rationales /instant pdf
Question 1
The nurse is obtaining a health history from a new client. Which question is open-ended?
A. "Does your chest hurt?"
B. "Have you had surgery?"
C. "Tell me what brought you to the clinic today."
D. "Do you smoke?"
Answer: C
Rationale: Open-ended questions encourage the client to provide detailed information and
establish rapport.
Question 2
Which statement is an example of subjective data?
A. Blood pressure is 138/84 mm Hg.
B. Respiratory rate is 20 breaths/min.
C. "I've had a headache since yesterday."
D. Temperature is 37°C (98.6°F).
Answer: C
Rationale: Subjective data are symptoms reported by the client.
Question 3
Which assessment finding is objective data?
A. "I feel dizzy."
B. "My stomach hurts."
C. Pulse is 88 beats/min.
,D. "I have nausea."
Answer: C
Rationale: Objective data are measurable or observable by the examiner.
Question 4
The nurse is preparing to examine a client's abdomen. Which sequence is correct?
A. Inspection → Palpation → Percussion → Auscultation
B. Inspection → Auscultation → Percussion → Palpation
C. Palpation → Inspection → Auscultation → Percussion
D. Auscultation → Inspection → Percussion → Palpation
Answer: B
Rationale: The abdomen is assessed in the order of inspection, auscultation, percussion, and
palpation to avoid altering bowel sounds.
Question 5
Which assessment technique should generally be performed first?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
Answer: C
Question 6 (SATA)
Which are components of a complete health history?
,Select all that apply.
A. Chief complaint
B. History of present illness
C. Past medical history
D. Family history
E. Review of systems
Answers:
• ✅A
• ✅B
• ✅C
• ✅D
• ✅E
Rationale: A complete health history includes all of these components.
Question 7
The nurse observes a client grimacing while walking.
This is an example of:
A. Subjective data
B. Objective data
C. Family history
D. Review of systems
Answer: B
Question 8
Which question best assesses alcohol use?
, A. "You don't drink much, do you?"
B. "Do you drink alcohol? If so, how often and how much?"
C. "Alcohol isn't good for you."
D. "You should stop drinking."
Answer: B
Question 9
The nurse is interviewing a client who begins crying.
What is the best response?
A. "Don't cry."
B. Sit quietly and allow the client time to express emotions.
C. Change the subject.
D. Leave the room.
Answer: B
Question 10
Which finding requires immediate follow-up?
A. Temperature of 37°C (98.6°F)
B. Sudden difficulty speaking
C. Heart rate of 76 beats/min
D. Respiratory rate of 16 breaths/min
Answer: B
Rationale: Sudden speech difficulty may indicate an acute neurological emergency such as a
stroke.