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 —
Prioritization of Assessment Data
Stem: A 68-year-old man arrives to the clinic complaining of
sudden onset left-sided chest discomfort and shortness of
breath. His spouse reports diaphoresis and that he looks pale.
As the nurse begins the assessment, what should the nurse
perform first?
A. Obtain a full cardiovascular history including angina risk
factors.
B. Measure vital signs and apply cardiac telemetry if available.
C. Ask about recent dietary intake and caffeine use.
D. Perform a focused musculoskeletal exam of the chest wall.
Correct answer: B
,Rationale — Correct (B): Measuring vital signs and initiating
telemetry provides immediate objective data to detect
hemodynamic instability or arrhythmia and supports rapid
clinical decision-making. In suspected acute cardiac events,
prompt physiologic assessment and monitoring are priority
nursing actions to guide interventions and escalation of care.
Rationales — Incorrect:
A. A full history is important but is secondary to obtaining
objective vital signs and monitoring when acute
cardiopulmonary symptoms are present.
C. Dietary history is low yield in the immediate assessment of
potential acute coronary or respiratory compromise.
D. A musculoskeletal exam is unlikely to address the urgent
cardiopulmonary risk suggested by the presentation and would
delay critical monitoring.
Teaching point: Prioritize objective cardiopulmonary
assessment (vitals/telemetry) for acute chest complaints.
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: During a home visit a 45-year-old patient reports “feeling
more tired than usual” and notes a 5-lb weight gain over two
weeks. The nurse measures a weight increase of 5 lb and
,documents bilateral lower extremity pitting edema. Which
documentation best separates subjective and objective data?
A. “Patient reports fatigue and 5-lb weight gain; measured
weight +5 lb; pitting edema noted bilaterally.”
B. “Patient has fatigue and edema; likely heart failure.”
C. “Patient’s symptoms indicate decreased activity tolerance.”
D. “Patient reports weight gain; nurse observed signs of heart
failure.”
Correct answer: A
Rationale — Correct (A): Option A clearly differentiates the
patient’s reported symptoms (subjective) from nurse-observed
and measured findings (objective), which is essential for
accurate assessment, communication, and subsequent clinical
decision-making. This format supports legal documentation and
interprofessional handoff.
Rationales — Incorrect:
B. Provides an interpretation (medical diagnosis) rather than
separating subjective/objective data; premature diagnostic
labeling by nurse is inappropriate.
C. States an inference (decreased activity tolerance) without
documenting specific objective measures or patient report.
D. Mixes subjective report with an implied medical diagnosis
rather than clearly documenting separate observations.
Teaching point: Document subjective reports and objective
findings distinctly and avoid premature medical diagnoses.
Citation: Weber & Kelley-Landaeta (2025). Ch. 1.
, 3)
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Delegation and Accountability
Stem: A staff nurse assigns a nursing assistant to obtain routine
vital signs on a postoperative patient. The assistant reports a
temperature of 38.4°C and pulse of 110/min. The nurse notes
warm, erythematous incision edges on quick inspection. What
is the nurse’s next best action?
A. Ask the assistant to recheck vitals in 4 hours and document.
B. Initiate a focused nursing assessment and notify the surgeon
or provider.
C. Administer PRN acetaminophen and continue routine care.
D. Tell the assistant to continue routine postoperative tasks and
chart the findings.
Correct answer: B
Rationale — Correct (B): The nurse remains accountable for
assessment interpretation and must perform a focused
assessment, evaluate for signs of infection or systemic
response, and promptly notify the provider because
tachycardia, fever, and local incision changes suggest possible
postoperative infection. Delegation does not transfer clinical
judgment or responsibility.
Rationales — Incorrect:
A. Waiting 4 hours risks delayed recognition of deterioration
and fails to meet accountability for abnormal findings.
C. Administering antipyretic without assessment and
notification addresses a symptom but not the potential 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 —
Prioritization of Assessment Data
Stem: A 68-year-old man arrives to the clinic complaining of
sudden onset left-sided chest discomfort and shortness of
breath. His spouse reports diaphoresis and that he looks pale.
As the nurse begins the assessment, what should the nurse
perform first?
A. Obtain a full cardiovascular history including angina risk
factors.
B. Measure vital signs and apply cardiac telemetry if available.
C. Ask about recent dietary intake and caffeine use.
D. Perform a focused musculoskeletal exam of the chest wall.
Correct answer: B
,Rationale — Correct (B): Measuring vital signs and initiating
telemetry provides immediate objective data to detect
hemodynamic instability or arrhythmia and supports rapid
clinical decision-making. In suspected acute cardiac events,
prompt physiologic assessment and monitoring are priority
nursing actions to guide interventions and escalation of care.
Rationales — Incorrect:
A. A full history is important but is secondary to obtaining
objective vital signs and monitoring when acute
cardiopulmonary symptoms are present.
C. Dietary history is low yield in the immediate assessment of
potential acute coronary or respiratory compromise.
D. A musculoskeletal exam is unlikely to address the urgent
cardiopulmonary risk suggested by the presentation and would
delay critical monitoring.
Teaching point: Prioritize objective cardiopulmonary
assessment (vitals/telemetry) for acute chest complaints.
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: During a home visit a 45-year-old patient reports “feeling
more tired than usual” and notes a 5-lb weight gain over two
weeks. The nurse measures a weight increase of 5 lb and
,documents bilateral lower extremity pitting edema. Which
documentation best separates subjective and objective data?
A. “Patient reports fatigue and 5-lb weight gain; measured
weight +5 lb; pitting edema noted bilaterally.”
B. “Patient has fatigue and edema; likely heart failure.”
C. “Patient’s symptoms indicate decreased activity tolerance.”
D. “Patient reports weight gain; nurse observed signs of heart
failure.”
Correct answer: A
Rationale — Correct (A): Option A clearly differentiates the
patient’s reported symptoms (subjective) from nurse-observed
and measured findings (objective), which is essential for
accurate assessment, communication, and subsequent clinical
decision-making. This format supports legal documentation and
interprofessional handoff.
Rationales — Incorrect:
B. Provides an interpretation (medical diagnosis) rather than
separating subjective/objective data; premature diagnostic
labeling by nurse is inappropriate.
C. States an inference (decreased activity tolerance) without
documenting specific objective measures or patient report.
D. Mixes subjective report with an implied medical diagnosis
rather than clearly documenting separate observations.
Teaching point: Document subjective reports and objective
findings distinctly and avoid premature medical diagnoses.
Citation: Weber & Kelley-Landaeta (2025). Ch. 1.
, 3)
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Delegation and Accountability
Stem: A staff nurse assigns a nursing assistant to obtain routine
vital signs on a postoperative patient. The assistant reports a
temperature of 38.4°C and pulse of 110/min. The nurse notes
warm, erythematous incision edges on quick inspection. What
is the nurse’s next best action?
A. Ask the assistant to recheck vitals in 4 hours and document.
B. Initiate a focused nursing assessment and notify the surgeon
or provider.
C. Administer PRN acetaminophen and continue routine care.
D. Tell the assistant to continue routine postoperative tasks and
chart the findings.
Correct answer: B
Rationale — Correct (B): The nurse remains accountable for
assessment interpretation and must perform a focused
assessment, evaluate for signs of infection or systemic
response, and promptly notify the provider because
tachycardia, fever, and local incision changes suggest possible
postoperative infection. Delegation does not transfer clinical
judgment or responsibility.
Rationales — Incorrect:
A. Waiting 4 hours risks delayed recognition of deterioration
and fails to meet accountability for abnormal findings.
C. Administering antipyretic without assessment and
notification addresses a symptom but not the potential source
