Chapter 1: Understanding Health Assessment

1. The World Health Organization (WHO) established a global strategy called “Health for All.” The goal for this strategy is:
1. All individuals to get the same health care throughout their life spans.
2. The government to supply money to care for all the people in the world. 
3. Resources for health care to be evenly distributed and accessible.
4. Health-care providers can never deny patients health care.

2. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normal and abnormal findings.
3. Refer patients with abnormal findings.
4. Counsel patients with psychosocial needs.

3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police presence outside his door because the patient is a known drug dealer in the community. You know that nurses must treat all patients as persons. This is called:
1. Caring.
2. Holistic process.
3. Person-centered care (PCC).
4. Standards of care.

4. The science-based framework updated every 10 years by the U.S. Department of Health and Human Services that has set national goals and objectives for health promotion and disease prevention is:
1. Healthy People.
2. Healthy People 2020.
3. U.S. Preventive Task Force.
4. World Health Organization.

5. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age 48. The doctor recommended that this patient have a colonoscopy this year. This is an example of: 
1. Primary health prevention.
2. Secondary health prevention.
3. Tertiary health prevention.

6. A patient in the hospital puts on his call light and tells the person answering that he “thinks he is running a fever and has stomach discomfort.” You are the registered nurse in charge. What should you do?
1. Ask the medical assistant to go to the patient’s room and assess his complaints.
2. Go check to see if the patient has an order for Tylenol for a fever.
3. Page the resident on call immediately to assess the patient.
4. Go to the patient’s room and assess for fever and the epigastric discomfort. 

7. You are leading an interdisciplinary team conference to discuss how to provide better care for a challenging patient who has behavioral problems. There are several areas that need to be problem solved and new ideas formulated to create an improved plan of care. What cognitive skills are you using? 
1. Critical thinking
2. Clinical decision making
3. Intuitive thinking 
4. Clinical reasoning

8. Best practice assessment techniques and instruments have been validated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and Affordable Care Act.

9. Health and illness are determined by many factors. What are the determinants of health identified by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
1. Genetics and biology 
2. Gender and occupation 
3. Individual behavior 
4. Social environment 
5. Physical environment 
6. Health services 

10. The U.S. health-care system is evolving, and care is becoming more focused on which of the following? Select all that apply.
1. Wellness
2. Functional status
3. Disease prevention
4. Health promotion
5. Acute illness management

11. You are performing a health assessment on a 32-year-old female patient who reports “feeling fatigued all the time.” She states, “I have not had a physical in over 8 years because I did not have medical insurance.” The patient will be having a physical today. What will be part of the health assessment? Select all that apply.
1. Collecting data on past health
2. Collecting data on present health
3. Collecting data on significant other’s health
4. Assessing factors influencing health 
5. Performing a physical examination

12. You are working with a patient as a copartner in care. The patient has multiple medical problems. Put the following steps of the nursing process in the correct order (1–5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.)
1. Planning
2. Evaluation
3. Assessment
4. Implementation
5. Diagnosis 

13. You are working on a medical surgical unit and are caring for a 24-year-old patient who is 3 hours post-op. The patient seems confused and restless since you assessed her an hour ago. You have a gut feeling that something is very wrong. This is an example of ____________________ thinking. 

14. The four techniques of health assessment include inspection, palpation, percussion, and _________________.

Answers

1. The World Health Organization (WHO) established a global strategy called “Health for All.” The goal for this strategy is:
1. All individuals to get the same health care throughout their life spans.
2. The government to supply money to care for all the people in the world. 
3. Resources for health care to be evenly distributed and accessible.
4. Health-care providers can never deny patients health care.

ANS: 3
Page: 1

	Feedback	
1.	This is incorrect. “Health for All” does not mean that all individuals get the same health care throughout their life spans.	
2.	This is incorrect. “Health for All” does not mean the government will supply money to care for all the people in the world. 	
3.	This is correct. “Health for All” means that resources for health care are evenly distributed and accessible to everyone.	
4.	This is incorrect. “Health for All” does not mean that health-care providers can deny patients health care.	

2. Health assessment is a foundational and priority nursing skill. This essential skill requires registered nurses (RNs) to:
1. Diagnose and treat patients.
2. Identify normal and abnormal findings.
3. Refer patients with abnormal findings.
4. Counsel patients with psychosocial needs.

ANS: 2
Page: 5-6

	Feedback	
1.	This is incorrect. The role of the RN is not to diagnose and treat patients.	
2.	This is correct. Assessing patients and being able to identify normal from abnormal findings is an essential role of the RN.	
3.	This is incorrect. RNs in collaboration with the health-care providers do refer patients. This is not the essential and foundational role in health assessment.	
4.	This is incorrect. RNs do counsel patients, but it is not the essential and foundational role in health assessment. 	

3. You are assessing a patient with five gunshot wounds on a trauma unit. There is a police presence outside his door because the patient is a known drug dealer in the community. You know that nurses must treat all patients as persons. This is called:
1. Caring.
2. Holistic process.
3. Person-centered care (PCC).
4. Standards of care.

ANS: 3
Page: 2

	Feedback	
1.	This is incorrect. Caring is displaying a concern for patients.	
2.	This is incorrect. The holistic caring process is a relational process; the nurse collaborates with the individual to pursue goals for health and well-being.	
3.	This is correct. The new movement in health care is person-centered care (PCC), which emphasizes the intrinsic value of treating all patients as persons.	
4.	This is incorrect. Standards of care identify standards of professional nursing practice. 	

4. The science-based framework updated every 10 years by the U.S. Department of Health and Human Services that has set national goals and objectives for health promotion and disease prevention is:
1. Healthy People.
2. Healthy People 2020.
3. U.S. Preventive Task Force.
4. World Health Organization.

ANS: 2 
Page: 2

	Feedback	
1.	This is incorrect. Healthy People is the general title for the nation’s federal initiative.	
2.	This is correct. Healthy People 2020 specifically identifies science-based, national goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States.	
3.	This is incorrect. The U.S. Preventive Services Task Force’s goal is to use evidence-based medicine to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.	
4.	This is incorrect. The World Health Organization is a specialized agency of the United Nations working to improve the health of the world’s people. 	

5. A 38-year-old male has a family history of colon cancer. His father died of colon cancer at age 48. The doctor recommended that this patient have a colonoscopy this year. This is an example of: 
1. Primary health prevention.
2. Secondary health prevention.
3. Tertiary health prevention.

ANS: 2
Page: 4

	Feedback	
1.	This is incorrect. This is not an example of primary prevention. Primary prevention is the prevention of disease and disability and focuses on improving an individual’s overall health and well-being. Immunizations and health education are examples of primary prevention.	
2.	This is correct. Colonoscopy is an example of secondary prevention, which encompasses early screenings and detection of disease and treatment of diseases.	
3.	This is incorrect. This is not an example of tertiary prevention. Tertiary prevention encompasses the restoration of health after illness or disease has occurred. A rehabilitation program for stroke patients is an example of tertiary prevention. 	

6. A patient in the hospital puts on his call light and tells the person answering that he “thinks he is running a fever and has stomach discomfort.” You are the registered nurse in charge. What should you do?
1. Ask the medical assistant to go to the patient’s room and assess his complaints.
2. Go check to see if the patient has an order for Tylenol for a fever.
3. Page the resident on call immediately to assess the patient.
4. Go to the patient’s room and assess for fever and the epigastric discomfort. 

ANS: 4
Page: 5

	Feedback	
1.	This is incorrect. The medical assistant role should never be to assess a patient.	
2.	This is incorrect. The first priority would be to assess the patient prior to checking medication orders for fever. 	
3.	This is incorrect. The nurse should first assess the patient to give an objective report to the resident. 	
4.	This is correct. Assessing a patient is always a priority role of the RN. This is a role that should never be delegated to the licensed practical nurse or unlicensed assistive personnel.	

7. You are leading an interdisciplinary team conference to discuss how to provide better care for a challenging patient who has behavioral problems. There are several areas that need to be problem solved and new ideas formulated to create an improved plan of care. What cognitive skills are you using? 
1. Critical thinking
2. Clinical decision making
3. Intuitive thinking 
4. Clinical reasoning

ANS: 1
Page: 5

	Feedback	
1.	This is correct. Critical thinking is a unique problem-solving, reflective process.	
2.	This is incorrect. Clinical decision making determines what is needed and when it is needed.	
3.	This is incorrect. Intuitive thinking is a “gut feeling” that something is wrong or that the nurse should do something, even if there is no real evidence to support that feeling.	
4.	This is incorrect. Clinical reasoning uses an individual’s history, physical signs, symptoms, laboratory data, and diagnostic imaging to arrive at a diagnosis and formulate a treatment plan.	

8. Best practice assessment techniques and instruments have been validated by:
1. American Nurses Association.
2. Code of Ethics for Nurses With Interpretive Statements.
3. Research and evidence-based practice.
4. Patient Protection and Affordable Care Act.

ANS: 3
Page: 7

	Feedback	
1.	This is incorrect. The American Nurses Association is the professional nursing organization providing standards of nursing care, promoting a safe and ethical work environment, and advocating health-care issues. 	
2.	This is incorrect. The Code of Ethics for Nurses With Interpretive Statements provides a statement of the ethical values and duties of every individual who enters the nursing profession.	
3.	This is correct. Best practice assessments and instruments have been validated by research. Nursing research and evidence-based practice guide our assessments and clinical decisions to provide safe and effective care.	
4.	This is incorrect. The Patient Protection and Affordable Care Act, known as Obamacare, has goals to provide higher-quality, safer, and more affordable and accessible care.	

9. Health and illness are determined by many factors. What are the determinants of health identified by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
1. Genetics and biology 
2. Gender and occupation 
3. Individual behavior 
4. Social environment 
5. Physical environment 
6. Health services 

ANS: 1, 3, 4, 5, 6
Page: 2

	Feedback	
1.	This is correct. The CDC identifies genetics and biology (i.e., age and sex) as a determinant of health.	
2.	This is incorrect. Occupation is not identified as a determinant of health. 	
3.	This is correct. The CDC identifies individual behavior (i.e., alcohol use, unprotected sex, smoking) as a determinant of health.	
4.	This is correct. The CDC identifies social environment (i.e., income and lifestyle) as a determinant of health.	
5.	This is correct. The CDC identifies physical environment (i.e., where the individual lives) as a determinant of health.	
6.	This is correct. The CDC identifies health services (i.e., insurance and access to health care) as a determinant of health.	

10. The U.S. health-care system is evolving, and care is becoming more focused on which of the following? Select all that apply.
1. Wellness
2. Functional status
3. Disease prevention
4. Health promotion
5. Acute illness management

ANS: 1, 3, 4
Page: 1

	Feedback	
1.	This is correct. The U.S. health-care system is evolving, and care is becoming more focused on wellness.	
2.	This is incorrect. The U.S. health-care system is not becoming more focused on the individual’s functional status. 	
3.	This is correct. The U.S. health-care system is evolving, and care is becoming more focused on disease prevention.	
4.	This is correct. The U.S. health-care system is evolving, and care is becoming more focused on health promotion.	
5.	This is incorrect. The U.S. health-care system is becoming more focused on chronic illness management, not acute illness management. 	

11. You are performing a health assessment on a 32-year-old female patient who reports “feeling fatigued all the time.” She states, “I have not had a physical in over 8 years because I did not have medical insurance.” The patient will be having a physical today. What will be part of the health assessment? Select all that apply.
1. Collecting data on past health
2. Collecting data on present health
3. Collecting data on significant other’s health
4. Assessing factors influencing health 
5. Performing a physical examination

ANS: 1, 2, 4, 5,
Page: 4

	Feedback	
1.	This is correct. Data on past health will be collected and reviewed.	
2.	This is correct. Data on present health will be collected and reviewed.	
3.	This is incorrect. Data on a significant other’s health will not be included; however, discussing who the patient lives with may be discussed as part of the psychosocial history. 	
4.	This is correct. Factors influencing health and health promotion topics will be reviewed. 	
5.	This is correct. A physical examination will be done on this patient. 	

12. You are working with a patient as a copartner in care. The patient has multiple medical problems. Put the following steps of the nursing process in the correct order (1–5). (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234.)
1. Planning
2. Evaluation
3. Assessment
4. Implementation
5. Diagnosis 

ANS: 35142
Page: 5

Feedback: The five steps of the nursing process are as follows: Assessment is the first, essential step requiring the nurse to collect and analyze information about the whole individual. Diagnosis involves analyzing a patient’s potential or actual health problem. Planning/Outcomes involves working with the individual as a copartner in care to meet the needs or short- and long-term goals of the individual. Implementation of interventions includes the nursing and individual actions and plan of care to meet the individual’s goals. Evaluation is the ongoing process that assesses whether the short- and long-term goals have been met.

13. You are working on a medical surgical unit and are caring for a 24-year-old patient who is 3 hours post-op. The patient seems confused and restless since you assessed her an hour ago. You have a gut feeling that something is very wrong. This is an example of ____________________ thinking. 

ANS: intuitive
Page: 6

Feedback: Intuitive thinking is a “gut feeling” that something is wrong or that the nurse should do something, even if there is no real evidence to support that feeling.

14. The four techniques of health assessment include inspection, palpation, percussion, and _________________.

ANS: auscultation
Page: 6

Feedback: Assessment is a “doing” process. The four techniques of physical assessment are inspection (looking), palpation (using your hands to feel surface characteristics), percussion (tapping different areas of the body to assess underlying structures), and auscultation (listening for sounds).