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 — Scope &
Purpose of Assessment
Stem
A 68-year-old man is admitted after a fall at home. He is alert,
reports mild hip pain, and has a history of hypertension and
mild cognitive impairment. As the admitting nurse, you must
decide the immediate next step in the assessment to ensure
safe care during the initial shift change. Which action best
reflects the nurse’s role in focused assessment and
prioritization?
,Options
A. Perform a full head-to-toe physical assessment immediately,
recording all findings in the electronic record.
B. Conduct a focused musculoskeletal and neurovascular
assessment of the injured area and screen for fall-related
injuries.
C. Delegate the initial assessment to nursing assistive personnel
and begin medication reconciliation.
D. Ask the patient to ambulate to determine mobility and assess
pain tolerance.
Correct answer
B
Rationales
Correct (B): A focused assessment of the injured area plus
neurovascular checks addresses immediate safety concerns
after a fall and aligns with nursing scope to identify urgent
problems. It prioritizes findings that affect immediate
interventions (immobilization, analgesia, transfer).
Incorrect (A): A full head-to-toe is comprehensive but not the
most time-sensitive for a fall with focal pain; it may delay urgent
checks.
Incorrect (C): Delegating initial focused assessment is unsafe;
the nurse retains responsibility for clinical judgment and initial
prioritization.
Incorrect (D): Encouraging ambulation before assessing for
fracture or neurovascular compromise risks harm.
,Teaching point
Prioritize focused assessments that identify immediate threats
to safety first.
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 — Levels of
Assessment
Stem
A newly hired graduate nurse is preparing to perform admission
assessments on a pediatric unit. The preceptor asks the nurse
to explain when to use a focused assessment versus a
comprehensive assessment. Which example best demonstrates
appropriate selection of assessment level?
Options
A. Use a comprehensive assessment for every clinic visit
regardless of presenting complaint.
B. Use a focused assessment for a child brought in for an acute
earache, concentrating on ear, respiratory, and pain findings.
C. Use a focused assessment only when the comprehensive
assessment cannot be completed.
, D. Use comprehensive assessments only for patients over 65
years old.
Correct answer
B
Rationales
Correct (B): Focused assessments target the chief complaint
and related systems—appropriate for an acute earache and
efficient for urgent management while still being within nursing
assessment scope.
Incorrect (A): Comprehensive assessments are not required for
every visit; they are reserved for initial/periodic exams or when
indicated.
Incorrect (C): Focused assessments are a deliberate choice
based on clinical need, not merely a fallback.
Incorrect (D): Age alone does not mandate comprehensive
assessment; clinical context determines level.
Teaching point
Choose focused assessments to evaluate specific patient
complaints and related systems efficiently.
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 — Scope &
Purpose of Assessment
Stem
A 68-year-old man is admitted after a fall at home. He is alert,
reports mild hip pain, and has a history of hypertension and
mild cognitive impairment. As the admitting nurse, you must
decide the immediate next step in the assessment to ensure
safe care during the initial shift change. Which action best
reflects the nurse’s role in focused assessment and
prioritization?
,Options
A. Perform a full head-to-toe physical assessment immediately,
recording all findings in the electronic record.
B. Conduct a focused musculoskeletal and neurovascular
assessment of the injured area and screen for fall-related
injuries.
C. Delegate the initial assessment to nursing assistive personnel
and begin medication reconciliation.
D. Ask the patient to ambulate to determine mobility and assess
pain tolerance.
Correct answer
B
Rationales
Correct (B): A focused assessment of the injured area plus
neurovascular checks addresses immediate safety concerns
after a fall and aligns with nursing scope to identify urgent
problems. It prioritizes findings that affect immediate
interventions (immobilization, analgesia, transfer).
Incorrect (A): A full head-to-toe is comprehensive but not the
most time-sensitive for a fall with focal pain; it may delay urgent
checks.
Incorrect (C): Delegating initial focused assessment is unsafe;
the nurse retains responsibility for clinical judgment and initial
prioritization.
Incorrect (D): Encouraging ambulation before assessing for
fracture or neurovascular compromise risks harm.
,Teaching point
Prioritize focused assessments that identify immediate threats
to safety first.
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 — Levels of
Assessment
Stem
A newly hired graduate nurse is preparing to perform admission
assessments on a pediatric unit. The preceptor asks the nurse
to explain when to use a focused assessment versus a
comprehensive assessment. Which example best demonstrates
appropriate selection of assessment level?
Options
A. Use a comprehensive assessment for every clinic visit
regardless of presenting complaint.
B. Use a focused assessment for a child brought in for an acute
earache, concentrating on ear, respiratory, and pain findings.
C. Use a focused assessment only when the comprehensive
assessment cannot be completed.
, D. Use comprehensive assessments only for patients over 65
years old.
Correct answer
B
Rationales
Correct (B): Focused assessments target the chief complaint
and related systems—appropriate for an acute earache and
efficient for urgent management while still being within nursing
assessment scope.
Incorrect (A): Comprehensive assessments are not required for
every visit; they are reserved for initial/periodic exams or when
indicated.
Incorrect (C): Focused assessments are a deliberate choice
based on clinical need, not merely a fallback.
Incorrect (D): Age alone does not mandate comprehensive
assessment; clinical context determines level.
Teaching point
Choose focused assessments to evaluate specific patient
complaints and related systems efficiently.
Citation
Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health Assessment
in Nursing (8th ed.). Ch. 1.
3
