to use percussion during the physical examination of a patient. Which is the reason for
using percussion?
1) To assess areas of tenderness
2) To assess organ and tissue density
3) To assess areas of inflammation
4) To assess consistency
26. Which action by the nurse is appropriate when using an otoscope to assess the tympanic membrane of an
adult?
1) Pulling the earlobe up and back
2) Pulling the earlobe down and back
3) Pulling the earlobe horizontally to straighten the ear canal
4) Avoiding moving the canal out of the normal anatomic position
27. The nurse is preparing to assess the fetal heart rate during the 32nd week of gestation. Which action is
appropriate?
1) Using the bell of the stethoscope
2) Using the diaphragm of the stethoscope
3) Using palpation to feel the fetal heart rate
4) Using a fetoscope
28. The nurse is using an ophthalmoscope during a routine head-to-toe assessment. Which is the nurse assessing?
1) External ear canal
2) Tympanic membrane
3) Red light reflex
4) Cranial nerves
29. Which is the correct technique for using the bell portion of the stethoscope?
1) Avoid touching the bell during auscultation
2) Hold the bell lightly on the chest wall
3) Apply light pressure with the bell slightly tilted up
4) Hold the bell firmly against the chest wall
30. The nurse is preparing to assess the patient’s thyroid gland. Which action is appropriate?
1) Asking the patient to identify a scent
2) Asking the patient to swallow water
3) Asking the patient to identify a taste
4) Asking the person to repeat “99”
31. The nurse uses a tongue depressor to assess the gag reflex. Which action is appropriate by the nurse?
1) Sending the depressor for sterilization
2) Discarding the depressor in one piece
3) Breaking the depressor and then discarding it
4) Using the depressor for another patient
32. The nurse is assessing the patient’s range of motion. Which tool is a requirement for this assessment?
1) Stethoscope
2) Otoscope
3) Ophthalmoscope
4) Ganiometer
33. The nurse is assisting the healthcare provider during a pelvic examination. Which action by the nurse is
appropriate?
, 1) Preparing the hemoccult test
2) Placing the patient in Sims’ position
3) Preparing the speculum
4) Placing sterile gloves on the provider
34. The nurse is assessing the circumference of a patient’s abdomen. Which will the nurse use when documenting
the findings?
1) Millimeters
2) Centimeters
3) Inches
4) Kilograms
35. The nurse is preparing to weigh a patient on a medical-surgical unit. Which is the priority action?
1) Asking the patient to remove his or her shoes for the weight assessment
2) Asking the patient to refrain from eating or drinking before the weight assessment
3) Calibrating the scale
4) Cleaning the scale
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
36. The nurse is conducting a neurologic assessment. Which items are needed? Select all that apply.
1) Cotton balls
2) Test tubes
3) Scents
4) Salts
5) Latex gloves
37. The nurse is using a nasoscope during a head-to-toe assessment. Which assessments require the use of this
tool? Select all that apply.
1) Nostrils
2) Nasal mucosa
3) Scrotum
4) Fontanels
5) Septum
,Chapter 01: The Complete Health Assessment
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 1
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Critical Thinking
Difficulty: Easy
Feedback
1 Divergent thinking allows the nurse to analyze different points of view.
2 Reasoning allows the nurse to differentiate fact from assumptions.
3 Critical thinking is a thinking process that is used during the assessment process.
Creativity is a critical thinking skill that allows the nurse to think outside of the box.
4 Reflection allows the nurse to step back and consider “if…then” possibilities.
PTS: 1 CON: Assessment | Critical Thinking
2. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1 There are three levels of preventive health care. Primary prevention focuses health
promotion.
2 Secondary prevention focuses on early detection, prompt intervention, and health
maintenance.
3 Secondary prevention focuses on prompt intervention and health maintenance.
4 Tertiary prevention focuses on rehabilitation, extended care, and end-of-life care.
PTS: 1 CON: Promoting Health
3. ANS: 4
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 3
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
, Feedback
1 A pain rating of 4 on a 1 to 10 scale is secondary data. This finding requires prompt
attention to prevent further progression or deterioration.
2 A new diagnosis of type 2 DM is tertiary data that is important but does not require
immediate intervention. Tertiary data often requires patient teaching.
3 A slightly elevated blood pressure is secondary data. This finding requires prompt
attention to prevent further progression or deterioration.
4 Primary data is anything that is a life threatening problem. A pulse oximetry reading of
73% indicates the blood is not being oxygenated appropriately and requires an
immediate intervention to correct the problem.
PTS: 1 CON: Assessment
4. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Easy
Feedback
1 The psychomotor skills are inspection, palpation, percussion, and auscultation. These
are considered the most important assessment skills.
2 Interpersonal skills are assessment skills, but they are not considered to be the most
important assessment skills.
3 Ethical skills are assessment skills, but they are not considered to be the most important
assessment skills.
4 Affective skills are assessment skills, but they are not considered to be the most
important assessment skills.
PTS: 1 CON: Assessment
5. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1 Wound care, including wound débridement, is an example of secondary prevention.
2 Immunization is an example of primary prevention.
3 Preoperative teaching is an example of tertiary prevention.
4 Long-term nasogastric feedings are an example of tertiary prevention.
PTS: 1 CON: Promoting Health
6. ANS: 4
Nursing Health Assessment The Foundation of Clinical Practice,
3rd Edition, Patricia M. Dillon
,Table of Contents
1. Introduction to Assessment
2. Assessing the Integumentary System
3. Assessing the Head, Face and Neck
4. Assessing Eyes and the Ears
5. Assessing the Respiratory System
6. Assessing the Cardiovascular System
7. Assessing the Peripheral -Vascular and Lymphatic Systems
8. Assessing the Breasts
9. Assessing the Abdomen
10. Assessing the Female Genitourinary
11. Assessing the Male Genitourinary
12. Assessing the Motor Musculoskeletal System
13. Assessing the Sensory Neurological System
14. Assessing the Mother to Be
15. Assessing the Newborn and Infant
16. Assessing the Toddler and Preschooler
17. Assessing the School-Age Child and Adolescent
18. Assessing the Older Adult
19. Assessing the Homeless Person
20. Assessing Pain
,21. Approach to the Mental Health Assessment
22. Assessing Nutrition
23. Assessing Spirituality
24. Assessing Culture
25. Assessing the Patient’s Environment
26. Assessing Abuse
27. Assessing the Dying Patient—new
,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
4) Dorsal surface
,25. The nurse is planning to use percussion during the physical examination of a patient. Which is the reason for
using percussion?
1) To assess areas of tenderness
2) To assess organ and tissue density
3) To assess areas of inflammation
4) To assess consistency
26. Which action by the nurse is appropriate when using an otoscope to assess the tympanic membrane of an
adult?
1) Pulling the earlobe up and back
2) Pulling the earlobe down and back
3) Pulling the earlobe horizontally to straighten the ear canal
4) Avoiding moving the canal out of the normal anatomic position
27. The nurse is preparing to assess the fetal heart rate during the 32nd week of gestation. Which action is
appropriate?
1) Using the bell of the stethoscope
2) Using the diaphragm of the stethoscope
3) Using palpation to feel the fetal heart rate
4) Using a fetoscope
28. The nurse is using an ophthalmoscope during a routine head-to-toe assessment. Which is the nurse assessing?
1) External ear canal
2) Tympanic membrane
3) Red light reflex
4) Cranial nerves
29. Which is the correct technique for using the bell portion of the stethoscope?
1) Avoid touching the bell during auscultation
2) Hold the bell lightly on the chest wall
3) Apply light pressure with the bell slightly tilted up
4) Hold the bell firmly against the chest wall
30. The nurse is preparing to assess the patient’s thyroid gland. Which action is appropriate?
1) Asking the patient to identify a scent
2) Asking the patient to swallow water
3) Asking the patient to identify a taste
4) Asking the person to repeat “99”
31. The nurse uses a tongue depressor to assess the gag reflex. Which action is appropriate by the nurse?
1) Sending the depressor for sterilization
2) Discarding the depressor in one piece
3) Breaking the depressor and then discarding it
4) Using the depressor for another patient
32. The nurse is assessing the patient’s range of motion. Which tool is a requirement for this assessment?
1) Stethoscope
2) Otoscope
3) Ophthalmoscope
4) Ganiometer
33. The nurse is assisting the healthcare provider during a pelvic examination. Which action by the nurse is
appropriate?
, 1) Preparing the hemoccult test
2) Placing the patient in Sims’ position
3) Preparing the speculum
4) Placing sterile gloves on the provider
34. The nurse is assessing the circumference of a patient’s abdomen. Which will the nurse use when documenting
the findings?
1) Millimeters
2) Centimeters
3) Inches
4) Kilograms
35. The nurse is preparing to weigh a patient on a medical-surgical unit. Which is the priority action?
1) Asking the patient to remove his or her shoes for the weight assessment
2) Asking the patient to refrain from eating or drinking before the weight assessment
3) Calibrating the scale
4) Cleaning the scale
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
36. The nurse is conducting a neurologic assessment. Which items are needed? Select all that apply.
1) Cotton balls
2) Test tubes
3) Scents
4) Salts
5) Latex gloves
37. The nurse is using a nasoscope during a head-to-toe assessment. Which assessments require the use of this
tool? Select all that apply.
1) Nostrils
2) Nasal mucosa
3) Scrotum
4) Fontanels
5) Septum
,Chapter 01: The Complete Health Assessment
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 1
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Knowledge [Remembering]
Concept: Assessment, Critical Thinking
Difficulty: Easy
Feedback
1 Divergent thinking allows the nurse to analyze different points of view.
2 Reasoning allows the nurse to differentiate fact from assumptions.
3 Critical thinking is a thinking process that is used during the assessment process.
Creativity is a critical thinking skill that allows the nurse to think outside of the box.
4 Reflection allows the nurse to step back and consider “if…then” possibilities.
PTS: 1 CON: Assessment | Critical Thinking
2. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive level: Comprehension [Understanding]
Concept: Promoting Health
Difficulty: Easy
Feedback
1 There are three levels of preventive health care. Primary prevention focuses health
promotion.
2 Secondary prevention focuses on early detection, prompt intervention, and health
maintenance.
3 Secondary prevention focuses on prompt intervention and health maintenance.
4 Tertiary prevention focuses on rehabilitation, extended care, and end-of-life care.
PTS: 1 CON: Promoting Health
3. ANS: 4
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 3
Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Moderate
, Feedback
1 A pain rating of 4 on a 1 to 10 scale is secondary data. This finding requires prompt
attention to prevent further progression or deterioration.
2 A new diagnosis of type 2 DM is tertiary data that is important but does not require
immediate intervention. Tertiary data often requires patient teaching.
3 A slightly elevated blood pressure is secondary data. This finding requires prompt
attention to prevent further progression or deterioration.
4 Primary data is anything that is a life threatening problem. A pulse oximetry reading of
73% indicates the blood is not being oxygenated appropriately and requires an
immediate intervention to correct the problem.
PTS: 1 CON: Assessment
4. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive level: Analysis [Analyzing]
Concept: Assessment
Difficulty: Easy
Feedback
1 The psychomotor skills are inspection, palpation, percussion, and auscultation. These
are considered the most important assessment skills.
2 Interpersonal skills are assessment skills, but they are not considered to be the most
important assessment skills.
3 Ethical skills are assessment skills, but they are not considered to be the most important
assessment skills.
4 Affective skills are assessment skills, but they are not considered to be the most
important assessment skills.
PTS: 1 CON: Assessment
5. ANS: 1
Chapter number and title: 1, The Complete Health Assessment
Chapter learning objective: N/A
Chapter page reference: 2
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive level: Application [Applying]
Concept: Promoting Health
Difficulty: Moderate
Feedback
1 Wound care, including wound débridement, is an example of secondary prevention.
2 Immunization is an example of primary prevention.
3 Preoperative teaching is an example of tertiary prevention.
4 Long-term nasogastric feedings are an example of tertiary prevention.
PTS: 1 CON: Promoting Health
6. ANS: 4
