Chapter 23: Documenting the Head-to-Toe Health Assessment Nursing School Test Banks

Chapter 23: Documenting the Head-to-Toe Health Assessment
Test Bank

MULTIPLE CHOICE

1. Which documentation by a nurse is most descriptive?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. S1 murmur is heard at second right sternal border.
d. Pulse within normal limits.
ANS: C

Feedback
A This information is not specific without a description of what is considered within normal limits for hair color, texture, length, etc.
B This description is not specific because the number of permanent teeth is not detailed.
C This is the most descriptive data, specifying what is heard and the location.
D This description would be more descriptive if the pain scale were used to indicate the level of tenderness and if the location on the abdomen were documented.
DIF: Cognitive Level: Apply REF: 540
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

2. The nurse documents which data under the category of present health status?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. Apical pulse palpated at 5th left intercostal space, midclavicular line
d. Pulse within normal limits.
ANS: D

Feedback
A This information is not specific without a description of what is considered within normal limits for heart sounds
B This description is not specific
C This is the most descriptive data, specifying what is heard and the location.
D This description would be more descriptive such as which pulse and the rate
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

3. Which data do nurses document under the category of past health history?
a. Chronic diseases
b. Immunizations received
c. Allergies to medications or food
d. Causes of death of the patients parents
ANS: B

Feedback
A Chronic diseases are documented under the present health status category.
B Immunizations are documented under the past health history category.
C Allergies to medications or food are documented under the present health status category.
D Causes of death of parents are documented under the family history category.
DIF: Cognitive Level: Apply REF: 538
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

4. A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?
a. Review of systems
b. Present health status
c. Past health history
d. Functional ability
ANS: A

Feedback
A In the review systems part of the history, the nurse asks patients whether they have had symptoms from specific body systems. Patients either deny or admit to having the symptoms.
B The present health status category contains data on chronic diseases, medications, and allergies.
C The past health history category contains data on childhood diseases, surgeries and hospitalizations, and immunizations.
D The functional ability category contains data on patients activities, including maintaining a home and working full-time.
DIF: Cognitive Level: Understand REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

5. What data do nurses document under the category general survey?
a. Mental health
b. Functional ability
c. Diet and nutrition
d. Orientation
ANS: D

Feedback
A Mental health is described under the heading of personal and psychosocial history.
B Functional ability data are collected during the history.
C Diet and nutrition data are collected during the history.
D The general survey is the beginning of the examination when the nurse is collecting data about the patient.
DIF: Cognitive Level: Understand REF: 540
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

MULTIPLE RESPONSE

1. Which data do nurses document under the category of personal and psychosocial health history? Select all that apply.
a. Allergies to medications or food
b. Diet and foods eaten on a regular basis
c. Type of employment
d. Address and date of birth
e. Activities that promote health
f. Use of tobacco and alcohol
ANS: B, E, F
Correct: These data are documented under the heading of personal and psychosocial health.
Incorrect: Allergies to medications or food is documented under the present health status category. Type of employment is documented under the heading of biographic data. Address and date of birth are documented under the heading of biographic data.

DIF: Cognitive Level: Apply REF: 539
TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Management of Care

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