Health Assessment - Exam 1
A patient complains of a cough for 4 days unrelieved with position changes. The nurse
interprets this as a symptom and documents the finding under ____________on the
patient's chart.
A. The nursing care plan
B. Assessment
C. History
D. Vital signs - ✔️✔️C. History
A symptom is something described by the patient and considered subjective; therefore it
would be documented under "History."
The nurse is administering an influenza (flu) shot to a patient in a retail health setting. Of
which level of prevention is this an example?
A. Primary
B. Secondary
C. Post secondary
D. Tertiary - ✔️✔️A. Primary Prevention
Vaccinations protect from disease and are considered primary prevention.
The nurse is documenting the findings from the health assessment. Which example of
data documentation reflects the opinion of the nurse?
A. The patient is uncooperative and unfriendly.
B. The patient avoids eye contact.
C. The patient states, "I do not want to get out of bed."
D. The patient states, "I am very angry." - ✔️✔️A. The patient is uncooperative and
unfriendly
Nurses must record data accurately, concisely, and without bias or opinion. In this
example, the nurse is offering an opinion, which may contain bias.
A patient is admitted to the medical-surgical unit with a diagnosis of hypertension. The
nurse is using the nursing process to develop the plan of care. Which steps should the
nurse incorporate?
A. Assessment, treatment, planning, evaluation, discharge, follow-up
B. Admission, assessment, diagnosis, treatment, discharge planning
C. Admission, diagnosis, treatment, evaluation, discharge planning
,D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation
- ✔️✔️D. Assessment, diagnosis, outcome identification, planning, implementation,
evaluation
The nursing process is a method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation. The nurse
must analyze and interpret these data before initiating a plan of care.
The nurse is incorporating the principles of the quality and safety competencies from the
Institute of Medicine (IOM) recommendations into the health assessment of a patient in
the long-term care setting. What principles should the nurse consider? Select all that
apply:
A. Use evidence to support interventions.
B. Evaluate the plan of care.
C. Use a step-by-step approach to problem solving.
D. Use technologies and informatics in delivering care.
E. Place the patient at the center of care.
F. Include other disciplines in the plan of care. - ✔️✔️A, D, E, F
Use Evidence to support interventions
Use technologies and informatics in delivering care
Place the patient at the center of care
Include other disciplines in care
The Institute of Medicine identified five core competencies as essential for health care
professionals to demonstrate how to respond effectively to patient care needs: provide
patient-centered care, work in interdisciplinary teams, use evidence-based practice,
apply quality improvements, and use informatics.
The student nurse is preparing to assess a patient in the hospital clinical setting. Which
components best describe the concept of health assessment? Select all that apply:
A. Collection of objective data
B. Collection of subjective data
C. Collection of data and identification of nursing diagnosis
D. Planning and evaluation of data
E. Analysis of data
F. Physical exam
G. Documentation of data - ✔️✔️A, B, F, G
Collection of objective data
Collection of subjective data
Physical exam
Documentation of Data
, Components of health assessment include conducting a health history (the collection of
subjective data), performing a physical examination (the collection of objective data),
and documenting the findings.
The nurse is assessing a patient for the first time in the outpatient diabetic clinic. A
____________ type of health assessment would be most appropriate for this visit?
A. Focused assessment
B. Episodic follow-up assessment
C. Shift assessment
D. Comprehensive health assessment - ✔️✔️D. Comprehensive health assessment
The type of health assessment performed by the nurse is also driven by patient need. A
comprehensive health assessment involves a detailed history and physical examination
performed at the onset of care in a primary care setting or upon admission to a hospital
or long-term care facility.
A patient tells the nurse that he has had a headache and nausea for 3 days. Which type
of assessment should the nurse perform?
A. Focused assessment
B. Episodic follow-up assessment
C. Shift assessment
D. Comprehensive health assessment - ✔️✔️A. focused assessment
The type of health assessment performed by the nurse is also driven by patient need. A
focused assessment involves a history and examination that are limited to a specific
problem or complaint.
The nurse is conducting a data analysis on objective information obtained during the
health history. What should be included? Select all that apply
A. Vital signs
B. Pain assessment
C. Review of symptoms
D. Surgical history
E. Social history
F. Heart murmur - ✔️✔️A. Vital signs
F. Heart murmur
Pain assessment, review of symptoms, surgical history, and social history are
considered subjective data.
