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 & Scope of Assessment
Stem: A 68-year-old man is admitted for elective knee
replacement. During the admission assessment the nurse notes
scattered ecchymoses on the forearms and reports that the
patient is taking an over-the-counter herbal supplement for
“blood cleansing.” Which nursing action is the most appropriate
first step?
A. Document the ecchymoses and proceed with scheduled pre-
op teaching.
B. Notify the surgical team and hold all anticoagulant
medications.
,C. Ask focused questions about the supplement, document the
findings, and report to the provider per protocol.
D. Apply pressure dressings to the areas and instruct the patient
to stop the supplement.
Correct answer: C
Rationale — Correct: The nurse should clarify the supplement
use (type, dose, timing), document assessment, and report to
the provider per facility protocol because herbal agents (e.g.,
ginkgo, garlic) may increase bleeding risk preoperatively. This
integrates data collection, safety prioritization, and appropriate
communication.
Rationale — A: Proceeding without follow-up risks missing an
important preoperative bleeding risk. Documentation alone is
insufficient.
Rationale — B: Holding prescribed anticoagulants is a provider
decision; the nurse should report findings first.
Rationale — D: Applying dressings and instructing to stop is
premature without verifying the supplement and notifying the
provider.
Teaching point: Always assess and report herbal/supplement
use—document details and escalate per protocol.
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 —
Types of Assessment
Stem: A 23-year-old woman presents to urgent care with sore
throat and fever. The nurse must choose between a focused
and a comprehensive assessment. Which approach is most
appropriate and why?
A. Comprehensive assessment to collect baseline data for all
systems.
B. Focused assessment on the respiratory and ENT systems to
address the immediate complaint.
C. No assessment is necessary; obtain provider orders for
laboratory tests first.
D. Focused musculoskeletal assessment because young adults
commonly have viral myalgias.
Correct answer: B
Rationale — Correct: For an acute, specific complaint, a
focused assessment directed at relevant systems
(respiratory/ENT) efficiently identifies urgent findings and
guides immediate nursing actions. It balances thoroughness
with timeliness.
Rationale — A: A comprehensive assessment is time-consuming
and not immediately necessary for an acute focused problem.
Rationale — C: Skipping assessment and ordering tests
bypasses essential clinical judgment; assessment should guide
testing.
, Rationale — D: A musculoskeletal focus is not aligned with the
presenting symptom of sore throat and fever.
Teaching point: Use focused assessments for specific acute
complaints to quickly identify relevant findings.
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 —
Sources of Data & Validation
Stem: A nurse obtains a patient's history from an interviewer at
bedside because the patient is aphasic after a stroke. The nurse
notes inconsistencies between the interviewer’s report and the
medication list from the electronic health record (EHR). What is
the nurse’s best next action?
A. Accept the interviewer's report as accurate and continue
care.
B. Validate the information by contacting the patient’s primary
caregiver and cross-checking the EHR.
C. Remove the medication from the EHR to avoid confusion.
D. Delay all medication administration until the patient can
speak.
Correct answer: B
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 & Scope of Assessment
Stem: A 68-year-old man is admitted for elective knee
replacement. During the admission assessment the nurse notes
scattered ecchymoses on the forearms and reports that the
patient is taking an over-the-counter herbal supplement for
“blood cleansing.” Which nursing action is the most appropriate
first step?
A. Document the ecchymoses and proceed with scheduled pre-
op teaching.
B. Notify the surgical team and hold all anticoagulant
medications.
,C. Ask focused questions about the supplement, document the
findings, and report to the provider per protocol.
D. Apply pressure dressings to the areas and instruct the patient
to stop the supplement.
Correct answer: C
Rationale — Correct: The nurse should clarify the supplement
use (type, dose, timing), document assessment, and report to
the provider per facility protocol because herbal agents (e.g.,
ginkgo, garlic) may increase bleeding risk preoperatively. This
integrates data collection, safety prioritization, and appropriate
communication.
Rationale — A: Proceeding without follow-up risks missing an
important preoperative bleeding risk. Documentation alone is
insufficient.
Rationale — B: Holding prescribed anticoagulants is a provider
decision; the nurse should report findings first.
Rationale — D: Applying dressings and instructing to stop is
premature without verifying the supplement and notifying the
provider.
Teaching point: Always assess and report herbal/supplement
use—document details and escalate per protocol.
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 —
Types of Assessment
Stem: A 23-year-old woman presents to urgent care with sore
throat and fever. The nurse must choose between a focused
and a comprehensive assessment. Which approach is most
appropriate and why?
A. Comprehensive assessment to collect baseline data for all
systems.
B. Focused assessment on the respiratory and ENT systems to
address the immediate complaint.
C. No assessment is necessary; obtain provider orders for
laboratory tests first.
D. Focused musculoskeletal assessment because young adults
commonly have viral myalgias.
Correct answer: B
Rationale — Correct: For an acute, specific complaint, a
focused assessment directed at relevant systems
(respiratory/ENT) efficiently identifies urgent findings and
guides immediate nursing actions. It balances thoroughness
with timeliness.
Rationale — A: A comprehensive assessment is time-consuming
and not immediately necessary for an acute focused problem.
Rationale — C: Skipping assessment and ordering tests
bypasses essential clinical judgment; assessment should guide
testing.
, Rationale — D: A musculoskeletal focus is not aligned with the
presenting symptom of sore throat and fever.
Teaching point: Use focused assessments for specific acute
complaints to quickly identify relevant findings.
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 —
Sources of Data & Validation
Stem: A nurse obtains a patient's history from an interviewer at
bedside because the patient is aphasic after a stroke. The nurse
notes inconsistencies between the interviewer’s report and the
medication list from the electronic health record (EHR). What is
the nurse’s best next action?
A. Accept the interviewer's report as accurate and continue
care.
B. Validate the information by contacting the patient’s primary
caregiver and cross-checking the EHR.
C. Remove the medication from the EHR to avoid confusion.
D. Delay all medication administration until the patient can
speak.
Correct answer: B
