TEST BANK
Nursing Health Assessment: A Clinical Judgment Approach
Sharon Jensen
4th Edition
,Table of Contents
Chapter 01 The Nurse's Role in Health Assessment 1
Chapter 02 Health History and Interview 10
Chapter 03 Assessment Techniques, Safety, and Infection Control 20
Chapter 04 Documentation and Interprofessional Communication 29
Chapter 05 Vital Signs and General Survey 37
Chapter 06 Pain Assessment 46
Chapter 07 Nutrition Assessment 55
Chapter 08 Assessment of Developmental Stages 64
Chapter 09 Mental Health, Violence, and Substance Use Disorder 74
Chapter 10 Cultural Assessment 84
Chapter 11 Skin, Hair, and Nails Assessment 94
Chapter 12 Head and Neck, with Vision and Hearing Basics 103
Chapter 13 Eye Assessment for Advanced and Specialty Practice 112
Chapter 14 Ear Assessment for Advanced and Specialty Practice 120
Chapter 15 Nose, Sinuses, Mouth, and Throat Assessment 129
Chapter 16 Thorax and Lungs Assessment 139
Chapter 17 Heart and Neck Vessels Assessment 148
Chapter 18 Peripheral Vascular with Lymphatics Assessment 157
Chapter 19 Breast and Axillae Assessment 166
Chapter 20 Abdominal Assessment 175
Chapter 21 Musculoskeletal Assessment 184
Chapter 22 Neurological and Mental Status Assessment 193
Chapter 23 Male Genitalia and Rectum Assessment 202
Chapter 24 Female Genitalia and Rectum Assessment 211
Chapter 25 Pregnancy 219
Chapter 26 Newborns and Infants 228
Chapter 27 Children and Adolescents 236
Chapter 28 Older Adults 245
Chapter 29 Assessment of the Hospitalized Adult 255
Chapter 30 Head-to-Toe Assessment of Adult 265
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
Chapter 01: The Nurse's Role in Health Assessment
1. What is one of the broad goals within nursing?
A. To provide cost effective care
B. To form broad nursing diagnoses
C. To promote self-care
D. To treat human responses
ANS: D
Feedback: Four broad goals are within nursing: (1) to promote health (state of optimal
functioning or well-being with physical, social, and mental components); (2) to prevent
illness; (3) to treat human responses to health or illness; and (4) to advocate for
individuals, families, communities, and populations. The other options listed are not
broad goals. Nursing, focuses on promoting health; while cost-effective care is strived
for, is not a part of the broad goal, therefore, this is not a broad goal within nursing.
Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is
important, but does not correctly answer the question.
PTS: 1 REF: p. 4 OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Caring BLM: Cognitive Level: Remember
NOT: Multiple Choice
2. What do nursing activities that promote health and prevent disease accomplish? (Select
all that apply.)
A. Reduce the risk of disease
B. Maintain optimal functioning
C. Reinforce good habits
D. Optimize self-care abilities
E. Create home care safety
ANS: A, B, C
Feedback: Nursing activities that promote health and prevent illness reduce the risk of
disease, reinforce good habits, and maintain optimal functioning. They do not optimize
self-care abilities or create home care safety.
PTS: 1 REF: p. 4 OBJ: 1
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze NOT: Multiple Select
3. The purpose of a health assessment includes what? (Select all that apply.)
A. Identifying the client's major disease process
B. Collecting information about the health status of the client
C. Clarifying the client's ability to pay for health care
D. Evaluating client outcomes
E. Synthesizing collected data
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
ANS: B, D, E
Feedback: Health assessment is "gathering information about the health status of the
client, analyzing and synthesizing those data, making judgments about nursing
interventions based on the findings and evaluating client care outcomes" (AACN, 2008).
While the nurse may elicit financial information and information about disease processes
during a health assessment, the purposes of the activity are not to identify the client's
major disease process or ability to pay.
PTS: 1 REF: p. 6 OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Select
4. The nurse is conducting a physical assessment. The data the nurse would collect vary
depending on what?
A. How much time the nurse has
B. The seriousness of a client's condition
C. The client's cooperation
D. Onset of current symptoms
ANS: B
Feedback: Data that nurses collect during a physical assessment vary depending on a
client's acuity (condition), health history, and current symptoms. The data collected
during a physical assessment do not depend on how much time the nurse has, how
cooperative the client is, or the onset of the current symptoms.
PTS: 1 REF: p. 7 OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
5. A nursing instructor is discussing the purposes of health assessment. What is one
purpose of health assessment?
A. To establish a database against which subsequent assessments can be measured
B. To establish rapport with the client and family
C. To gather information for specialists to whom the client might be referred
D. To quantify the degree of pain a client may be experiencing
ANS: A
Feedback: A health assessment is performed to gain further insight into the current
condition and to establish a database that subsequent assessments can be measured
against.
PTS: 1 REF: p. 7 OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
6. How do nurses facilitate the achievement of high-level wellness with a client?
A. Encouraging the client to keep appointments
B. Providing the client information on alternative treatments
C. Promoting health in the client
D. Providing good client care
ANS: C
Feedback: High-level wellness is a process by which people maintain balance and
direction in the most favorable environment. The role of nurses is to facilitate this
achievement through health promotion and teaching. Nurses do not facilitate the
achievement of high-level wellness by encouraging clients to keep appointments,
providing information on alternative treatments, or providing "good" client care.
PTS: 1 REF: p. 6 OBJ: 3
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Caring BLM: Cognitive Level: Understand
NOT: Multiple Choice
7. The nurse is caring for a client who, on the continuum between wellness and illness, is
moving toward illness and premature death. How would the nurse know this to be true?
A. The client stops doing wellness-promoting activities
B. The client develops signs and symptoms
C. The client begins exercising
D. The client verbalizes anxiety over the cost of medications
ANS: B
Feedback: The person who moves toward illness and premature death develops signs,
symptoms, and disability, which, unfortunately, is when most treatment occurs in the
current health care system. The client may stop doing wellness-promoting activities and
not tell the nurse of this fact, which makes "The client stops doing wellness-promoting
activities" incorrect. "The client begins exercising" is incorrect because a client who
begins exercising is moving toward wellness, not illness. "The client verbalizes anxiety
over the cost of medications" is incorrect because the verbalization of anxiety over
financial matters is not an indication of illness.
PTS: 1 REF: p. 6 OBJ: 3
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Caring BLM: Cognitive Level: Understand
NOT: Multiple Choice
8. A nurse is writing a care plan for a newly admitted client. When formulating the
diagnostic statements in the care plan, what would the nurse use?
A. Rationale
B. American Nurses Association recommendations
C. Physical assessment skills
D. Diagnostic reasoning
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
ANS: D
Feedback: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic
statements. Rationale, ANA recommendations, and physical assessment skills are not
part of formulating diagnostic statements. Rationale supports the nursing interventions of
the nursing care plan. The American Nurses Association does not have recommendations
regarding formulation of diagnostic statements for the care plan. Physical assessment
skills are important in the assessment step of the nursing process, not the formulation of
the diagnostic statements.
PTS: 1 REF: p. 16 OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Apply NOT: Multiple Choice
9. A nurse is caring for three clients whose care involves complex situations and multiple
responsibilities. What is the key to resolving problems for this nurse?
A. Diagnostic reasoning
B. Physical assessment
C. Critical thinking
D. Nursing care plan
ANS: C
Feedback: Nurses are frequently involved in complex situations with multiple
responsibilities. They are required to think through the analysis, develop alternatives,
and implement the best interventions. Critical thinking is the key to resolving problems.
Diagnostic reasoning is important in developing diagnostic statements, not in caring for
multiple clients with complex care needs. Physical assessment is important in the
building the foundation of the nursing care plan. The nursing care plan directs the care
that will be provided for the individual client, but does not address the needs of caring
for multiple clients.
PTS: 1 REF: p. 8-9 OBJ: 4
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
10. A community health nurse is planning individualized care for a community. What does
the nurse use as a framework for this plan?
A. Nursing process
B. Diagnostic reasoning
C. Critical thinking
D. Community care map
ANS: A
Feedback: The nursing process serves as a framework for providing individualized care
not only to individuals but also to families and communities. Diagnostic reasoning,
critical thinking, and community care maps are not frameworks for providing
individualized care to a community.
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
PTS: 1 REF: p. 7 OBJ: 4
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Analyze NOT: Multiple Choice
11. What are the types of nursing assessments? (Select all that apply.)
A. Physical
B. Focused
C. Mental
D. Emergency
E. Comprehensive
ANS: B, D, E
Feedback: Three types of nursing assessments are common: emergency, focused, and
comprehensive. Physical and mental assessments are areas addressed in the various types
of nursing assessments.
PTS: 1 REF: p. 9 OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Remember NOT: Multiple Select
12. A nurse performs a comprehensive assessment on a client. Which is included only in a
comprehensive assessment?
A. Circulatory assessment
B. Assessment of the airway
C. Complete health history
D. Disability assessment
ANS: C
Feedback: The comprehensive assessment includes a complete health history and
physical assessment. It is done annually on an outpatient basis, following admission to a
hospital or long-term care facility, or as defined in a facility's standards of care in the
acute care setting. Circulatory assessment, assessment of the airway, and disability
assessment are part of an emergency assessment.
PTS: 1 REF: p. 10 OBJ: 6
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
13. The nurse is admitting a client to the clinic and performs a focused assessment. What
makes a focused assessment different from a comprehensive assessment?
A. A focused assessment covers the body head to toe, unlike a comprehensive
assessment
B. A focused assessment occurs only in the clinic area, unlike a comprehensive
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
assessment
C. A focused assessment involves all body systems, unlike a comprehensive
assessment
D. A focused assessment is more in-depth on specific issues, unlike a comprehensive
assessment
ANS: D
Feedback: A focused assessment is based on the client's issues. This type of assessment
can occur in all settings, including the clinic, hospital, and home health. It usually
involves one or two body systems and is smaller in scope than the comprehensive
assessment but is more in-depth on the specific issue(s). The comprehensive assessment
includes a head-to-toe evaluation.
PTS: 1 REF: p. 10 OBJ: 5
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
14. A nurse is admitting a client, having completed the health history, and is now doing a
physical assessment. The physical assessment will provide what type of data?
A. Patient centered
B. Subjective
C. Unconfirmed
D. Objective
ANS: D
Feedback: The physical assessment follows the history and focused interview and
includes objective data, which are measurable. Subjective data are gathered during the
health history and generally provided by the client. All data collected regardless of
method should be client centered. Unconfirmed data is common and will be evaluated
through diagnostic studies regardless of how it was obtained.
PTS: 1 REF: p. 13 OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Remember NOT: Multiple Choice
15. The nurse is performing a health assessment on a new client. While taking the detailed
history, the nurse knows to include what?
A. Functional status
B. Data focusing on the client complaint
C. A focused assessment of the client complaint
D. Family history for the past three generations
ANS: A
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
Feedback: A detailed history includes data on all systems, psychosocial and mental
health, and functional status. Data must be included information other than the client
complaint. Family histories generally go back only to grandparents, not
great-grandparents.
PTS: 1 REF: p. 12 OBJ: 6
NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
16. What does the Health Insurance Portability and Accountability Act (HIPAA, 1996)
regulate?
A. Who will provide client care
B. Privacy of information
C. How insurance information is obtained
D. Where a chart can be stored
ANS: B
Feedback: HIPAA regulates the security and privacy of information. It does not regulate
who will provide client care, how insurance information is obtained, or where a chart is
stored.
PTS: 1 REF: p. 13 OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Communication and Documentation
BLM: Cognitive Level: Remember NOT: Multiple Choice
17. The nursing instructor is teaching about health assessment and explains to students how
to assess the roles and relationships of the client. The students know that this type of
information is assessed in what type of assessment?
A. Body systems
B. Head to toe
C. Functional
D. Focused
ANS: C
Feedback: A functional assessment focuses on the patterns that all humans share: health
perception and health management, activity and exercise, nutrition and metabolism,
elimination, sleep and rest, cognition and perception, self-perception and self-concept,
roles and relationships, coping and stress tolerance, sexuality and reproduction, and
values and beliefs (Gordon, 1987). The body systems, the focused nor the head to toe
assessment addresses the holistic needs of the client. The roles and relationships of the
client would not be included in these assessment
PTS: 1 REF: p. 13 OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
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Test Bank - Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition (Jensen, 2023)
BLM: Cognitive Level: Apply NOT: Multiple Choice
18. A clinical instructor is teaching a nursing student group about organizing data when
documenting and communicating assessment findings. The clinical instructor knows that
the method being taught promotes critical thinking and clustering of similar data. The
instructor is teaching about which type of assessment?
A. Body systems
B. Comprehensive
C. Head to toe
D. Emergency
ANS: A
Feedback: A body systems approach is a logical tool for organizing data when
documenting and communicating findings. This method promotes critical thinking and
allows nurses to analyze findings as they cluster similar data. The comprehensive
assessment is more encompassing in nature, including more aspects that the body
systems approach. The head-to-toe assessment does not look at promoting critical
thinking and clustering, rather going through a process to organize data in a logical
fashion. The emergency assessment involves a life-threatening or unstable situation
PTS: 1 REF: p. 15 OBJ: 7
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
19. The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse
knows that an efficient assessment framework that provides additional modesty for the
client is what?
A. Body systems
B. Functional
C. Focused
D. Head to toe
ANS: D
Feedback: The head-to-toe method is efficient and provides more modesty for clients.
The body systems and functional assessment does not address the modesty issue in the
question. The focused assessment is not appropriate for the newly admitted client.
PTS: 1 REF: p. 14 OBJ: 7
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 1: The Nurse's Role in Health Assessment
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
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