Test Bank For Health Assessment in Nursing, 5th Edition

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Page 11.Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weightloss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose levelmeasured by finger stick of 348 mg/dL. Which of the following nursing diagnoseswould be the nurse's priority?A)Risk for imbalanced fluid volume related to inadequate oral intake and frequenturinationB)Imbalanced nutrition: more than body requirements related to diabetesC)Potential complication: hypertensionD)Powerlessness related to diabetes self-care and management2.The nurse's assessment reveals that a client is in a low percentile for midarm musclecircumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness.Which of the following would be appropriate?A)Teaching the client muscle-building exercisesB)Discussing ways to increase body fat storesC)Assisting client in reducing the amount of fluid build-upD)Encouraging the use of a multivitamin supplement3.An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines thatthe client's body mass index is which of the following?A)12B)18C)25D)284.A client weighs 106 pounds and is 5 feet 5 inches tall. As a result, her ideal body weightis 120 pounds. After determining the client's percentage of ideal body weight, which ofthe following should the nurse conclude?A)Client is mildly malnourished.B)Client is experiencing moderate malnutrition.C)Severe malnutrition is present.D)The client's body weight is within 10% of ideal body weight.5.A nurse is reviewing the laboratory test results of an adult client who has numerouschronic health challenges. Which assessment result would alert the nurse to potentialmalnutrition?A)Hemoglobin of 13.1 g/dLB)Hematocrit of 40%C)Serum albumin of 2.6 g/dLD)Total protein of 7 g/dL

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Page 26.The nurse should prioritize assessments related to overhydration for a clientexperiencing which of the following health problems?A)Early congestive heart failureB)Chronic emphysemaC)Newly diagnosed hepatitis C virus infectionD)Adult respiratory distress syndrome7.The nurse is assessing a client who has been admitted with signs and symptoms that areconsistent with malnutrition. Which of the following physiological phenomena wouldthe nurse recognize as an early indicator of malnutrition?A)Protein stores are lower than normalB)Bone is metabolized to compensate for missing nutrientsC)Calcium levels decreaseD)Hemoglobin levels decrease8.A client is receiving an intradermal injection to evaluate general immunity during anutritional assessment. Which of the following conclusions is suggested if the client hasno reaction?A)It indicates high cholesterol and triglyceride levels.B)It shows a sacrifice of skeletal muscle proteins and blood proteins.C)It is indicative of unhealthy dietary habits.D)It may be immunosuppression resulting from undernourishment.9.The nurse is preparing to perform a nutritional assessment of a newly admitted client.Which of the following questions would be most appropriate to use when initiating theassessment?A)ìDid you eat breakfast today?îB)ìHow many meals do you eat each day?îC)ìCan you tell me what you've eaten in the last 24 hours?îD)ìHow often do you eat out?î10.A nurse is assessing a client's skeletal muscle mass in the context of a comprehensivenutritional assessment. Which measurement would yield the most valid and reliabledata?A)Body mass indexB)Triceps skin fold measurementC)Mid-arm circumferenceD)Waist circumference

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Page 311.When evaluating nutrition in an adult female client, which laboratory value would mostconcern the nurse?A)Hemoglobin A1c of 9%B)Serum albumin of 4.9 g/dLC)Total protein of 6.7 g/dLD)Hematocrit of 39%12.A nurse weighs a client today and finds that the client's weight has increased 2.2 lbsfrom the previous day. The nurse interprets this finding as suggesting a fluid gain ofwhich amount?A)0.5 litersB)1.0 litersC)1.5 litersD)2.0 liters13.The nurse analyzes the data obtained from a client's nutritional assessment and developsa health promotion diagnosis related to nutrition for a client. Which of the followingwould be the best example?A)Health-seeking behaviors related to desire and request to alter amount of foodintakeB)Imbalanced nutrition: less than body requirements related to inadequate caloricintakeC)Imbalanced nutrition: more than body requirements related to excessive caloricintakeD)Ineffective thermoregulation related to decreased adaptability to cold secondary todecreased subcutaneous tissue14.The nurse is collecting data from a client about his nutrition. Which of the followingwould the nurse document as objective data?A)Client states he is not eating well.B)Client complains of nausea and vomiting.C)Clients experiences urinary frequency.D)Tenting of client's skin observed upon skin pinch.15.A nurse in the intensive care unit is calculating an acutely ill client's 24-hour fluidbalance. The nurse should include insensible fluid losses of what volume whenperforming this assessment?A)100 to 300 mLB)450 to 650 mLC)800 to 1000 mLD)1200 to 1400 mL

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Page 416.A nurse is assessing a client for possible fluid overload. Which of the followingassessment findings is most consistent with this diagnosis?A)Venous filling of 3 secondsB)Distended neck veins with head elevated at 45 degreesC)Moist, plump tongueD)Boggy eyeball17.During a nutritional assessment, the client asks the nurse for suggestions to improve herdiet. The nurse identifies a nursing diagnosis of health-seeking behaviors related todesire to improve diet. Which of the following suggestions would be most appropriate?A)ìThe majority of your diet should consist of whole grains.îB)ìChoose low-fat versions of milk products such as yogurt.îC)ìDrink at least 2 to 3 glasses of fruit juices a day.îD)ìEat fewer orange vegetables and more dark green vegetables daily.î18.A group of students is reviewing information about general assessment indicators ofnutritional status. The students demonstrate a need for additional review when theyidentify which of the following as an indicator of adequate nutritional status?A)Flat, firm abdomenB)Brittle hairC)Pink mucous membranesD)Elastic skin19.When obtaining the nutritional health history from a female client, which of the nurse'squestions would best elicit information about the client's knowledge of her own healthstatus?A)ìAre you now or have you been on a diet recently?îB)ìHow much fluid do you drink in a day?îC)ìWhat are your height and usual weight?îD)ìCan you tell me what you consider to be a healthy meal?î20.The nurse needs to obtain the height of a client who is unable to stand. Which of thefollowing would the nurse do?A)Estimate the height while the client is lying in bed.B)Measure the distance from the top of the client's head to his ankles.C)Measure from client's arm span using one of his arms outstretched.D)Extend a ruler from the forehead to the tip of the client's toes.

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Page 521.An older adult client has presented to the emergency department with signs andsymptoms of dehydration. When assessing the client for risk factors that may havecontributed to this condition, what question should the nurse prioritize?A)ìDo you use any over-the-counter dietary supplements?îB)ìAre you familiar with the USDA's MyPlate recommendations?îC)ìHave you ever been diagnosed with heart disease?îD)ìAre you currently taking any diuretic medications?î22.An older adult client has a body mass index of 15.5 and is consequently considered tobe underweight. The client lives alone and states that she has ìnever been a heavy eater.îHow can the nurse most accurately assess the client's nutritional habits?A)Assess the client's waist circumference and waist-to-hip ratio.B)Measure the client's mid-arm circumference.C)Elicit the client's 24-hour food recall.D)Have the client describe an ìidealî meal.23.During a new client's nutritional assessment, the nurse asks the client's height and usualweight. The client states that he has no idea how much he weighs. How should the nurserespond?A)ìDo you feel like your weight has increased, decreased, or stayed the same lately?îB)ìWhy do you feel that it's not important to monitor your weight?îC)ìIn a typical day, what do you eat and drink?îD)ìHow would you describe your feelings around your body type and body mass?î24.A hospital nurse is performing a nutritional assessment of a 39-year-old obese clientwho has been recently diagnosed with type 2 diabetes. The nurse has completed thecollection of subjective data and is preparing to proceed with objective data collection.Which principle should guide the nurse's subsequent actions?A)There are likely to be inconsistencies between subjective data and objective data.B)The nurse should be aware that the client may find assessment embarrassing.C)The nurse should avoid performing anthropometric measurements due to theclient's obesity.D)The assessment should be performed over a series of brief sessions rather than onecontinuous assessment.

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Page 625.During an initial prenatal visit, the nurse is performing a nutritional assessment of awoman who has just learned that she is pregnant for the first time. The nurse hasdetermined that the client has an average stature and is 5 feet, 3 inches tall. What is thisclient's ideal body weight?A)105 lbs.B)115 lbs.C)125 lbs.D)135 lbs.26.A client's recent complaints of polyuria have prompted a full diagnostic work-up fordiabetes mellitus, including a nutritional assessment. To determine the client's bodymass index (BMI), the nurse must know which of the following assessment parameters?Select all that apply.A)GenderB)AgeC)WeightD)Waist circumferenceE)Height27.The nurse is completing a comprehensive nutritional assessment and has assessed anddocumented the client's triceps skin fold thickness (TSF) using calipers. This assessmentfinding allows the nurse to determine which of the following?A)The client's ratio of muscle to adipose tissueB)The client's body mass indexC)The client's proportion of muscle massD)The amount of the client's subcutaneous fat stores28.A nurse at a long-term care facility is completing the nutrition assessment of a man whohas just moved to the facility. The nurse has lowered the client's arm and observed howlong it takes for venous filling, then raised the same arm and watched how long it takesto empty. After determining that venous filling and emptying each take approximately10 seconds, the nurse should perform further assessments related to what healthproblem?A)Fluid volume deficitB)Third spacingC)AscitesD)Malnutrition

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Page 729.The nurse is providing care for a client with a history of chronic heart failure. The clientis in bed with the head of her bed at 45 degrees, and the nurse is assessing the client'sneck veins. What assessment finding would be most consistent with a nursing diagnosisof fluid volume excess related to chronic heart failure?A)The client's carotid arteries are not palpable.B)The client's jugular veins are clearly visible and firm to palpation.C)The client's carotid pulses are asymmetrical and difficult to palpate.D)The client's carotid pulses are easier to palpate than the jugular pulses.30.An obese teenage boy from a culture that values increased body mass has been referredto the clinic. The nurse is assessing him for malnutrition based on his electronic healthrecord and current health complaints. His mother questions the nurse's rationale, stating,ìAnyone can see he's not malnourished. Just look at the size of him!î How should thenurse best respond?A)ìPeople sometimes become obese because their bodies are storing up nutrients thatthey often lack.îB)ìIt's actually very possible for a person to be overweight but have inadequatenutrition.îC)ìAssessment for malnutrition is a standard component of a larger nutritionalassessment, which is very important for your son's health.îD)ìActually, there's very little relationship between body mass and nutritional state.î

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Page 8Answer Key1.A2.A3.D4.A5.C6.A7.A8.D9.C10.C11.A12.B13.A14.D15.C16.B17.B18.B19.C20.C21.D22.C23.A24.B25.B26.C, E27.D28.A29.B30.B

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Page 11.The nurse is assessing a client's breasts. When assessing the area of the breast mostvulnerable to breast cancer, where should the nurse to assess?A)Upper inner quadrantB)Lower inner quadrantC)Upper outer quadrantD)Lower outer quadrant2.During a prenatal class, a participant says that she was told that her breasts are not largeenough to breastfeed. When responding to this client, the nurse should understand thatthe functional capacity of the breast is primarily determined by which of the followingvariables?A)Amount of glandular tissueB)Breast size and weightC)Amount of fatty tissueD)Depth of the subcutaneous fat layer3.The nurse has asked a female client if she has noticed any lumps or swelling in herbreasts. After the client responds “yes,” which question should the nurse ask next?A)“Have any of the other women in your family had this happen?”B)“Has there been any corresponding change in your breast size?”C)“Does the lump change over the course of your menstrual cycle?”D)“What do you think is causing this change?”4.When taking a health history for a female client, which factor should the nurse identifyas placing the client at increased risk for breast cancer?A)The client smokes six to eight cigarettes per dayB)The client had her first child at age 38C)The client breast-fed her child for a full yearD)The client has a low body mass index5.Which of the following factors should a nurse include when discussing risk factorsabout breast cancer for a group of women?A)Early menarcheB)One or more pregnancies before age 20C)Consumption of a high-protein dietD)Early menopause

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6.While assessing a woman's breasts, the nurse notes a pronounced and asymmetricpattern of veins on the client's breasts. Follow-up care is ordered because the nurseshould suspect which of the following?A)PregnancyB)Fibrocystic changesC)MalignancyD)A low platelet count7.A 42-year-old female client says she does not perform breast self-examination becauseshe believes that mammograms are more thorough. Which response by the nurse wouldbe most appropriate?A)“You should do the exam. It's the best way to detect breast cancer early.”B)“Be sure to have your breasts checked by a doctor and have a mammogram everyyear.”C)“Mammograms don't always detect the lumps that you might feel.”D)“Once you hit age 50, you really won't have a choice about doing them.”8.An 18-year-old woman complains because one breast is larger than the other. Whatadditional interview data would suggest a need for referral?A)The client states that she is sexually active.B)The client states that she does not perform breast self-examination.C)The client states that her problem affects her body image.D)The client states that this represents a sudden change in her breast size.9.The nurse is assessing the breasts of a Caucasian woman who has just been diagnosedwith Paget disease. Which of the following would the nurse expect to find?A)Orange-peel skinB)Nipple retractionC)Dark pink areolaD)Red and scaling on the areola10.A woman reports a sudden onset of spontaneous nipple discharge. Which of thefollowing would be the nurse's most appropriate action?A)Refer the client for cytologic study of the discharge.B)Observe the breast for eversion of the nipples.C)Reassure the woman that this is a result of hormonal fluctuations.D)Collect a sample for culture and sensitivity testing.

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Page 311.The nurse is preparing to inspect a woman's breasts for retraction and dimpling. Whichposition would be most appropriate?A)StandingB)SupineC)Semi-FowlersD)Sitting12.A client has large, pendulous breasts. Which of the following would be most appropriateto ensure better access while examining the client's breasts for retraction and dimpling?A)Have the client stand and lean forwardB)Have the client lie on her sideC)Have the client sit and then lean forwardD)Have the client lie flat on her back13.The nurse is preparing to palpate the breasts of a female client. Which technique shouldthe nurse utilize during this aspect of assessment?A)Use the flat pads of three fingers.B)Use the fingertips of both hands.C)Gently pinch the skin between two fingers.D)Use the palm of one hand.14.A woman appears restless and is wringing her hands prior to having a clinical breastexamination performed. Which statement by the nurse would be most appropriate?A)“I know you are worried, but your risk for cancer is low.”B)“You need to pay attention to these instructions so we can finish as quickly aspossible.”C)“You seem to be anxious. Can you tell me what you are thinking?”D)“You appear restless but I can assure you that your doctor is very good.”15.A nurse has completed the assessment of a client's breasts. The nurse should suspect thatthe client has fibroadenomas based on which findings?A)Lobular, ovoid, or round lesionsB)Irregular, firm cystsC)Round, defined mobile cystsD)Nondefined, mobile cysts

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16.After teaching a group of young women about breast self-examination, the nursedetermines that the teaching was successful when the women state that they will palpatetheir breasts using which pattern?A)A circular patternB)A clockwise patternC)A random patternD)An up-and-down pattern17.When palpating a female client's axillae, which of the following actions is mostappropriate?A)Have the client hold the arm of the side being examined slightly away from thebody.B)Tell the client to raise her arm on the side being examined up over her head.C)Hold the client's elbow of the side being examined with one hand.D)Have the client lean forward from the waist with arms outstretched.18.When palpating a female client's axillae, which finding would the nurse document asnormal?A)Node size is 1.2 cm.B)Nodes are fixed.C)Nodes are hard.D)Nodes are discrete.19.A nurse is teaching an older adult client about breast self-examination. The nurseincludes teaching on expected changes in the client's breasts due to aging. Which of thefollowing would the nurse include?A)Increase in glandular tissueB)Increase in fatty tissueC)Larger nipple areaD)Less “granular” in texture20.A group of students is preparing for a quiz on breast assessment and the assessmentfindings that are associated with breast cancer. The students demonstrate understandingof the material when they identify which of the following? Select all that apply.A)Irregular, firm lumpsB)Elastic, tender, mobile lumpsC)Dimpling and nipple retractionD)Orange peel-like appearanceE)Redness and warmth with smooth textureF)Breast fullness and pain

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Page 521.A client has presented for care to the clinic, stating, “I'm pretty sure that I feel a newlump in my breast.” After confirming the presence of a lump, what action should thenurse take?A)Arrange for the client to be brought to the hospital emergency departmentimmediately.B)Tell the client to monitor the lump for the next three weeks and seek care if itincreases in size.C)Arrange for a prompt referral to her primary care provider.D)Facilitate a referral to an oncologist if more lumps emerge in the coming weeks.22.A client who takes oral contraceptives states that she often experiences breast pain justbefore her menstrual cycle begins. When using the COLDSPA mnemonic to assess theclient's pain, the nurse should begin by asking which of the following?A)“How would you describe your pain? Is it sharp? Is it an ache?”B)“Has the pain changed over time?”C)“Would you describe the pain as being constant or as intermittent?”D)“Is there anything that makes the pain worse or better?”23.During the health interview, the nurse asks a middle-aged client at what age she beganmenstruating. This question addresses a risk factor for what health problem?A)MastitisB)Breast cancerC)Benign breast diseaseD)Paget's disease24.The nurse has completed the assessment of a client's breast and lymphatic system. Thenurse has ended the assessment by offering to teach the client how to perform breastself-examination (BSE). The client states, “That's alright. I already know how to dothat.” What should the nurse do next?A)Encourage the client to perform BSE as often as possible.B)Ask the client to demonstrate BSE.C)Encourage the client to promote BSE to her peers.D)Reiterate the correct technique for BSE.25.The nurse is beginning the inspection of a young adult client's breasts. The client states,“My left breast has always been a bit bigger than the right.” How should the nurse bestrespond to the client's statement?A)“Many women have this, and it's rarely a sign of a health problem.”B)“That's very normal, and it usually resolves over time as you get older.”C)“If you lose some weight, the size disparity will likely decrease.”D)“I'll make sure to refer to the doctor to get this assessed further.”

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26.The nurse is examining a client's breasts and notes the presence of pronounceddimpling. How should the nurse best respond to this assessment finding?A)Confirm whether the client has breast implants in place.B)Ask the client about any history of mastitis (breast infection).C)Explain to the client that this is a normal, age-related change.D)Promptly refer the client for further medical assessment.27.The nurse is assessing an adult client's areolas and nipples. What assessment findingwould most clearly warrant referral?A)Small Montgomery tubercles are present on the areolas.B)Supernumerary nipples are present.C)The patient's nipple has recently become inverted.D)The patient's areola puckers upon palpation.28.The nurse is palpating the axillary lymph nodes of a client who has been experiencingrecent malaise. The nurse should consider a lymph node to be enlarged if its diameterexceeds what size?A)0.5 cmB)1 cmC)2 cmD)2.5 cm29.In which of the following male clients would gynecomastia be considered to be anexpected assessment finding?A)A 14-year-old boy who began puberty last yearB)An older adult who takes antihypertensive medicationsC)A 59-year-old man who has been exposed to heavy metals in the workplaceD)A male client who has been diagnosed with breast cancer30.Assessment of a client's breasts reveals tenderness on palpation and diffuse redness.What collaborative problem is most clearly suggested by these data?A)RC: Breast cancerB)RC: Benign breast diseaseC)RC: HematomaD)RC: Infection

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Page 7Answer Key1.C2.A3.C4.B5.A6.C7.B8.D9.D10.A11.D12.C13.A14.C15.A16.D17.C18.D19.B20.A, C, D21.C22.A23.B24.B25.A26.D27.C28.B29.A30.D

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Page 11.To examine the Bartholin's glands of a female client, the nurse would palpate at whichanatomic location?A)On both sides of the clitorisB)Just inside the urethral orificeC)Between the vaginal opening and labia minoraD)Inside the vaginal orifice2.During the health history, a postmenopausal client mentions that she is experiencingvaginal dryness. When explaining the most likely reason to the client, the nurse shouldexplain the role of which hormone?A)EstrogenB)ProgesteroneC)Follicle-stimulating hormone (FSH)D)Oxytocin3.A client's health history reveals that she had a total hysterectomy at age 33 to treatsevere endometriosis. She says that the surgeon also removed both ovaries and fallopiantubes. The nurse would interpret this as which of the following?A)Natural menopauseB)Delayed menopauseC)Premature menopauseD)Artificial menopause4.An older adult client states, ìSometimes when I sneeze, I notice that I wet my pants.îThe nurse interprets this as which of the following?A)Reflex incontinenceB)Stress incontinenceC)Urge incontinenceD)Total incontinence5.A postmenopausal woman tells the nurse that she experiences discomfort during sexualintercourse. Which of the following should the nurse suggest?A)Use of a lubricantB)Abstinence from intercourseC)Use of a condom by the partnerD)Kegel exercises

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Page 26.A young female client refuses treatment for a sexually transmitted infection. The nurseexplains that lack of treatment may put her at risk for which condition?A)EndometriosisB)Urinary tract infectionC)Cervical cancerD)Pelvic inflammatory disease7.A client has been to the clinic multiple times in the past year with vaginal infections, themost frequent of which was candidiasis. The nurse would assess the client for symptomsmost likely related to which condition?A)Intestinal parasitesB)Urinary tract infectionsC)HypothyroidismD)Diabetes mellitus8.During the health history, the nurse teaches a client about toxic shock syndrome andways to reduce her risks. The nurse determines that the teaching was successful whenthe client states which of the following?A)ìI will get a Pap smear regularly.îB)ìIt is important to use latex condoms.îC)ìI should change tampons at least every 4 to 6 hours.îD)ìI should stop using oral contraceptives.î9.When assessing the vaginal orifice of a young female client who has never beensexually active, the nurse notes a fold of fibrous tissue at the introitus. The nurserecognizes this as which structure?A)LabiaB)UrethraC)HymenD)Clitoris10.When palpating the Bartholin's glands, the nurse expresses a purulent discharge. Whichof the following would be most appropriate for the nurse to do next?A)Recommend sitz baths.B)Palpate the uterus.C)Obtain a culture.D)Perform a rectal exam.

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Page 311.The nurse notes a malodorous, yellow discharge upon inserting the speculum into theclient's vagina. Which of the following should the nurse do next?A)Obtain a urine specimen.B)Obtain a wet mount slide.C)Procure a Papanicolaou (Pap) smear.D)Perform a bimanual exam.12.The nurse is presenting a class to a group of high school students about sexuallytransmitted infections. Which of the following should the nurse include as a major riskfactor for cervical cancer?A)GonorrheaB)ChlamydiaC)SyphilisD)Human papilloma virus13.When obtaining a cervical specimen for aNeisseria gonorrhoeaeculture, which of thefollowing would be most appropriate?A)Wipe the cotton-tipped applicator onto a slide.B)Spread the specimen in a ìZî pattern on a special culture plate.C)Immerse the swab in a liquid medium and refrigerate.D)Roll the endocervical brush onto a slide.14.The nurse is inspecting the client's vaginal musculature and asks the client to bear down.Which finding would lead the nurse to suspect that the client has a cystocele?A)Bulging of the anterior vaginal wallB)Protrusion of the cervixC)Urine leakageD)Protrusion at the back of the vaginal wall15.The nurse is preparing to perform a speculum examination on a client. The nurselubricates the speculum with which of the following?A)Petroleum jellyB)Water-soluble lubricantC)Client's vaginal secretionsD)Antimicrobial ointment

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Page 416.The nurse is inspecting the cervix of a client who has two children. The nurse wouldexpect the cervical os to appear as which of the following?A)RoundB)Slit-likeC)TransverseD)Stellate17.When assessing the cervix of an older postmenopausal woman, which of the followingwould the nurse document as a normal finding?A)Bluish colorB)Bright redC)Pale pinkD)White patches18.The nurse is assessing a female client's genitourinary system. Which of the followingfindings would lead the nurse to suspect a problem with the ovaries during palpation?A)Slight tenderness on palpationB)Walnut-sized ovariesC)Immobile ovariesD)Smooth ovarian surface19.The nurse is preparing to perform a rectovaginal examination on a client. Whichstatement by the nurse would be most appropriate?A)ìI have to do this exam to make sure everything is okay, so just bear with me.îB)ìYou might feel uncomfortable, almost like you have to move your bowels.îC)ìJust relax, it will only take a minute and then I'll be all finished.îD)ìI want you to hold your breath as I insert my fingers into the openings.î20.While inspecting the vagina, the nurse observes a thin, grayish-white vaginal dischargewith a fishy odor. Which of the following would the nurse suspect?A)MoniliasisB)TrichomoniasisC)Bacterial vaginosisD)Atrophic vaginitis

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Page 521.A 49-year-old woman has sought care because of severe perimenopausal symptoms.The client has asked the nurse if she should talk to her doctor about beginning hormonereplacement therapy (HRT). How should the nurse best respond?A)ìThe most recent research suggests that the benefits of HRT have been greatlyoverstated.îB)ìHRT often relieves many of the symptoms of menopause, but it's not withoutsome risks.îC)ìHRT is a good option for many women, mostly because it's a naturally occurringsubstance.îD)ìYour doctor will likely recommend HRT because you're beginning menopausequite young.î22.A 52-year-old woman's current medication regimen includes estrogen-progestin therapy(EPT). In addition to reduced symptoms of menopause, the nurse should be aware thatthis therapy confers what secondary benefit?A)Weight lossB)Reduced risk of colorectal cancerC)Protection against strokeD)Increased libido23.A female client has presented for a Pap smear test, and the nurse is discussing riskfactors for cervical cancer. What risk factor should the nurse describe?A)Having multiple sexual partnersB)Previous treatment for chlamydial infectionC)Pregnancy before age 21D)African-American ethnicity24.The nurse is completing a client's genitourinary assessment and is preparing to assessthe client's cervix. What finding would most clearly warrant referral?A)The cervix is firm on palpation.B)The cervix is immobile on palpation.C)The cervix is smooth and pink on inspection.D)The cervix projects 2 cm into the client's vagina.25.Scar tissue is visible on the perineum of an adult female client. The nurse shouldconsequently question the client about which of the following?A)Surgical correction of a rectoceleB)History of sexually transmitted infectionsC)History of sexual abuseD)Tearing during vaginal delivery

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Page 626.In which of the following clients would the nurse consider a bluish tint to the cervix anexpected assessment finding?A)A client who is 17 years old and sexually active.B)A client who is 10 weeks' pregnant.C)A 71-year-old multiparous clientD)A client who has a 24 pack-year smoking history.27.The nurse is assessing the genitalia and rectum of a 71-year-old client. When assessingthe client's vagina, the nurse should know that age-related changes increase the client'srisk of what abnormal finding?A)Trichomonas vaginitisB)Bacterial vaginosisC)Candidal vaginitisD)Atrophic vaginitis28.A nurse is preparing a female client for a genitourinary examination that has beenscheduled for later in the week. What anticipatory guidance should the nurse provide tothe client?A)ìStop taking any antibiotics for 24 hours before your examination.îB)ìMake sure not to douche for 48 hours before the examination.îC)ìDon't bathe or shower on the morning of the appointment.îD)ìDrink at least 48 ounces of fluid the morning before the appointment.î29.The nurse is preparing a client for an assessment of her genitalia and rectum. Whataction should the nurse perform when preparing the client?A)Assist the client into a prone position.B)Explain the rationale for using foot stirrups.C)Reassure the client that no one other than the nurse will be in the room.D)Obtain written, informed consent for the examination.30.An adult client has sought care at the clinic, stating that she believes she has ìa ragingyeast infection.î The nurse would expect to assess what type of vaginal discharge?A)Thick, white vaginal dischargeB)Copious clear, foul-smelling dischargeC)Yellowish discharge with a metallic odorD)Blood-tinged vaginal discharge

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Page 7Answer Key1.C2.A3.D4.B5.A6.D7.D8.C9.C10.C11.B12.D13.B14.A15.C16.B17.C18.C19.B20.C21.B22.B23.A24.B25.D26.B27.D28.B29.B30.A

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Page 11.A nurse is performing an assessment within the legal parameters of assessment anddiagnosis. These legal guidelines would be specified in which of the following?A)The state's Nurse Practice ActB)The client's informed consent documentsC)The nurse's terms of licenseD)The institution's policies and procedures guidelines2.When preparing to do a comprehensive health assessment, the nurse obtains the client'spermission based on an understanding of which of the following principles?A)The client has the right to refuse the assessment.B)Obtaining permission enhances therapeutic rapport.C)The client will be more willing to disclose after giving permission.D)The client's level of comfort will be increased by granting explicit consent.3.The nurse is completing the general survey. In addition to observing the client'sappearance, the nurse would assess which of the following?A)Mental statusB)Cognitive abilitiesC)Vital signsD)Thought processes4.A novice nurse is practicing how to complete a comprehensive assessment to gainconfidence and skill. Which of the following would be most important for the nurse toremember?A)Always gather objective data before subjective data.B)Intersperse the physical exam with the history.C)Establish a routine for the assessment.D)Allow the client a break between the two parts of the history/exam.5.When analyzing data related to a client's behavior, the nurse should compare theobservations with which of the following?A)The client's developmental stageB)The client's motivation for changeC)The client's body mass indexD)The client's vital signs

Test Bank For Health Assessment in Nursing, 5th Edition - Page 25 preview image

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Page 26.When performing a client's head-to-toe assessment, during which part would the nurseassess the motor function of cranial nerve VII?A)Mental status examinationB)Head and face assessmentC)Ears assessmentD)Examination of mouth and throat7.When documenting a comprehensive assessment, which statement would the nurserecord as the reason for seeking health care?A)ìI try not to let the pain affect my life.îB)ìI haven't had a checkup in over 5 years.îC)ìI had my appendix removed when I was 14 years old.îD)ìI have an aunt who had breast cancer.î8.The nurse would test for stereognosis during which part of the comprehensive exam?A)Posterior and lateral chestB)Nose and sinusesC)Arms, hands, and fingersD)Legs, feet, and toes9.A nurse has finished examining a client's nose and sinuses and is about to examine theclient's mouth and throat. Which of the following would be most important for the nurseto do?A)Warm the handsB)Put on glovesC)Obtain a tuning forkD)Collect a saliva specimen10.When assessing a client's mental status, which of the following would the nurse assess?Select all that apply.A)Remote memoryB)Coping skillsC)SpeechD)Abstract reasoningE)Judgment

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Page 311.The nurse is performing a head-to-toe assessment of a client. Which of the followingwould be an example of information obtained during the review of the client's bodysystems?A)Wears dentures; denies problems with eating, chewing, and swallowing.B)States her father died of a heart attack at age 70.C)Uses over-the-counter antacid for occasional heartburn.D)Vaginal delivery of two children without complications.12.A nurse is preparing to complete a comprehensive health assessment on a female client.Prior to beginning the assessment, the client states, ìI'm really having a good deal ofpain in my hip now.î Which of the following would be most appropriate for the nurse todo?A)Begin the comprehensive assessment and aim to complete it efficiently.B)Explain the reason for the client's assessment.C)Delay the full exam until the client's pain has been addressed.D)Provide education on pain control.13.A nurse is performing a head-to-toe assessment and is preparing to examine the client'sears. Which equipment would the nurse need to have readily available?A)OphthalmoscopeB)Tuning forkC)Facial tissuesD)Stethoscope14.A nurse should assess the client's epitrochlear lymph nodes when assessing which of thefollowing?A)NeckB)ArmsC)Posterior chestD)Sinuses15.The nurse will palpate a client's axillae during a head-to-toe assessment. The nurseshould combine this with examination of which area?A)NeckB)Anterior chestC)HeartD)Breasts

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Page 416.The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes.The nurse is most likely examining which area during a comprehensive assessment?A)Nose and sinusesB)AbdomenC)NeckD)Face17.During which part of the comprehensive assessment would the nurse auscultate afterinspecting but before percussing?A)AbdomenB)Anterior chestC)NeckD)Heart18.When assessing the client's legs, feet, and toes, which pulses would the nurse expect topalpate? Select all that apply.A)FemoralB)BrachialC)TemporalD)Dorsalis pedisE)PoplitealF)Posterior tibial19.The nurse is documenting findings of a comprehensive assessment. Which statementwould be categorized as part of the general survey?A)Hair neat and clean with white and gray streaks; no scalp lesions notedB)Sclera white; conjunctiva slightly reddened without lesionsC)Client alert and cooperative; sitting comfortably on chair with hands in lapD)Head symmetrically round; neck nontender with full range of motion20.A nurse is preparing to complete a comprehensive assessment on a client. Whencollecting objective data, which of the following should the nurse do first?A)Assess the client's vital signs.B)Take the client's body measurements.C)Assess the client's mental status.D)Observe the client's overall appearance.

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Page 521.The nurse is preparing to perform a comprehensive assessment of a client who has adiagnosis of Alzheimer's disease. How should the nurse accommodate the client'scognitive deficit when obtaining the client's health history?A)Obtain the client's history from the electronic health record and proceed withphysical assessment.B)Focus the assessment on aspects of the client's history that he is able to accuratelydescribe.C)Perform the assessment as quickly as possible in order to minimize the client'sstress.D)Supplement the client's statements with data from the client's friends and family.22.The nurse is preparing to gather equipment prior to a client's head-to-toe assessment.The nurse's selection of equipment should be based primarily on what variable?A)The nurse's time allowanceB)The nurse's level of expertiseC)The client's health needsD)The client's level of participation23.The nurse is performing an abbreviated head-to-toe assessment of a hospital client.What question should the nurse ask when assessing the client's level of consciousness?A)ìIf there were a fire in your house, what would you do?îB)ìHow would you describe your overall level of stress?îC)ìCan you tell me the current month and year?îD)ìCan you tell me what you ate for breakfast this morning?î24.The nurse is performing an abbreviated head-to-toe assessment of a client. When thenurse asks the client about his pain, the client states, ìMy stomach's really killing meright now.î How should the nurse first respond to this client's statement?A)Offer analgesia to the clientB)Ask the client to rate his pain on a 0-to-10 scaleC)Assess the client's level of consciousnessD)Assure the client that his pain will be addressed immediately following theassessment25.The nurse is completing an abbreviated head-to-toe assessment of a client. Which of thefollowing should the nurse perform when assessing the client's eyes?A)Test the client's pupillary response to light.B)Test the client's visual fields.C)Perform the cover test.D)Test the client's vision.

Test Bank For Health Assessment in Nursing, 5th Edition - Page 29 preview image

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Page 626.A client has been recovering from surgery in the hospital, and the nurse is beginning ashift by conducting an abbreviated head-to-toe assessment. How should the nurse assessthe client's bowel sounds?A)Auscultate for 2 to 3 minutes in the client's right upper abdominal quadrant.B)Auscultate for bowel sounds in each of the client's four abdominal quadrants.C)Auscultate for 5 minutes to confirm the presence of consistent bowel sounds.D)Auscultate to determine which quadrant contains the most active bowel sounds.27.The nurse is planning the comprehensive head-to-toe assessment of a client. Whatassessment should the nurse usually conduct last?A)Assessment of the abdomenB)Assessment of the genitalia and rectumC)Assessment of the lower extremitiesD)Assessment of the posterior thorax28.The nurse is using the COLDSPA mnemonic during the client's head-to-toe assessment.This tool will allow the nurse to address what component of assessment?A)The client's present health concernB)The review of the client's body systemsC)The client's personal health historyD)The client's health practices profile29.The nurse is assessing a client's judgment during a comprehensive head-to-toeassessment. How can the nurse best appraise this aspect of cognitive function?A)ìWhat would you do if you found a stamped, addressed envelope on the ground?îB)ìWhat kinds of activities do you do to improve your health?îC)ìWho is the most important person in your life, and why?îD)ìWhat is your idea of the ideal vacation?î30.The nurse should ensure that a Doppler ultrasound is available when performing whichof the following assessments?A)Respiratory assessmentB)Peripheral vascular assessmentC)Abdominal assessmentD)Musculoskeletal assessment

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Page 7Answer Key1.A2.A3.C4.C5.A6.B7.B8.C9.B10.A, C, D, E11.A12.C13.B14.B15.D16.C17.A18.A, D, E, F19.C20.D21.D22.C23.C24.B25.A26.B27.B28.A29.A30.B

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Page 11.A nurse is preparing to assess a client who is new to the clinic. When beginning thecollection of the client database, which of the following actions should the nurseprioritize?A)Establishing a trusting relationshipB)Determining the client's strengthsC)Identifying potential health problemsD)Making clinical inferences2.A nurse is interpreting and validating information from an older adult client who hasbeen experiencing a functional decline. The nurse is in which phase of the interview?A)IntroductoryB)WorkingC)SummaryD)Closing3.A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, andthe nurse is collecting subjective data prior to surgery. Which statement by the nursecould be construed as judgmental?A)“How often do your adult children typically visit you?”B)“Your husband's death must have been very difficult for you.”C)“You must quit smoking because it affects others, not only you.”D)“How would you describe your feelings about getting older?”4.A nurse is interviewing a 22-year-old client of the campus medical clinic. Whichnonverbal behavior should the nurse adopt to best facilitate communication during thisphase of assessment?A)Standing while the client is seatedB)Using a moderate amount of eye contactC)Sitting across the room from the clientD)Minimizing facial expressions5.A nurse is providing feedback to a colleague after observing the colleague's interview ofa newly admitted client. Which of the following would the nurse identify as an exampleof a closed-ended question or statement?A)“Tell me about your relationship with your children?”B)“Tell me what you eat in a normal day?”C)“Are you allergic to any medications?”D)“What is your typical day like?”

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