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 Nursing Assessment
Stem
A 68-year-old man is admitted after a fall at home. He is alert
but reports mild hip pain and dizziness. As the admitting nurse,
which assessment action best fulfills the primary purpose of a
comprehensive nursing health assessment at admission?
A. Perform a head-to-toe focused physical exam centered only
on the injured hip.
B. Obtain a complete health history, review medications, and
perform a full head-to-toe assessment.
,C. Ask the patient to describe the fall and document his version
without additional assessment.
D. Request the physician perform the initial history and only
record vitals.
Correct Answer: B
Rationales
Correct (B): A comprehensive nursing assessment at admission
gathers data across bio-psychosocial domains, including current
complaint, medications, and a head-to-toe exam to identify
immediate risks (e.g., injury, medication interactions,
orthostatic dizziness). This information guides nursing priorities
and safe care planning.
A: Too narrow—focusing only on the hip misses other urgent
issues (e.g., head injury, dehydration).
C: Patient narration is important but insufficient; observation
and physical exam add objective data for safety.
D: Delegating initial history to physician delays nursing data
collection and misses nursing scope responsibilities.
Teaching Point: Admission assessment must integrate history,
meds, and full physical exam to identify immediate risks.
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 — Subjective vs
Objective Data
Stem
A 24-year-old female presents to the clinic complaining of
"shortness of breath." During assessment, you observe
increased respiratory rate, use of accessory muscles, and
oxygen saturation 90% on room air. Which statement best
classifies and prioritizes these findings for nursing action?
A. All findings are subjective and should be documented as the
patient's complaint.
B. The respiratory rate and accessory muscle use are objective
and require immediate nursing interventions.
C. Oxygen saturation of 90% is subjective and can be addressed
at the next routine check.
D. Shortness of breath is the only prioritized finding; vital signs
are secondary.
Correct Answer: B
Rationales
Correct (B): Increased respiratory rate, accessory muscle use,
and SpO₂ 90% are objective signs indicating respiratory
compromise; they require prompt nursing actions (oxygen,
positioning, rapid assessment). Objective data guide urgency.
A: Incorrect—shortness of breath is subjective; vital signs and
SpO₂ are objective.
C: Incorrect—SpO₂ is objective and low; delaying care is unsafe.
, D: Incorrect—subjective complaint is important, but objective
indicators determine acuity and priority.
Teaching Point: Objective respiratory signs (RR, work of
breathing, SpO₂) determine urgency and immediate
interventions.
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 & Communication
Stem
You are assessing an 82-year-old patient with moderate
dementia who cannot reliably answer health history questions.
The patient's daughter is present and offers detailed history.
Which approach best adheres to assessment standards?
A. Rely solely on the daughter's report and skip the physical
assessment.
B. Combine the daughter's collateral history with objective
interview, physical exam, and documentation of the data
source.
C. Record only the daughter's comments as the official patient
history without noting source.
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 Nursing Assessment
Stem
A 68-year-old man is admitted after a fall at home. He is alert
but reports mild hip pain and dizziness. As the admitting nurse,
which assessment action best fulfills the primary purpose of a
comprehensive nursing health assessment at admission?
A. Perform a head-to-toe focused physical exam centered only
on the injured hip.
B. Obtain a complete health history, review medications, and
perform a full head-to-toe assessment.
,C. Ask the patient to describe the fall and document his version
without additional assessment.
D. Request the physician perform the initial history and only
record vitals.
Correct Answer: B
Rationales
Correct (B): A comprehensive nursing assessment at admission
gathers data across bio-psychosocial domains, including current
complaint, medications, and a head-to-toe exam to identify
immediate risks (e.g., injury, medication interactions,
orthostatic dizziness). This information guides nursing priorities
and safe care planning.
A: Too narrow—focusing only on the hip misses other urgent
issues (e.g., head injury, dehydration).
C: Patient narration is important but insufficient; observation
and physical exam add objective data for safety.
D: Delegating initial history to physician delays nursing data
collection and misses nursing scope responsibilities.
Teaching Point: Admission assessment must integrate history,
meds, and full physical exam to identify immediate risks.
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 — Subjective vs
Objective Data
Stem
A 24-year-old female presents to the clinic complaining of
"shortness of breath." During assessment, you observe
increased respiratory rate, use of accessory muscles, and
oxygen saturation 90% on room air. Which statement best
classifies and prioritizes these findings for nursing action?
A. All findings are subjective and should be documented as the
patient's complaint.
B. The respiratory rate and accessory muscle use are objective
and require immediate nursing interventions.
C. Oxygen saturation of 90% is subjective and can be addressed
at the next routine check.
D. Shortness of breath is the only prioritized finding; vital signs
are secondary.
Correct Answer: B
Rationales
Correct (B): Increased respiratory rate, accessory muscle use,
and SpO₂ 90% are objective signs indicating respiratory
compromise; they require prompt nursing actions (oxygen,
positioning, rapid assessment). Objective data guide urgency.
A: Incorrect—shortness of breath is subjective; vital signs and
SpO₂ are objective.
C: Incorrect—SpO₂ is objective and low; delaying care is unsafe.
, D: Incorrect—subjective complaint is important, but objective
indicators determine acuity and priority.
Teaching Point: Objective respiratory signs (RR, work of
breathing, SpO₂) determine urgency and immediate
interventions.
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 & Communication
Stem
You are assessing an 82-year-old patient with moderate
dementia who cannot reliably answer health history questions.
The patient's daughter is present and offers detailed history.
Which approach best adheres to assessment standards?
A. Rely solely on the daughter's report and skip the physical
assessment.
B. Combine the daughter's collateral history with objective
interview, physical exam, and documentation of the data
source.
C. Record only the daughter's comments as the official patient
history without noting source.
