Health Assessment Final Test Bank
Questions
After completing an initial assessment of a patient, the nurse has charted that his respirations
are eupneic and his pulse is 58 beats per minute. These types of data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective - ANS a. Objective
Rationale: Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination. Subjective data is what the person
says about him or herself during history taking. The terms reflective and introspective are not
used to describe data.
A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of
data would be:
a. Objective
b. Reflective
c. Subjective
d. Introspective - ANS c. Subjective
Rationale: Subjective data are what the person says about him or herself during history taking.
Objective data are what the health professional observes by inspecting, percussing, palpating,
and auscultating during the physical examination. The terms reflective and introspective are not
used to describe data.
When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The
nurses next action should be to:
a. Immediately notify the patients physician
b. Document the sound exactly as it was heard
c. Validate the data by asking a coworker to listen to the breath sounds
d. Assess again in 20 minutes to note whether the sound is still present - ANS c. Validate the
data by asking a coworker to listen to the breath sounds
Rationale: When unsure of a sound heard while listening to a patients breath sounds, the nurse
validates the data to ensure accuracy. If the nurse has less experience in an area, then he or
she asks an expert to listen.
,The patients record, laboratory studies, objective data, and subjective data combine to form the:
a. Data base
b. Admitting data
c. Financial statement
d. Discharge summary - ANS a. Data base
Rationale: Together with the patients record and laboratory studies, the objective and subjective
data form the data base. The other items are not part of the patients record, laboratory studies,
or data.
The nursing process is a sequential method of problem solving that nurses use and includes
which steps?
a. Assessment, treatment, planning, evaluation, discharge, and follow-up
b. Admission, assessment, diagnosis, treatment, and discharge planning
c. Admission, diagnosis, treatment, evaluation, and discharge planning
d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation -
ANS d. Assessment, diagnosis, outcome identification, planning, implementation, and
evaluation
Rationale: The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation.
Barriers to incorporating EBP include:
a. Nurses lack of research skills in evaluating the quality of research studies
b. Lack of significant research studies
c. Insufficient clinical skills of nurses
d. Inadequate physical assessment skills - ANS a. Nurses lack of research skills in evaluating
the quality of research studies
,Rationale: As individuals, nurses lack research skills in evaluating the quality of research
studies, are isolated from other colleagues who are knowledgeable in research, and often lack
the time to visit the library to read research. The other responses are not considered barriers.
The nurse is reviewing data collected after an assessment. Of the data listed below, which
would be considered related cues that would be clustered together during data analysis? Select
all that apply.
a. Inspiratory wheezes noted in left lower lobes
b. Hypoactive bowel sounds
c. Nonproductive cough
d. Edema, +2, noted on left hand
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute - ANS a. Inspiratory wheezes noted in left lower
lobes
c. Nonproductive cough
e. Patient reports dyspnea upon exertion
f. Rate of respirations 16 breaths per minute
Rationale: Clustering related cues help the nurse recognize relationships among the data. The
cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea,
respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are
not related to the respiratory cues.
The nurse is conducting an interview. Which of these statements is true regarding open-ended
questions? Select all that apply.
a. Open-ended questions elicit cold facts
b. They allow for self-expression
c. Open-ended questions build and enhance rapport
d. They leave interactions neutral
e. Open-ended questions call for short one- to two-word answers
f. They are used when narrative information is needed - ANS b. They allow for self-expression
, c. Open-ended questions build and enhance rapport
f. They are used when narrative information is needed
Rationale: Open-ended questions allow for self-expression, build and enhance rapport, and
obtain narrative information. These features enhance communication during an interview. The
other statements are appropriate for closed or direct questions.
The nurse is conducting an interview in an outpatient clinic and is using a computer to record
data. Which are the best uses of the computer in this situation? Select all that apply.
a. Collect the patients data in a direct, face-to-face manner.
b. Enter all the data as the patient states them.
c. Ask the patient to wait as the nurse enters the data.
d. Type the data into the computer after the narrative is fully explored.
e. Allow the patient to see the monitor during typing. - ANS a. Collect the patients data in a
direct, face-to-face manner.
d. Type the data into the computer after the narrative is fully explored.
e. Allow the patient to see the monitor during typing.
Rationale: The use of a computer can become a barrier. The nurse should begin the interview
as usual by greeting the patient, establishing rapport, and collecting the patients narrative story
in a direct, face-to-face manner. Only after the narrative is fully explored should the nurse type
data into the computer. When typing, the nurse should position the monitor so that the patient
can see it.
During an interview, the nurse would expect that most of the interview will take place at what
distance?
a. Intimate zone
b. Personal distance
c. Social distance
d. Public distance - ANS c. Social distance
