Test Bank For Nursing Health Assessment A Clinical Judgment Approach 4th
Edition by SHARON JENSEN
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,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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, 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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, 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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