DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
15. The nurse working in a clinic in a primarily black community notes a higher incidence of
uncontrolled hypertension in the patients. To address this health disparity and promote health
equity, which action would the nurse take first?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.
ANS: C
Before other actions are taken, additional assessment data are needed to determine the reason
for the disparity. The other actions also may be appropriate, but additional assessment is
needed before the next action is selected.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is performing an admission assessment for a patient from China who does not speak
English. Which actions by the nurse would enhance communication? (Select all that apply.)
a. Ask the patient‘s young child to interpret.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Use exaggerated gestures to convey information.
e. Use an electronic translation software application.
ANS: B, C, E
Electronic translation applications, telephone-based interpreters, and agency interpreters are
all appropriate to use to communicate with non–English-speaking patients. When no
interpreter is available, family members may be considered, but some information that will be
needed in an admission assessment may be misunderstood or not shared if a child is used as
the interpreter. Gestures are appropriate to use for some information, but exaggeration of the
gestures is not needed.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
Chapter 03: Health History and Physical Examination
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. A patient who is actively bleeding is admitted to the emergency department. Which approach
would the nurse use to obtain an accurate health history?
a. Briefly interview the patient while obtaining vital signs.
b. Obtain subjective data about the patient from family members.
c. Omit subjective data collection and obtain the physical examination.
d. Use the health care provider‘s medical history to obtain subjective data.
ANS: A
In an emergency situation, the nurse may need to ask only the most pertinent questions for a
specific problem and obtain more information later. A complete health history will include
subjective information that is not available in the health care provider‘s medical history.
Family members may be able to provide some data, but only the patient will be able to give
subjective information about the bleeding. Because the subjective data about the cause of the
patient‘s bleeding will be essential, obtaining the physical examination alone will not provide
sufficient information.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
2. Immediate surgery is planned for a patient with acute abdominal pain. Which question by the
nurse will elicit direct information about the patient‘s coping–stress tolerance pattern?
a. ―Can you rate your pain on a 0 to 10 scale?‖
b. ―What do you think caused this abdominal pain?‖
c. ―Are there other problems or concerns right now?‖
d. ―How do you feel about yourself and being hospitalized?‖
ANS: C
The coping–stress tolerance pattern includes information about other major stressors
confronting the patient. The health perception–health management pattern includes
information about the patient‘s ideas about risk factors. Feelings about self and the
hospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain is
part of the cognitive–perceptual pattern.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
3. During the health history interview, a patient tells the nurse about periodic fainting spells.
Which question would the nurse ask to elicit any associated clinical manifestations?
a. ―How frequently do you have the fainting spells?‖
b. ―Do the spells occur at any particular time of day?‖
c. ―Where are you when you have the fainting spells?‖
d. ―Do you have other symptoms along with the spells?‖
ANS: D
Asking about other associated symptoms will provide the nurse more information about all the
clinical manifestations related to the fainting spells. Information about the setting is obtained
by asking where the patient was and what the patient was doing when the symptom occurred.
The other questions from the nurse are appropriate for obtaining information about
chronology and frequency.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
4. The nurse records the following general survey: ―The patient is a 50-year-old Asian female
accompanied by her husband and two daughters. Alert and oriented. Does not make eye
contact with the nurse and responds slowly, but appropriately, to questions. No apparent
disabilities or distinguishing features.‖ What additional information should the nurse add to
this general survey?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about the condition
ANS: A
The general survey also describes the patient‘s general nutritional status. The other
information will be obtained when doing the complete nursing history and examination but is
not obtained through the initial scanning of a patient.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
5. A nurse performs a health history and physical examination with a patient who has a right leg
fracture. Which data would be a pertinent negative finding?
a. Patient has several bruised and swollen areas on the right leg.
b. Patient states that there have been no other recent health problems.
c. Patient refuses to bend the right knee because of the associated pain.
d. Patient denies having pain when the area over the fracture is palpated.
ANS: D
The nurse expects that a patient with a leg fracture will have pain over the fractured area. The
bruising and swelling and pain with bending are positive findings. Having no other recent
health problems is neither a positive nor a negative finding with regard to a leg fracture.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
6. The nurse asks an older adult patient with rectal bleeding, ―Have you ever had a
colonoscopy?‖ Which type of assessment is the nurse performing?
a. Focused assessment
b. Emergency assessment
c. Detailed health assessment
d. Comprehensive assessment
ANS: A
A focused assessment is an abbreviated assessment used to evaluate the status of previously
identified problems and monitor for signs of new problems. It can be done when a specific
problem is identified. An emergency assessment is done when the nurse needs to obtain
information about life-threatening problems quickly while simultaneously taking action to
maintain vital function. A comprehensive assessment includes a detailed health history and
physical examination of one body system or many body systems. It is typically done on
admission to the hospital or onset of care in a primary care setting.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is preparing to perform a focused assessment for a patient reporting shortness of
breath. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used to auscultate breath sounds. The other equipment may be used for a
comprehensive assessment but will not be needed for a focused respiratory assessment.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
8. Which adaptation to the physical examination technique would the nurse include for an alert
older adult patient?
a. Avoid the use of touch as much as possible.
b. Use slightly more pressure for palpation of the liver.
c. Organize the sequence to minimize position changes.
d. Speak softly and slowly when talking with the patient.
ANS: C
Older patients may have age-related changes in mobility that make it more difficult to change
position. There is no need to avoid the use of touch when examining older patients. Less
pressure should be used over the liver. Because the patient is alert, there is no indication that
there is any age-related difficulty in understanding directions from the nurse.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
9. While the nurse is taking the health history, a patient states, ―My mother and sister both had
double mastectomies and were unable to exercise for weeks.‖ Which functional health pattern
is represented by this patient‘s statement?
a. Activity–exercise
b. Cognitive–perceptual
c. Coping–stress tolerance
d. Health perception–health management
ANS: D
The information in the patient statement relates to risk factors and important information
about the family history. Identification of risk factors falls into the health perception–health
maintenance pattern.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
10. A patient has arrived at the hospital with severe abdominal pain and hypotension. Which type
of assessment would the nurse do at this time?
a. Focused assessment
b. Subjective assessment
c. Emergency assessment
d. Comprehensive assessment
ANS: C
Because the patient is hemodynamically unstable, an emergency assessment is needed.
Comprehensive and focused assessments may be needed after the patient is stabilized.
Subjective information is needed, but objective data such as vital signs are essential for the
unstable patient.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
11. The registered nurse (RN) cares for a patient who was admitted a few hours previously with
back pain after a fall. Which action can the RN delegate to assistive personnel (AP)?
a. Determine the patient‘s priority problems.
b. Finish documenting the admission assessment.
c. Obtain the health history from the patient‘s caregiver.
d. Take the patient‘s temperature, pulse, and blood pressure.
ANS: D
The RN may delegate vital signs to the AP. Obtaining the health history, documenting the
admission assessment, and determining priority problems require the education and scope of
practice of the RN.
DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
12. Which action would the nurse take first to assess for a possible blood clot in a patient‘s lower
leg?
a. Visually inspect the leg.
b. Feel the leg temperature.
c. Check the patient‘s pedal pulses using the fingertips.
d. Compress the nail beds to determine capillary refill time.
ANS: A
Inspection is the first of the major techniques used in the physical examination. Palpation and
auscultation are then used later in the examination.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance
13. Which physical assessment action should the nurse take after inspecting a patient‘s abdomen?
a. Feel for any masses.
b. Palpate the abdomen.
c. Listen for bowel sounds.
d. Percuss the liver borders.
ANS: C
When assessing the abdomen, auscultation is done before palpation or percussion because
palpation and percussion can cause changes in bowel sounds and alter the findings. All of the
techniques are appropriate, but auscultation should be done first.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance