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
Stem: A 72-year-old man is admitted for dehydration. During
the admission assessment the nurse documents the patient’s
complaint as “not drinking much” and notes dry mucous
membranes, a urine output of 150 mL over 8 hours, and
orthostatic BP changes when sitting up. Which nursing action is
the most appropriate next step?
A. Continue routine monitoring and recheck intake and output
at the next scheduled time.
B. Initiate a focused hydration plan, increase oral fluids, and
request close monitoring of urine output.
C. Notify the provider immediately and recommend IV fluids
,and laboratory tests.
D. Encourage the patient to ambulate to stimulate thirst and
improve hydration.
Correct answer: C
Rationale — Correct (C): Orthostatic hypotension, oliguria (150
mL/8 hr), and dry mucous membranes in an older adult indicate
possible significant dehydration and risk for hypovolemia.
Notifying the provider for IV fluids and labs (electrolytes,
BUN/creatinine) is appropriate and urgent. This action aligns
with nursing assessment, early recognition of abnormal
findings, and escalation within scope.
Rationale — Incorrect (A): Waiting for routine monitoring
delays necessary evaluation and treatment for potentially
significant dehydration; unsafe.
Rationale — Incorrect (B): Increasing oral fluids is reasonable
but insufficient given oliguria and orthostatic changes—IV
therapy/labs should be considered first.
Rationale — Incorrect (D): Ambulation may worsen orthostatic
hypotension and risk falls; it does not address fluid deficit.
Teaching Point: Orthostatic changes + low urine output in older
adults = escalate for IV fluids and labs.
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
Stem: While performing a focused respiratory assessment, a
nurse documents the patient’s reported “tight chest” and notes
audible wheezes bilaterally with an SpO₂ of 91%. The patient is
speaking in short sentences and appears anxious. Which
nursing priority reflects appropriate clinical judgment?
A. Teach pursed-lip breathing and schedule a follow-up
respiratory assessment in two hours.
B. Administer prescribed bronchodilator and reassess breath
sounds and oxygenation.
C. Chart the findings as “patient anxious; no acute distress” and
continue routine care.
D. Encourage the patient to cough and deep breathe and
document the response.
Correct answer: B
Rationale — Correct (B): Audible wheezes, SpO₂ 91%, and
difficulty speaking in full sentences indicate active airway
compromise and hypoxemia; administering a prescribed
bronchodilator (per orders/protocol) and rapid reassessment is
the appropriate, timely nursing intervention. This demonstrates
application of assessment data to immediate action.
Rationale — Incorrect (A): Teaching breathing techniques is
supportive but delays urgent pharmacologic treatment; two-
hour wait is unsafe.
Rationale — Incorrect (C): Minimizing findings ignores objective
, hypoxemia and respiratory distress; unsafe.
Rationale — Incorrect (D): Coughing/deep breathing is helpful
for secretion clearance but is unlikely to relieve bronchospasm
causing wheeze and hypoxemia.
Teaching Point: Audible wheeze + SpO₂ ≤92% with speaking
difficulty = immediate treatment and reassessment.
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
Stem: During a cultural-sensitive admission interview, a nurse
asks open-ended questions and notices the patient avoids eye
contact and answers briefly. The patient’s family later says
direct eye contact is disrespectful in their culture. How should
the nurse document and proceed?
A. Note “poor eye contact” as a mental status finding and refer
for psychiatric evaluation.
B. Document the patient’s affect and that cultural norms may
influence eye contact; continue with assessment using
appropriate communication adjustments.
C. Record the behavior as noncompliant and insist on direct eye
contact to ensure accuracy of assessment.
D. Skip psychosocial history and proceed with physical
assessment only.
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1
Reference: Ch. 1 — The Nurse’s Role in Health Assessment
Stem: A 72-year-old man is admitted for dehydration. During
the admission assessment the nurse documents the patient’s
complaint as “not drinking much” and notes dry mucous
membranes, a urine output of 150 mL over 8 hours, and
orthostatic BP changes when sitting up. Which nursing action is
the most appropriate next step?
A. Continue routine monitoring and recheck intake and output
at the next scheduled time.
B. Initiate a focused hydration plan, increase oral fluids, and
request close monitoring of urine output.
C. Notify the provider immediately and recommend IV fluids
,and laboratory tests.
D. Encourage the patient to ambulate to stimulate thirst and
improve hydration.
Correct answer: C
Rationale — Correct (C): Orthostatic hypotension, oliguria (150
mL/8 hr), and dry mucous membranes in an older adult indicate
possible significant dehydration and risk for hypovolemia.
Notifying the provider for IV fluids and labs (electrolytes,
BUN/creatinine) is appropriate and urgent. This action aligns
with nursing assessment, early recognition of abnormal
findings, and escalation within scope.
Rationale — Incorrect (A): Waiting for routine monitoring
delays necessary evaluation and treatment for potentially
significant dehydration; unsafe.
Rationale — Incorrect (B): Increasing oral fluids is reasonable
but insufficient given oliguria and orthostatic changes—IV
therapy/labs should be considered first.
Rationale — Incorrect (D): Ambulation may worsen orthostatic
hypotension and risk falls; it does not address fluid deficit.
Teaching Point: Orthostatic changes + low urine output in older
adults = escalate for IV fluids and labs.
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
Stem: While performing a focused respiratory assessment, a
nurse documents the patient’s reported “tight chest” and notes
audible wheezes bilaterally with an SpO₂ of 91%. The patient is
speaking in short sentences and appears anxious. Which
nursing priority reflects appropriate clinical judgment?
A. Teach pursed-lip breathing and schedule a follow-up
respiratory assessment in two hours.
B. Administer prescribed bronchodilator and reassess breath
sounds and oxygenation.
C. Chart the findings as “patient anxious; no acute distress” and
continue routine care.
D. Encourage the patient to cough and deep breathe and
document the response.
Correct answer: B
Rationale — Correct (B): Audible wheezes, SpO₂ 91%, and
difficulty speaking in full sentences indicate active airway
compromise and hypoxemia; administering a prescribed
bronchodilator (per orders/protocol) and rapid reassessment is
the appropriate, timely nursing intervention. This demonstrates
application of assessment data to immediate action.
Rationale — Incorrect (A): Teaching breathing techniques is
supportive but delays urgent pharmacologic treatment; two-
hour wait is unsafe.
Rationale — Incorrect (C): Minimizing findings ignores objective
, hypoxemia and respiratory distress; unsafe.
Rationale — Incorrect (D): Coughing/deep breathing is helpful
for secretion clearance but is unlikely to relieve bronchospasm
causing wheeze and hypoxemia.
Teaching Point: Audible wheeze + SpO₂ ≤92% with speaking
difficulty = immediate treatment and reassessment.
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
Stem: During a cultural-sensitive admission interview, a nurse
asks open-ended questions and notices the patient avoids eye
contact and answers briefly. The patient’s family later says
direct eye contact is disrespectful in their culture. How should
the nurse document and proceed?
A. Note “poor eye contact” as a mental status finding and refer
for psychiatric evaluation.
B. Document the patient’s affect and that cultural norms may
influence eye contact; continue with assessment using
appropriate communication adjustments.
C. Record the behavior as noncompliant and insist on direct eye
contact to ensure accuracy of assessment.
D. Skip psychosocial history and proceed with physical
assessment only.
