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 —
Professional Scope & Responsibilities
Stem: A 68-year-old man with COPD arrives for a routine
assessment. He reports increased shortness of breath over 2
days and used his rescue inhaler three times with limited relief.
As the nurse completing the health assessment, what is the
most appropriate immediate nursing action?
A. Document the patient's report and schedule a follow-up visit
next week.
B. Perform focused respiratory assessment (including pulse
oximetry and auscultation) and notify the provider of abnormal
findings.
C. Reinforce inhaler technique education and advise patient to
,continue current medications.
D. Ask the patient to demonstrate his inhaler use and then
discharge with written instructions.
Correct answer: B
Rationale — Correct (B): The nurse’s role is to gather focused
objective data when a patient reports worsening respiratory
symptoms. Performing pulse oximetry and lung auscultation
identifies current physiologic status and provides information to
the provider; prompt notification is warranted for potential
exacerbation. This action prioritizes patient safety and timely
escalation.
Rationale — Incorrect:
A. Scheduling a routine follow-up is unsafe and delays urgent
assessment and potential treatment.
C. Education is important but premature without assessing
current respiratory function and oxygenation.
D. Asking for inhaler demonstration is useful but insufficient as
an immediate single action given acute symptom change.
Teaching point: Focused assessments guide urgency; escalate
abnormal respiratory findings immediately.
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 —
,Data Sources & Validation
Stem: During admission, a 24-year-old woman reports no
allergies on her history form, but her spouse tells you she
develops hives when given penicillin. Vital signs are stable.
What is the best nursing action to ensure accurate assessment
data?
A. Accept the spouse’s report and label the patient as penicillin-
allergic in the chart without further verification.
B. Ask the patient privately about past reactions specifically to
penicillin and document both patient and spouse reports.
C. Ignore the spouse’s comment because the patient denied
allergies on the intake form.
D. Administer a test dose of penicillin to confirm whether she
reacts.
Correct answer: B
Rationale — Correct (B): The nurse must validate inconsistent
data by asking the patient directly in private, clarifying the type
and timing of reaction, and documenting both the patient’s
statement and the spouse’s information. This preserves patient
autonomy and produces accurate, actionable information.
Rationale — Incorrect:
A. Labeling without patient confirmation may violate autonomy
and lead to errors if the patient later denies the allergy.
C. Ignoring collateral information risks patient safety if the
allergy is real.
D. Administering a test dose is beyond routine nursing
, assessment and unsafe without provider order and allergy
workup.
Teaching point: Always validate conflicting data directly with
the patient and document both sources.
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 —
Subjective vs Objective Data
Stem: A 45-year-old patient states, "I feel feverish," yet you
record an oral temperature of 36.8°C (98.2°F). Which action
best reflects accurate nursing assessment and documentation?
A. Record only the objective temperature and omit the patient’s
subjective complaint.
B. Note both the subjective complaint and the objective
measurement, perform further assessment for other signs, and
recheck temperature if indicated.
C. Tell the patient they are not having a fever and document
that the complaint was unfounded.
D. Immediately start antipyretic treatment based on the
patient’s subjective report.
Correct answer: B
Rationale — Correct (B): Accurate assessment and
documentation include both subjective symptoms and objective
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Professional Scope & Responsibilities
Stem: A 68-year-old man with COPD arrives for a routine
assessment. He reports increased shortness of breath over 2
days and used his rescue inhaler three times with limited relief.
As the nurse completing the health assessment, what is the
most appropriate immediate nursing action?
A. Document the patient's report and schedule a follow-up visit
next week.
B. Perform focused respiratory assessment (including pulse
oximetry and auscultation) and notify the provider of abnormal
findings.
C. Reinforce inhaler technique education and advise patient to
,continue current medications.
D. Ask the patient to demonstrate his inhaler use and then
discharge with written instructions.
Correct answer: B
Rationale — Correct (B): The nurse’s role is to gather focused
objective data when a patient reports worsening respiratory
symptoms. Performing pulse oximetry and lung auscultation
identifies current physiologic status and provides information to
the provider; prompt notification is warranted for potential
exacerbation. This action prioritizes patient safety and timely
escalation.
Rationale — Incorrect:
A. Scheduling a routine follow-up is unsafe and delays urgent
assessment and potential treatment.
C. Education is important but premature without assessing
current respiratory function and oxygenation.
D. Asking for inhaler demonstration is useful but insufficient as
an immediate single action given acute symptom change.
Teaching point: Focused assessments guide urgency; escalate
abnormal respiratory findings immediately.
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 —
,Data Sources & Validation
Stem: During admission, a 24-year-old woman reports no
allergies on her history form, but her spouse tells you she
develops hives when given penicillin. Vital signs are stable.
What is the best nursing action to ensure accurate assessment
data?
A. Accept the spouse’s report and label the patient as penicillin-
allergic in the chart without further verification.
B. Ask the patient privately about past reactions specifically to
penicillin and document both patient and spouse reports.
C. Ignore the spouse’s comment because the patient denied
allergies on the intake form.
D. Administer a test dose of penicillin to confirm whether she
reacts.
Correct answer: B
Rationale — Correct (B): The nurse must validate inconsistent
data by asking the patient directly in private, clarifying the type
and timing of reaction, and documenting both the patient’s
statement and the spouse’s information. This preserves patient
autonomy and produces accurate, actionable information.
Rationale — Incorrect:
A. Labeling without patient confirmation may violate autonomy
and lead to errors if the patient later denies the allergy.
C. Ignoring collateral information risks patient safety if the
allergy is real.
D. Administering a test dose is beyond routine nursing
, assessment and unsafe without provider order and allergy
workup.
Teaching point: Always validate conflicting data directly with
the patient and document both sources.
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 —
Subjective vs Objective Data
Stem: A 45-year-old patient states, "I feel feverish," yet you
record an oral temperature of 36.8°C (98.2°F). Which action
best reflects accurate nursing assessment and documentation?
A. Record only the objective temperature and omit the patient’s
subjective complaint.
B. Note both the subjective complaint and the objective
measurement, perform further assessment for other signs, and
recheck temperature if indicated.
C. Tell the patient they are not having a fever and document
that the complaint was unfounded.
D. Immediately start antipyretic treatment based on the
patient’s subjective report.
Correct answer: B
Rationale — Correct (B): Accurate assessment and
documentation include both subjective symptoms and objective
