Chapter - 004 Health Assessment

Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 4: Health Assessment
MULTIPLE CHOICE
1. When the nurse records a client’s response in the the computerized health history
program, the program branches to a subset of questions. The nurse is
a. reminded to inquire further into this health area.
b. distressed that he has omitted necessary information.
c. delayed because he must go back to an earlier aspect of the interview.
d. annoyed in that subset questions are generic and time-consuming.
ANS: a
Branching programs are initiated when a patient response indicates a need for additional
information. The branching aspect of the program reminds the nurse about significant questions
that can be asked to obtain a complete picture.
DIF: Cognitive Level: Application REF: Text Reference: 68

TOP: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse records the client’s information regarding address and location of major
residence to include data that is
a. biographical.
b. demographic.
c. traceable.
d. changeable.
ANS: b
Demographics can be referenced as to health risks; for example, persons living in certain areas
are at risk for environmentally aggravated health problems.

3. When the nurse is obtaining a noncomputerized health history from a fatigued 74-
year-client, she realizes that the best time to compile the written report is
a. throughout the interview.
b. when the client is more able to review the data.
c. after validation with the health care provider.
d. at the conclusion of the interview.
ANS: d
Elsevier items and derived items 2005 by Elsevier Inc.

Chapter 4: Health Assessment 2
Extensive notetaking is discouraged because it is time-consuming and suggests to the client that
the nurse is not listening. To conserve the client’s energy, the compilation is best left at the
conclusion when the client has gone.

TOP: Nursing Process Step: Intervention
4. Because a client has difficulty focusing on the interview, the nurse administers the
“serial 7” test. This intervention by the nurse provides further data on the client’s
a. articulation.
b. affect.
c. judgment.
d. attention span.
ANS: d
The “serial 7” test asks the client to subtract 7 from 100 and then continue with the subtraction
until the client is unable to do so; it tests the attention span as well as the ability to calculate.

5. The chief complaint of the client is the major factor in limiting the depth of the
interview and may preclude any exhaustive health interview. The major factor that
leads the nurse to determine the depth of the health interview is
a. the age and gender of the client.
b. the reason the client is seeking help.
c. the number of socioeconomic factors present.
d. the client’s attention span.
ANS: b
The chief complaint of the client is the major factor in limiting the depth of the interview and
may preclude any exhaustive health interview.

6. To assess precipitating factors, the nurse interviewer would ask

a. “What were you doing when you first noticed the problem?”
b. “How many times has the problem been related to activity?”
c. “Do you remember the first time you had this problem?”
d. “What measures relieve this problem for you?”
ANS: a

To ask what the client was doing and where he was at the time the manifestation was noticed is
an abbreviated way to obtain information as to cause or environmental precipitators. The other
options are related to timing, aggravating factors, and remedy.

7. Because the psychosocial assessment includes many more personal aspects of the client’s
history, the most significant variable that may affect the quality and usefulness of the collected
data is the
a. reluctance of most clients to share information with health care providers.
b. value the client places on the health interview.
c. nurse’s ability to establish a therapeutic relationship.
d. nurse’s difficulty in differentiating normal from abnormal.
ANS: c
The client must feel comfortable to share some of the information assessed in the psychosocial
portion; therefore the nurse’s ability to establish a therapeutic relationship is the major element in
securing accurate data.
DIF: Cognitive Level: Analysis REF: Text Reference: 71

8. When the nurse asks the client to identify the usual ways of dealing with stress, the
collected data is used to
a. standardize the responses to other questions.
b. assess the adequacy of the reported style.
c. determine if the client is a substance abuser.
d. correct the maladaptive style.
ANS: b
The question is designed to evaluate the adequacy and the variation of coping styles.
DIF: Cognitive Level: Comprehension REF: Text Reference: 73, Box 4-3;
9. In the preparation of a nursing care plan relative to the client’s mental status, the least
helpful data would be those resulting from
a. formal psychological tests.
b. notation of appropriateness of affect.
c. observation of nonverbal behavior.
d. client’s overall response to the interview.
ANS: a

Mental status assessment consists of evaluation of verbal and nonverbal responses to the
individualized questions, as well as evalutation of mood and affect. Psychological tests cannot
measure these factors.

10. The nurse observes and describes the outward demeanor of a client to evaluate
a. affect.
b. thought processes.
c. judgment.
d. socialization.
ANS: a
Affect is the outward demeanor of a client that reflects an emotional tone.
DIF: Cognitive Level: Comprehension REF: Text Reference: 74

11. To evaluate a client’s remote memory, the nurse would ask

a. “What did you have to eat for breakfast yesterday?”
b. “Who is the president of the United States?”
c. “Where did you live as a child?”
d. “What is the day of the week?”
ANS: c
Having a client recall childhood memories tests for remote memory.

12. Assessing the client’s internal resources for stress adaptation, the nurse can use the
client’s
a. family support system.
b. economic stability.
c. nutritional status.
d. professional choice.
ANS: c
Internal resources are physiological and psychological attributes.


13. When a client becomes distressed that her family history of hypertension and
cardiovascular disease may have an effect on her health, the nurse hastens to assure
the client that familial tendencies are
a. easily modified by lifestyle changes.
b. a potential problem that can be managed.
c. a reflection of the role of heredity.
d. those over which there can be no remedy.
ANS: b
Awareness of health risk factors may motivate a client to practice preventive measures.

14. The nurse cautions a 37-year-old, white, nulliparous client employed as a firefighter
about clinical manifestations of skin cancer. The type of risk factor addressed by the
nurse is
a. behavioral.
b. racial.
c. occupational.
d. environmental.
ANS: b
The white skin of Caucasians is prone to skin cancers.

15. The client is a pipefitter on an oil freighter, which exposes him to many
environmental respiratory health risks. The nurse counsels this client to
a. consider changing professions.
b. engage in regular aerobic exercise.
c. immediately have a complete pulmonary function assessment.
d. wear a disposable mask during his time on the freighter.
ANS: b
Aerobic exercise for 30 to 40 minutes a day stimulates deep breathing.

16. The nurse who performs a physical examination in the acute care setting is aware
that the major goal of the examination is
a. documentation of the findings in a meaningful manner.
b. differentiation of normal from abnormal findings.

c. relating the findings to structure and function.

d. interpreting the findings for the physician.
ANS: b
The purpose of the physical examination in the acute setting is to differentiate normal from
abnormal findings for the physician’s interpretation.

17. When the nurse places one hand on the client’s skin and applies the other hand over
the first, the nurse is using the examination technique of
a. bimanual palpation.
b. tactile inspection.
c. indirect percussion.
d. therapeutic touch.
ANS: a
The technique of bimanual palpation calls for the examiner to place one hand over the sensing
hand to apply pressure.
DIF: Cognitive Level: Knowledge REF: Text Reference: 83

18. When attempting to auscultate a heart murmur, the nurse should

a. apply KY jelly to the diaphragm to reduce picking up environmental noise.
b. place the diaphragm firmly on the chest wall to obtain a larger surface.
c. lightly place the bell of the stethoscope on the chest wall to hear faint noises.
d. press the bell of the stethoscope over a rib to better conduct sound.
ANS: c
The bell picks up fainter sounds better than the diaphragm. Conduction over a rib is impaired,
and KY jelly only smears the diaphragm.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
19. To assess balance, the nurse performs Romberg’s test and recognizes as a negative
sign the client’s
a. inability to touch the end of his nose with his finger.
b. inability to hold his arms at shoulder level without pronation.
c. ability to stand rigidly without swaying.
d. tendency to move his head toward his dominant side.
ANS: b

Romberg’s test requires that the client stand with eyes closed without swaying, then extend the
arms out at shoulder level without downward drift or pronation.

20. A client remarks to a nurse doing vital signs screening that his oral temperature of
99° F is his usual temperature unless he is ill. The most appropriate assessment the
nurse should make is that the client
a. is denying the significance of the clinical manifestations.
b. has a temperature within normal limits.
c. probably has a low-grade infection.
d. should be reevaluated with a rectal thermometer.
ANS: b
The oral temperature of 99° F is within normal limits.

21. The nurse records the pulse amplitude as “bounding.” This classification connotes
that the pulse is
a. indiscernible to palpation.
b. difficult to palpate and easily obliterated by pressure.
c. easily palpable and obliterated only with strong pressure.
d. easily palpable and not easily obliterated by pressure.
ANS: d
The bounding pulse is easily palpable and not easily obliterated by pressure.
DIF: Cognitive Level: Knowledge REF: Text Reference: 90, Box 4-7;
22. The nurse assesses that compared with an earlier reading, the recently taken blood
pressure of 154/95 shows an increased pulse pressure. The pulse pressure is
a. 200 mm Hg.
b. 134 mm Hg.
c. 76 mm Hg.
d. 59 mm Hg.
ANS: d
The pulse pressure is the difference between the systolic reading and the diastolic reading.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

23. The blood pressure that would prompt the industrial nurse to encourage the 35-year-
old client to seek treatment for hypertension would be
a. 120/80.
b. 132/85.
c. 138/92.
d. 140/80.
ANS: c
The signal for intervention is a systolic pressure above 140 with a corresponding diastolic
pressure of 90 or greater. An elevated systolic with a normal diastolic pressure may be the result
of tension or exercise.

24. The nurse records a that the client has a “thready pulse," which means that the pulse
is
a. difficult to palpate and easily to obliterate.
b. easily palpated and obliterated only with strong pressure.
c. slow but easily palpable.
d. weak but easily palpable.
ANS: a
The thready pulse is difficult to palpate and easy to obliterate.
DIF: Cognitive Level: Comprehension REF: Text Reference: 90, Box 4-7;
25. A client has an order for a particular diagnostic test. An independent nursing action
in regard to this test is
a. sedating the client before the diagnostic study.
b. interpreting the results of a diagnostic study to the client.
c. teaching the client what to expect during the diagnostic study.
d. suggesting a more appropriate preparation for the test.
ANS: c
The independent nursing action relative to diagnostic studies are client preparation, collection
and transportation of the specimen, monitoring of the client, and client teaching.

26. After a barium swallow for the assessment of a duodenal ulcer, the nurse encourages
the client to drink plenty of fluids and eat a high-fiber diet to prevent
a. perforated ulcer.
b. nausea and vomiting.
c. barium impaction.

d. abdominal pain.
ANS: c
Because barium may cause severe constipation and a possible impaction, the client should drink
extra fluid and eat a fiber-filled diet.

27. Because a female client is scheduled for magnetic resonance imaging (MRI)
tomorrow, the nurse should inquire
a. “Do you have claustrophobia?”
b. “Are you allergic to shrimp or iodine?”
c. “Have you had a bowel movement today?”
d. “Have you had alcohol or caffeine today.”
ANS: a
The MRI tunnel is very narrow and filled with sound. The nurse should prepare the client with
claustrophobia for this environment, as well as have a technician immediately available during
the procedure.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity
28. The nursing priority for a client who has had cerebral angiography through the
femoral artery is
a. assessment of blood pressure.
b. need for pain medication.
c. presence of bowel sounds.
d. confirming pedal pulses.
ANS: d
The dye injected in the femoral may cause local swelling and obstruction of the femoral artery.

29. The nurse assesses that a client having ultrasonography of the uterus has an
understanding of the preprocedure instruction when the client states
a. “I need to avoid having a bowel movement to give a contrast.”
b. “I won’t drink or eat anything after midnight to slightly dehydrate myself.”
c. “I will drink plenty of fluids to ensure that the bladder is full.”
d. “I need to stop all medication for 24 hours before the test.”
ANS: c
The bladder must be very full in order for the uterus to be viewed on ultrasonography.

30. The nurse collecting a serial port sample will stop the intravenous (IV) line, collect a
10-cc specimen, and then
a. discard it and collect another specimen in another syringe.
b. flush the line with saline and adjust the IV line to its previous rate.
c. return the stopcock to its original position and reset the IV line.
d. inject 5 cc of heparin flush and adjust the IV line.
ANS: a
The procedure follows: stop the IV flow, change the position of the stopcock or select the correct
lumen, withdraw 10 cc of blood, discard, withdraw another specimen of 10 to 20 cc, flush the
line with saline and heparin, and return the stopcock to the original position.


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Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, 7th Edition

Chapter 4: Health Assessment

DIF: Cognitive Level: Application REF: Text Reference: 68

DIF: Cognitive Level: Application REF: Text Reference: 70

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 69

DIF: Cognitive Level: Application REF: Text Reference: 74

DIF: Cognitive Level: Application REF: Text Reference: 70

6. To assess precipitating factors, the nurse interviewer would ask

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 70

DIF: Cognitive Level: Analysis REF: Text Reference: 71

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 73

DIF: Cognitive Level: Comprehension REF: Text Reference: 74

11. To evaluate a client’s remote memory, the nurse would ask

DIF: Cognitive Level: Comprehension REF: Text Reference: 74

DIF: Cognitive Level: Comprehension REF: Text Reference: 75

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Comprehension REF: Text Reference: 77

DIF: Cognitive Level: Analysis REF: Text Reference: 77

DIF: Cognitive Level: Comprehension REF: Text Reference: 77

Elsevier items and derived items 2005 by Elsevier Inc.

c. relating the findings to structure and function.

DIF: Cognitive Level: Comprehension REF: Text Reference: 80

DIF: Cognitive Level: Knowledge REF: Text Reference: 83

18. When attempting to auscultate a heart murmur, the nurse should

DIF: Cognitive Level: Analysis REF: Text Reference: 84

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 89

DIF: Cognitive Level: Comprehension REF: Text Reference: 90

DIF: Cognitive Level: Application REF: Text Reference: 91

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Analysis REF: Text Reference: 91

DIF: Cognitive Level: Application REF: Text Reference: 92

Elsevier items and derived items 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 100

DIF: Cognitive Level: Application REF: Text Reference: 102

DIF: Cognitive Level: Analysis REF: Text Reference: 103

DIF: Cognitive Level: Comprehension REF: Text Reference: 104

Elsevier items and derived items 2005 by Elsevier Inc.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

DIF: Cognitive Level: Application REF: Text Reference: 97

Elsevier items and derived items 2005 by Elsevier Inc.

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