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 congestive heart failure
exacerbation. During initial nursing assessment he reports
increased shortness of breath and orthopnea, and you observe
3+ pitting edema in both lower extremities. Which action best
reflects the nurse’s role in data collection and immediate
prioritization?
A. Document the findings in the EHR and notify the physician of
the assessment later in the shift.
B. Measure and record oxygen saturation, place the patient in
high-Fowler’s position, and alert the provider now.
C. Teach the patient about low-sodium diet and fluid restriction
,and schedule dietitian consult.
D. Arrange for daily weights tomorrow morning and document
edema as chronic.
Correct Answer: B
Rationale — Correct: Measuring oxygen saturation, improving
position for breathing, and notifying the provider are
immediate, safety-focused assessment and action steps. These
address current acute respiratory compromise and fluid
overload. This sequence reflects nursing assessment,
immediate intervention, and escalation within scope.
Rationale — A (incorrect): Delaying notification and only
documenting fails to address possible hypoxia and acute
decompensation; unsafe.
Rationale — C (incorrect): Education and dietitian referral are
appropriate but not the priority when there are signs of acute
respiratory compromise.
Rationale — D (incorrect): Waiting until tomorrow neglects
urgent needs; edema should be evaluated and trended now.
Teaching Point: Prioritize immediate physiologic threats: assess,
intervene, then escalate.
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 woman reports “dizziness when I stand up”
during triage. On standing you record a blood pressure drop
from 118/76 mm Hg (supine) to 92/60 mm Hg (standing) and a
pulse increase from 72 to 106 bpm. How should the nurse
interpret and act on these findings?
A. Document as anxiety-related palpitations and recommend
rest.
B. Recognize orthostatic hypotension, ensure patient safety, and
report for further evaluation.
C. Attribute findings to dehydration and immediately give a 1-
liter IV bolus.
D. Label the patient vertiginous and schedule an outpatient ENT
referral.
Correct Answer: B
Rationale — Correct: The BP drop ≥20 mm Hg systolic with HR
increase is consistent with orthostatic hypotension. The nurse
should prioritize safety (assist to sit/lie), monitor, and notify
provider for further evaluation (medication review, volume
status). This demonstrates correct interpretation of objective
and subjective data.
Rationale — A (incorrect): Dismissing physiologic causes as
anxiety ignores objective orthostatic changes and is unsafe.
Rationale — C (incorrect): Fluid resuscitation may be
inappropriate without assessment of volume status and
, provider orders. Immediate bolus is premature.
Rationale — D (incorrect): ENT referral may be considered
later; it does not address acute orthostatic findings or safety.
Teaching Point: Orthostatic changes require immediate safety
measures and further evaluation.
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 —
Therapeutic Communication & Interviewing
Stem: During a comprehensive health history a 16-year-old
patient refuses to allow her parent in the room and discloses
sexual activity but asks the nurse to not tell her parents. Which
action aligns with therapeutic interviewing and ethical/legal
responsibilities?
A. Honor confidentiality completely and document the sexual
history without parental notification.
B. Tell the teen that parents will be informed because she is a
minor.
C. Explain confidentiality limits, assess for safety or reportable
risks, provide sexual health counseling, and document findings.
D. Refuse to discuss sexual history and insist the parent remain
present.
Correct Answer: C
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 congestive heart failure
exacerbation. During initial nursing assessment he reports
increased shortness of breath and orthopnea, and you observe
3+ pitting edema in both lower extremities. Which action best
reflects the nurse’s role in data collection and immediate
prioritization?
A. Document the findings in the EHR and notify the physician of
the assessment later in the shift.
B. Measure and record oxygen saturation, place the patient in
high-Fowler’s position, and alert the provider now.
C. Teach the patient about low-sodium diet and fluid restriction
,and schedule dietitian consult.
D. Arrange for daily weights tomorrow morning and document
edema as chronic.
Correct Answer: B
Rationale — Correct: Measuring oxygen saturation, improving
position for breathing, and notifying the provider are
immediate, safety-focused assessment and action steps. These
address current acute respiratory compromise and fluid
overload. This sequence reflects nursing assessment,
immediate intervention, and escalation within scope.
Rationale — A (incorrect): Delaying notification and only
documenting fails to address possible hypoxia and acute
decompensation; unsafe.
Rationale — C (incorrect): Education and dietitian referral are
appropriate but not the priority when there are signs of acute
respiratory compromise.
Rationale — D (incorrect): Waiting until tomorrow neglects
urgent needs; edema should be evaluated and trended now.
Teaching Point: Prioritize immediate physiologic threats: assess,
intervene, then escalate.
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 woman reports “dizziness when I stand up”
during triage. On standing you record a blood pressure drop
from 118/76 mm Hg (supine) to 92/60 mm Hg (standing) and a
pulse increase from 72 to 106 bpm. How should the nurse
interpret and act on these findings?
A. Document as anxiety-related palpitations and recommend
rest.
B. Recognize orthostatic hypotension, ensure patient safety, and
report for further evaluation.
C. Attribute findings to dehydration and immediately give a 1-
liter IV bolus.
D. Label the patient vertiginous and schedule an outpatient ENT
referral.
Correct Answer: B
Rationale — Correct: The BP drop ≥20 mm Hg systolic with HR
increase is consistent with orthostatic hypotension. The nurse
should prioritize safety (assist to sit/lie), monitor, and notify
provider for further evaluation (medication review, volume
status). This demonstrates correct interpretation of objective
and subjective data.
Rationale — A (incorrect): Dismissing physiologic causes as
anxiety ignores objective orthostatic changes and is unsafe.
Rationale — C (incorrect): Fluid resuscitation may be
inappropriate without assessment of volume status and
, provider orders. Immediate bolus is premature.
Rationale — D (incorrect): ENT referral may be considered
later; it does not address acute orthostatic findings or safety.
Teaching Point: Orthostatic changes require immediate safety
measures and further evaluation.
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 —
Therapeutic Communication & Interviewing
Stem: During a comprehensive health history a 16-year-old
patient refuses to allow her parent in the room and discloses
sexual activity but asks the nurse to not tell her parents. Which
action aligns with therapeutic interviewing and ethical/legal
responsibilities?
A. Honor confidentiality completely and document the sexual
history without parental notification.
B. Tell the teen that parents will be informed because she is a
minor.
C. Explain confidentiality limits, assess for safety or reportable
risks, provide sexual health counseling, and document findings.
D. Refuse to discuss sexual history and insist the parent remain
present.
Correct Answer: C
