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 for elective hip repair. During the
initial assessment he reports chronic daily smoking and
shortness of breath with exertion over the past 6 months. His
pulse oximetry on room air is 92% and respirations 22/min.
Which nursing interpretation and next action is most
appropriate?
Options
A. Document the chronic shortness of breath as a baseline
,finding and proceed with routine pre-op orders.
B. Notify the surgeon immediately—this oxygen saturation
indicates acute respiratory failure.
C. Recognize a potentially abnormal finding for age and smoking
history and initiate further respiratory assessment and report to
the perioperative team.
D. Administer supplemental oxygen now without further
assessment because SpO₂ <95% is always abnormal.
Correct Answer
C
Rationales
Correct (C): SpO₂ 92% in a chronic smoker with exertional
dyspnea is an abnormal finding needing expanded assessment
(lung auscultation, ABG consideration, activity tolerance) and
communication with the perioperative team to guide risk
reduction. This aligns with nursing responsibilities to identify
and report abnormal assessment data.
Incorrect (A): Treating it as a routine baseline misses the need
for further evaluation and could compromise safety.
Incorrect (B): Immediate notification is appropriate, but
labeling it “acute respiratory failure” is premature; further
assessment should precede urgent escalation.
Incorrect (D): Providing oxygen without targeted assessment
and orders risks masking clinical status and deviates from scope.
,Teaching Point
Assess abnormal findings, contextualize with history, then
communicate to the team.
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 16-year-old adolescent tells the nurse she “feels tired all the
time” and “hasn’t had her usual appetite,” while her vitals are
within normal limits and weight is down 3 kg in two months.
Which action best reflects appropriate nursing assessment and
documentation?
Options
A. Document the complaint as “fatigue” and schedule routine
follow-up in one month.
B. Record the adolescent’s statements as subjective data,
document the weight loss objectively, and explore contributing
factors now.
C. Ignore subjective complaints since objective vitals are normal
and focus only on vital signs.
, D. Immediately refer to psychiatry without further nursing
assessment since appetite changes indicate depression.
Correct Answer
B
Rationales
Correct (B): Nursing assessment requires recording subjective
statements verbatim, noting objective signs (weight loss), and
further exploring causes (sleep, school stress, eating patterns)
immediately to identify risks. This integrates subjective and
objective data.
Incorrect (A): Vague documentation and delayed follow-up fails
to investigate a significant weight loss.
Incorrect (C): Omitting subjective data neglects important
patient-reported symptoms and risks.
Incorrect (D): Psychiatric referral may be appropriate later, but
immediate further nursing assessment is required before
referral.
Teaching Point
Document verbatim subjective reports and correlate with
objective data; assess causes promptly.
Citation
Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health Assessment
in Nursing (8th ed.). Ch. 1.
3
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 for elective hip repair. During the
initial assessment he reports chronic daily smoking and
shortness of breath with exertion over the past 6 months. His
pulse oximetry on room air is 92% and respirations 22/min.
Which nursing interpretation and next action is most
appropriate?
Options
A. Document the chronic shortness of breath as a baseline
,finding and proceed with routine pre-op orders.
B. Notify the surgeon immediately—this oxygen saturation
indicates acute respiratory failure.
C. Recognize a potentially abnormal finding for age and smoking
history and initiate further respiratory assessment and report to
the perioperative team.
D. Administer supplemental oxygen now without further
assessment because SpO₂ <95% is always abnormal.
Correct Answer
C
Rationales
Correct (C): SpO₂ 92% in a chronic smoker with exertional
dyspnea is an abnormal finding needing expanded assessment
(lung auscultation, ABG consideration, activity tolerance) and
communication with the perioperative team to guide risk
reduction. This aligns with nursing responsibilities to identify
and report abnormal assessment data.
Incorrect (A): Treating it as a routine baseline misses the need
for further evaluation and could compromise safety.
Incorrect (B): Immediate notification is appropriate, but
labeling it “acute respiratory failure” is premature; further
assessment should precede urgent escalation.
Incorrect (D): Providing oxygen without targeted assessment
and orders risks masking clinical status and deviates from scope.
,Teaching Point
Assess abnormal findings, contextualize with history, then
communicate to the team.
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 16-year-old adolescent tells the nurse she “feels tired all the
time” and “hasn’t had her usual appetite,” while her vitals are
within normal limits and weight is down 3 kg in two months.
Which action best reflects appropriate nursing assessment and
documentation?
Options
A. Document the complaint as “fatigue” and schedule routine
follow-up in one month.
B. Record the adolescent’s statements as subjective data,
document the weight loss objectively, and explore contributing
factors now.
C. Ignore subjective complaints since objective vitals are normal
and focus only on vital signs.
, D. Immediately refer to psychiatry without further nursing
assessment since appetite changes indicate depression.
Correct Answer
B
Rationales
Correct (B): Nursing assessment requires recording subjective
statements verbatim, noting objective signs (weight loss), and
further exploring causes (sleep, school stress, eating patterns)
immediately to identify risks. This integrates subjective and
objective data.
Incorrect (A): Vague documentation and delayed follow-up fails
to investigate a significant weight loss.
Incorrect (C): Omitting subjective data neglects important
patient-reported symptoms and risks.
Incorrect (D): Psychiatric referral may be appropriate later, but
immediate further nursing assessment is required before
referral.
Teaching Point
Document verbatim subjective reports and correlate with
objective data; assess causes promptly.
Citation
Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health Assessment
in Nursing (8th ed.). Ch. 1.
3
