HEALTH ASSESSMENT IN NURSING
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1
Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Purpose & Scope of Nursing Assessment
Stem: A 68-year-old man is admitted for evaluation after a fall
at home. During your initial assessment you collect subjective
data that he reports increased confusion for 2 days and
objective data showing a small laceration to his forehead and a
blood pressure of 88/56 mm Hg. Which nursing action is the
most appropriate next step?
A. Complete a comprehensive head-to-toe history and full
physical before notifying the provider.
B. Reassess blood pressure, apply oxygen if indicated, and notify
the provider immediately.
,C. Document findings in the electronic record and plan to
communicate during morning rounds.
D. Ask family members about his baseline cognition and
continue routine fall-prevention measures.
Correct answer: B
Rationale — Correct (B): The low blood pressure with new
confusion and head injury are urgent findings; reassessment
and immediate stabilization (ABC-focused) and provider
notification are time-sensitive nursing priorities. Repeating
vitals and providing supportive measures (oxygen, IV access per
protocol) support safe circulation and perfusion while escalating
care.
Rationale — Incorrect:
A. Unsafe delay—doing a full comprehensive assessment before
addressing hypotension risks deterioration.
C. Documentation without immediate action is inappropriate
for hypotension and acute confusion.
D. Obtaining collateral is useful but does not replace urgent
reassessment and escalation.
Teaching point: New hypotension with altered mentation
requires immediate reassessment and escalation.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
2
,Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Nursing Process & Phases of Assessment
Stem: During triage in the ED, a 24-year-old woman reports
sudden onset shortness of breath and chest tightness. You must
choose an assessment approach that balances speed with
completeness. Which assessment type best fits this situation?
A. Comprehensive head-to-toe assessment in the ED treatment
room.
B. Focused problem-centered assessment targeting
cardiopulmonary function.
C. Ongoing periodic assessment scheduled every 8 hours.
D. Complete health history interview before physical
assessment.
Correct answer: B
Rationale — Correct (B): In urgent, symptom-driven
presentations, a focused problem-centered assessment directed
at the cardiopulmonary system efficiently gathers high-yield
subjective and objective data necessary for immediate clinical
judgment and interventions.
Rationale — Incorrect:
A. Comprehensive assessment is time-consuming and not
appropriate as initial triage for acute respiratory symptoms.
C. Periodic routine assessments miss the need for immediate,
targeted evaluation.
D. Delaying the physical exam until a full history is completed is
unsafe in acute dyspnea.
, Teaching point: Use focused assessments for acute, symptom-
driven presentations to prioritize urgent data.
Citation: Weber & Kelley-Landaeta (2025), Ch. 1.
3
Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Subjective vs Objective Data
Stem: A 3-year-old presents with a fever and decreased oral
intake. The parent reports the child “seems more sleepy than
usual.” On exam the child is listless, capillary refill is 5 seconds,
and mucous membranes appear dry. Which statement best
interprets these findings?
A. Subjective parental report of sleepiness is less reliable than
objective vital signs.
B. Objective findings (delayed capillary refill, dry mucous
membranes) indicate possible dehydration and decreased
perfusion requiring prompt nursing intervention.
C. Since fever alone can cause sleepiness, no further action is
necessary beyond antipyretic administration.
D. Document the findings and schedule a follow-up with the
primary care provider within 48 hours.
Correct answer: B
Rationale — Correct (B): Objective signs (prolonged capillary
refill, dry mucous membranes, lethargy) support dehydration
with compromised perfusion in a young child — a potentially
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1
Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Purpose & Scope of Nursing Assessment
Stem: A 68-year-old man is admitted for evaluation after a fall
at home. During your initial assessment you collect subjective
data that he reports increased confusion for 2 days and
objective data showing a small laceration to his forehead and a
blood pressure of 88/56 mm Hg. Which nursing action is the
most appropriate next step?
A. Complete a comprehensive head-to-toe history and full
physical before notifying the provider.
B. Reassess blood pressure, apply oxygen if indicated, and notify
the provider immediately.
,C. Document findings in the electronic record and plan to
communicate during morning rounds.
D. Ask family members about his baseline cognition and
continue routine fall-prevention measures.
Correct answer: B
Rationale — Correct (B): The low blood pressure with new
confusion and head injury are urgent findings; reassessment
and immediate stabilization (ABC-focused) and provider
notification are time-sensitive nursing priorities. Repeating
vitals and providing supportive measures (oxygen, IV access per
protocol) support safe circulation and perfusion while escalating
care.
Rationale — Incorrect:
A. Unsafe delay—doing a full comprehensive assessment before
addressing hypotension risks deterioration.
C. Documentation without immediate action is inappropriate
for hypotension and acute confusion.
D. Obtaining collateral is useful but does not replace urgent
reassessment and escalation.
Teaching point: New hypotension with altered mentation
requires immediate reassessment and escalation.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
2
,Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Nursing Process & Phases of Assessment
Stem: During triage in the ED, a 24-year-old woman reports
sudden onset shortness of breath and chest tightness. You must
choose an assessment approach that balances speed with
completeness. Which assessment type best fits this situation?
A. Comprehensive head-to-toe assessment in the ED treatment
room.
B. Focused problem-centered assessment targeting
cardiopulmonary function.
C. Ongoing periodic assessment scheduled every 8 hours.
D. Complete health history interview before physical
assessment.
Correct answer: B
Rationale — Correct (B): In urgent, symptom-driven
presentations, a focused problem-centered assessment directed
at the cardiopulmonary system efficiently gathers high-yield
subjective and objective data necessary for immediate clinical
judgment and interventions.
Rationale — Incorrect:
A. Comprehensive assessment is time-consuming and not
appropriate as initial triage for acute respiratory symptoms.
C. Periodic routine assessments miss the need for immediate,
targeted evaluation.
D. Delaying the physical exam until a full history is completed is
unsafe in acute dyspnea.
, Teaching point: Use focused assessments for acute, symptom-
driven presentations to prioritize urgent data.
Citation: Weber & Kelley-Landaeta (2025), Ch. 1.
3
Reference: Ch. 1 — Nurse’s Role in Health Assessment —
Subjective vs Objective Data
Stem: A 3-year-old presents with a fever and decreased oral
intake. The parent reports the child “seems more sleepy than
usual.” On exam the child is listless, capillary refill is 5 seconds,
and mucous membranes appear dry. Which statement best
interprets these findings?
A. Subjective parental report of sleepiness is less reliable than
objective vital signs.
B. Objective findings (delayed capillary refill, dry mucous
membranes) indicate possible dehydration and decreased
perfusion requiring prompt nursing intervention.
C. Since fever alone can cause sleepiness, no further action is
necessary beyond antipyretic administration.
D. Document the findings and schedule a follow-up with the
primary care provider within 48 hours.
Correct answer: B
Rationale — Correct (B): Objective signs (prolonged capillary
refill, dry mucous membranes, lethargy) support dehydration
with compromised perfusion in a young child — a potentially
