Test Bank For
Nursing Health Assessment A
Clinical Judgment Approach 4th
Edition By Sharon Jensen
(All Chapters 1-30, 100% Original
Verified, A+ Grade)
All Chapters Arranged Reverse:
30-1
This is The Original Test Bank For
4th Edition, All other Files in The
Market are Fake/Old/Wrong
Edition.
,Chapter 30: Head-to-Toe Assessment of Adult
1. A student nurse asks the instructor why it is necessary to do a comprehensive health
assessment on a new client. What would be the instructor's best response?
A. "A new client needs a more complete assessment."
B. "It is a better assessment than any other assessment."
C. "The comprehensive health assessment integrates all body systems and helps give
the nurse an overall impression of the client's condition."
D. "You need to know what is going on with the client at that point in time."
ANS: C
Feedback: The comprehensive health assessment integrates all body systems; findings help
the nurse form an overall impression of the client and the client's condition. While many
new clients do need more complete assessments, there are times when new clients first
require emergency or focused assessments. Comprehensive assessments are not qualitatively
better than focused or emergency assessments if used at inappropriate times or settings. A
focused assessment is just as likely to help the nurse determine what is going on with the
client at that point in time as a comprehensive assessment is.
PTS: 1 REF: p. 962 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze NOT: Multiple Choice
2. When conducting a focused health assessment, the nurse asks questions specifically
targeting the client's:
A. culture.
B. gender.
C. sexual orientation.
D. specific issues and symptoms.
ANS: D
Feedback: The nurse focuses questions on issues and symptoms specific to the client. In this
way, the client is viewed as a person who has multiple things that are affected by the health
status. These questions are related to the client's primary problems and concerns. A focused
assessment does not ask questions specifically about culture, gender, or sexual orientation.
PTS: 1 REF: p. 960 OBJ: 1
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Remember NOT: Multiple Choice
3. Students are learning about subjective data collection. What data are collected subjectively?
(Select all that apply.)
A. Risk factors
B. Common symptoms
C. Family history
, D. Auscultated sounds
E. Visualized signs
ANS: A, B, C
Feedback: Subjective data collection includes health promotion, risk factors, history of
present problem, past medical and family histories, personal and social histories, and
common symptoms. Auscultated sounds and visualized signs are part of objective data
collection.
PTS: 1 REF: p. 960 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
4. When collecting subjective data, the nurse gives the client time and encouragement to do
what?
A. Tell stories about his or her family
B. Express complaints
C. List common findings
D. Tell about the client's concerns
ANS: D
Feedback: The nurse gives the client time and encouragement to tell their story and
experience of health or illness. Doing so provides an opportunity for the client to express
concerns; it often forms the foundation for a therapeutic relationship. Subjective data
collection involves learning about the client's family history and health concerns, but the
nurse would steer the conversation away from social discussions of the client's family or too
many unrelated complaints. Common findings are part of objective data collection and are
driven by the health provider, not the nurse.
PTS: 1 REF: p. 960 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. A nursing instructor is explaining to students about primary prevention services that nurses
offer as part of their professional responsibilities. What would the instructor list as these
services?
A. Palpation
B. Auscultation
C. Screening
D. Rehabilitation
ANS: C
Feedback: Screening and resulting teaching are primary prevention services that nurses offer
as part of their professional responsibilities. Palpation and auscultation are techniques of
physical examination. Rehabilitation is a tertiary prevention service.
, PTS: 1 REF: p. 962 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Remember NOT: Multiple Choice
6. The nurse is assessing risk factors on a new clinic client. These risk factors are assessed
according to what?
A. The individual's age
B. The individual's risks
C. The individual's gender
D. The individual's lifestyle
ANS: B
Feedback: The nurse assesses risk factors according to the individual's risks (e.g., injury in a
teenager, genetic diseases in a pregnant woman). All the remaining options have some
component of the correct answer, but risk includes all those factors.
PTS: 1 REF: p. 968 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the
nurse would be cause for concern? (Select all that apply.)
A. Freckles
B. Rashes
C. Goose bumps
D. Lesions
E. Infestations
ANS: B, D, E
Feedback: The nurse inspects the skin with each corresponding body area for rashes, lesions,
or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a
concern.
PTS: 1 REF: p. 971 OBJ: 6
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
8. While assessing a client's eyes, the nurse notes a depressed corneal response. In what type of
client would this finding be considered normal?
A. A client with cataracts
B. A client wearing of contact lenses
C. A client with a history of macular degeneration
D. A client who is blind
Nursing Health Assessment A
Clinical Judgment Approach 4th
Edition By Sharon Jensen
(All Chapters 1-30, 100% Original
Verified, A+ Grade)
All Chapters Arranged Reverse:
30-1
This is The Original Test Bank For
4th Edition, All other Files in The
Market are Fake/Old/Wrong
Edition.
,Chapter 30: Head-to-Toe Assessment of Adult
1. A student nurse asks the instructor why it is necessary to do a comprehensive health
assessment on a new client. What would be the instructor's best response?
A. "A new client needs a more complete assessment."
B. "It is a better assessment than any other assessment."
C. "The comprehensive health assessment integrates all body systems and helps give
the nurse an overall impression of the client's condition."
D. "You need to know what is going on with the client at that point in time."
ANS: C
Feedback: The comprehensive health assessment integrates all body systems; findings help
the nurse form an overall impression of the client and the client's condition. While many
new clients do need more complete assessments, there are times when new clients first
require emergency or focused assessments. Comprehensive assessments are not qualitatively
better than focused or emergency assessments if used at inappropriate times or settings. A
focused assessment is just as likely to help the nurse determine what is going on with the
client at that point in time as a comprehensive assessment is.
PTS: 1 REF: p. 962 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze NOT: Multiple Choice
2. When conducting a focused health assessment, the nurse asks questions specifically
targeting the client's:
A. culture.
B. gender.
C. sexual orientation.
D. specific issues and symptoms.
ANS: D
Feedback: The nurse focuses questions on issues and symptoms specific to the client. In this
way, the client is viewed as a person who has multiple things that are affected by the health
status. These questions are related to the client's primary problems and concerns. A focused
assessment does not ask questions specifically about culture, gender, or sexual orientation.
PTS: 1 REF: p. 960 OBJ: 1
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Remember NOT: Multiple Choice
3. Students are learning about subjective data collection. What data are collected subjectively?
(Select all that apply.)
A. Risk factors
B. Common symptoms
C. Family history
, D. Auscultated sounds
E. Visualized signs
ANS: A, B, C
Feedback: Subjective data collection includes health promotion, risk factors, history of
present problem, past medical and family histories, personal and social histories, and
common symptoms. Auscultated sounds and visualized signs are part of objective data
collection.
PTS: 1 REF: p. 960 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
4. When collecting subjective data, the nurse gives the client time and encouragement to do
what?
A. Tell stories about his or her family
B. Express complaints
C. List common findings
D. Tell about the client's concerns
ANS: D
Feedback: The nurse gives the client time and encouragement to tell their story and
experience of health or illness. Doing so provides an opportunity for the client to express
concerns; it often forms the foundation for a therapeutic relationship. Subjective data
collection involves learning about the client's family history and health concerns, but the
nurse would steer the conversation away from social discussions of the client's family or too
many unrelated complaints. Common findings are part of objective data collection and are
driven by the health provider, not the nurse.
PTS: 1 REF: p. 960 OBJ: 2
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. A nursing instructor is explaining to students about primary prevention services that nurses
offer as part of their professional responsibilities. What would the instructor list as these
services?
A. Palpation
B. Auscultation
C. Screening
D. Rehabilitation
ANS: C
Feedback: Screening and resulting teaching are primary prevention services that nurses offer
as part of their professional responsibilities. Palpation and auscultation are techniques of
physical examination. Rehabilitation is a tertiary prevention service.
, PTS: 1 REF: p. 962 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Remember NOT: Multiple Choice
6. The nurse is assessing risk factors on a new clinic client. These risk factors are assessed
according to what?
A. The individual's age
B. The individual's risks
C. The individual's gender
D. The individual's lifestyle
ANS: B
Feedback: The nurse assesses risk factors according to the individual's risks (e.g., injury in a
teenager, genetic diseases in a pregnant woman). All the remaining options have some
component of the correct answer, but risk includes all those factors.
PTS: 1 REF: p. 968 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the
nurse would be cause for concern? (Select all that apply.)
A. Freckles
B. Rashes
C. Goose bumps
D. Lesions
E. Infestations
ANS: B, D, E
Feedback: The nurse inspects the skin with each corresponding body area for rashes, lesions,
or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a
concern.
PTS: 1 REF: p. 971 OBJ: 6
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 30: Head-to-Toe Assessment of the Adult
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
8. While assessing a client's eyes, the nurse notes a depressed corneal response. In what type of
client would this finding be considered normal?
A. A client with cataracts
B. A client wearing of contact lenses
C. A client with a history of macular degeneration
D. A client who is blind
