HEALTH ASSESSMENT IN NURSING
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Purpose of Assessment & Clinical Judgment
Stem: A 68-year-old man arrives for a routine visit. He reports
increased fatigue and occasional dizziness when standing.
During your focused assessment you measure orthostatic vital
signs. Which nursing action best demonstrates accurate use of
health-assessment data to prioritize care?
A. Document the orthostatic readings and advise the patient to
return if symptoms worsen.
B. Compare orthostatic values to baseline, assist the patient to
sit, and notify the provider about a ≥20 mm Hg systolic drop.
C. Ask the patient to lie down immediately and schedule follow-
up in two weeks.
,D. Teach the patient to avoid standing quickly and give written
instructions only.
Correct answer: B
Rationale — Correct: Comparing to baseline and acting on a
clinically significant orthostatic drop (≥20 mm Hg systolic) shows
application of assessment, immediate safety action (assist to
sit), and escalation to provider—aligning with nursing
judgment. This integrates vital sign interpretation, prioritization
for potential hypovolemia or medication effects, and
appropriate reporting.
Rationale — A: Documenting and advising return is insufficient
for an acute orthostatic change that may require immediate
intervention or medication review.
Rationale — C: Lying down may be appropriate for severe
symptoms, but scheduling follow-up in two weeks neglects
urgent reporting for significant orthostatic changes.
Rationale — D: Patient education is useful but incomplete;
immediate safety and provider notification are required for
significant drops.
Teaching point: Compare to baseline and act immediately on
clinically significant orthostatic changes.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
,2.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Therapeutic Communication & Interviewing Technique
Stem: During an initial intake, a 22-year-old patient pauses and
seems hesitant when asked about substance use. Which
interview approach best promotes accurate data collection
while respecting patient autonomy?
A. Tell the patient substance use questions are routine and
insist they answer now.
B. State confidentiality limits, use open-ended questions, and
normalize the topic before asking again.
C. Skip the topic to avoid upsetting the patient and proceed to
the physical exam.
D. Ask closed yes/no questions repeatedly until the patient
responds.
Correct answer: B
Rationale — Correct: Stating confidentiality limits, using open-
ended questions, and normalizing the topic (e.g., “Many people
try substances…”) fosters trust and elicits accurate
information—reflecting therapeutic communication and ethical
respect for autonomy. This approach reduces shame and
increases disclosure.
Rationale — A: Insistence and coercion undermines rapport
and can reduce truthful reporting.
Rationale — C: Omitting relevant history risks unsafe omissions
and incomplete assessment.
, Rationale — D: Repeated closed questions can feel
interrogative and may not elicit contextual information
necessary for assessment.
Teaching point: Use confidentiality statements and open
questions to encourage honest disclosure.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Cultural Competence in Assessment
Stem: A Somali patient avoids eye contact and answers briefly
during the health history. As the nurse, how should you
interpret and proceed to ensure culturally sensitive
assessment?
A. Treat avoidance of eye contact as evasiveness and ask more
probing questions.
B. Recognize cultural norms may affect eye contact, use
respectful verbal prompts, and ask about health beliefs.
C. Note noncompliance and schedule a shorter follow-up.
D. Insist on direct eye contact to ensure patient honesty.
Correct answer: B
Rationale — Correct: Recognizing cultural differences in
nonverbal behavior prevents misinterpretation. Using respectful
prompts and eliciting health beliefs shows cultural competence
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Purpose of Assessment & Clinical Judgment
Stem: A 68-year-old man arrives for a routine visit. He reports
increased fatigue and occasional dizziness when standing.
During your focused assessment you measure orthostatic vital
signs. Which nursing action best demonstrates accurate use of
health-assessment data to prioritize care?
A. Document the orthostatic readings and advise the patient to
return if symptoms worsen.
B. Compare orthostatic values to baseline, assist the patient to
sit, and notify the provider about a ≥20 mm Hg systolic drop.
C. Ask the patient to lie down immediately and schedule follow-
up in two weeks.
,D. Teach the patient to avoid standing quickly and give written
instructions only.
Correct answer: B
Rationale — Correct: Comparing to baseline and acting on a
clinically significant orthostatic drop (≥20 mm Hg systolic) shows
application of assessment, immediate safety action (assist to
sit), and escalation to provider—aligning with nursing
judgment. This integrates vital sign interpretation, prioritization
for potential hypovolemia or medication effects, and
appropriate reporting.
Rationale — A: Documenting and advising return is insufficient
for an acute orthostatic change that may require immediate
intervention or medication review.
Rationale — C: Lying down may be appropriate for severe
symptoms, but scheduling follow-up in two weeks neglects
urgent reporting for significant orthostatic changes.
Rationale — D: Patient education is useful but incomplete;
immediate safety and provider notification are required for
significant drops.
Teaching point: Compare to baseline and act immediately on
clinically significant orthostatic changes.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
,2.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Therapeutic Communication & Interviewing Technique
Stem: During an initial intake, a 22-year-old patient pauses and
seems hesitant when asked about substance use. Which
interview approach best promotes accurate data collection
while respecting patient autonomy?
A. Tell the patient substance use questions are routine and
insist they answer now.
B. State confidentiality limits, use open-ended questions, and
normalize the topic before asking again.
C. Skip the topic to avoid upsetting the patient and proceed to
the physical exam.
D. Ask closed yes/no questions repeatedly until the patient
responds.
Correct answer: B
Rationale — Correct: Stating confidentiality limits, using open-
ended questions, and normalizing the topic (e.g., “Many people
try substances…”) fosters trust and elicits accurate
information—reflecting therapeutic communication and ethical
respect for autonomy. This approach reduces shame and
increases disclosure.
Rationale — A: Insistence and coercion undermines rapport
and can reduce truthful reporting.
Rationale — C: Omitting relevant history risks unsafe omissions
and incomplete assessment.
, Rationale — D: Repeated closed questions can feel
interrogative and may not elicit contextual information
necessary for assessment.
Teaching point: Use confidentiality statements and open
questions to encourage honest disclosure.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Cultural Competence in Assessment
Stem: A Somali patient avoids eye contact and answers briefly
during the health history. As the nurse, how should you
interpret and proceed to ensure culturally sensitive
assessment?
A. Treat avoidance of eye contact as evasiveness and ask more
probing questions.
B. Recognize cultural norms may affect eye contact, use
respectful verbal prompts, and ask about health beliefs.
C. Note noncompliance and schedule a shorter follow-up.
D. Insist on direct eye contact to ensure patient honesty.
Correct answer: B
Rationale — Correct: Recognizing cultural differences in
nonverbal behavior prevents misinterpretation. Using respectful
prompts and eliciting health beliefs shows cultural competence
