National University NUR 300 Module 4 (pdf) | 2026/2027 | Health
Assessment Q&A | Nursing
1. A nurse is performing a general survey on a newly admitted patient. Which
of the following is the primary purpose of this initial observation?
A) To collect objective data about the patient's overall appearance, body
structure, mobility, and behavior
B) To obtain a detailed family history of chronic illnesses
C) To determine the patient's health insurance coverage and financial status
D) To establish a therapeutic nurse-patient relationship through active
listening
Correct Answer: To collect objective data about the patient's overall
appearance, body structure, mobility, and behavior
Rationale: The general survey is the first component of the physical
examination and begins the moment the nurse meets the patient. It provides
a broad, objective overview of the patient's physical appearance, body
structure, mobility, and behavior. This data helps identify immediate
concerns and guides the focused assessment.
2. A nurse observes a patient who is well-groomed, makes appropriate eye
contact, and speaks clearly and coherently. This observation is part of the
assessment of:
A) Vital signs
B) General appearance and behavior
C) Neurological function
D) Nutritional status
Correct Answer: General appearance and behavior
,Rationale: The general survey includes observations of physical appearance,
body structure, mobility, and behavior. Grooming, eye contact, speech, and
emotional state are key behavioral indicators that provide valuable data
about the patient's overall status, including signs of distress, pain, or mental
health concerns.
3. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which of the following components is evaluated in the
GCS?
A) Eye opening, verbal response, and motor response
B) Orientation to person, place, and time
C) Memory, attention, and language
D) Mood, affect, and behavior
Correct Answer: Eye opening, verbal response, and motor response
Rationale: The Glasgow Coma Scale (GCS) is a standardized tool used to
assess level of consciousness by evaluating three components: eye opening
(scored 1-4), verbal response (scored 1-5), and motor response (scored 1-6).
The total score ranges from 3 to 15, with lower scores indicating a decreased
level of consciousness.
4. A nurse is assessing a patient's orientation and asks, "What is today's
date?" and "Where are you right now?" These questions assess the patient's:
A) Attention and concentration
B) Orientation to time, place, and person
C) Memory
D) Abstract reasoning
Correct Answer: Orientation to time, place, and person
,Rationale: Orientation is the awareness of one's self in relation to time (date,
season), place (location), and person (who they are and who the examiner
is). Asking about the date and location specifically assesses orientation to
time and place, which are key components of the mental status examination.
A patient who is oriented to all four domains is documented as "alert and
oriented x 4" (A&O x 4).
5. A nurse is performing a mental status examination and asks the patient to
repeat three unrelated words immediately and again after five minutes. This
tests which aspect of cognitive function?
A) Attention
B) Memory
C) Language
D) Executive function
Correct Answer: Memory
Rationale: Asking the patient to repeat three words immediately tests
immediate recall (registration), while asking for recall after a delay (e.g., five
minutes) assesses short-term memory. This is a common component of
mental status examinations to screen for cognitive impairment, such as
dementia.
6. A nurse is using the SPICES tool to assess an older adult patient. What
does the "S" in SPICES represent?
A) Sleep disorders
B) Social isolation
C) Skin breakdown
D) Somatic complaints
, Correct Answer: Sleep disorders
Rationale: The SPICES tool is a screening instrument for common geriatric
syndromes. The acronym stands for **S**leep disorders, **P**roblems with
eating/feeding, **I**ncontinence, **C**onfusion, **E**vidence of falls, and
**S**kin breakdown. It helps nurses identify key areas of concern in the
elderly population.
7. A nurse is assessing a patient's risk for falls. Which of the following is a
key component of a comprehensive fall risk assessment?
A) Assessing the patient's gait and balance
B) Reviewing the patient's medication list for side effects such as dizziness
C) Evaluating the patient's vision and environmental factors
D) All of the above
Correct Answer: All of the above
Rationale: A comprehensive fall risk assessment includes evaluating the
patient's gait and balance, reviewing medications that may cause dizziness
or hypotension, and assessing vision and environmental factors. All these
components contribute to identifying an individual's risk for falls and guide
prevention strategies.
8. A nurse is assessing a patient's pain. Which of the following is considered
the most reliable indicator of pain?
A) The patient's self-report
B) The nurse's observation of behavior
C) The patient's vital signs
D) The patient's facial expression
Assessment Q&A | Nursing
1. A nurse is performing a general survey on a newly admitted patient. Which
of the following is the primary purpose of this initial observation?
A) To collect objective data about the patient's overall appearance, body
structure, mobility, and behavior
B) To obtain a detailed family history of chronic illnesses
C) To determine the patient's health insurance coverage and financial status
D) To establish a therapeutic nurse-patient relationship through active
listening
Correct Answer: To collect objective data about the patient's overall
appearance, body structure, mobility, and behavior
Rationale: The general survey is the first component of the physical
examination and begins the moment the nurse meets the patient. It provides
a broad, objective overview of the patient's physical appearance, body
structure, mobility, and behavior. This data helps identify immediate
concerns and guides the focused assessment.
2. A nurse observes a patient who is well-groomed, makes appropriate eye
contact, and speaks clearly and coherently. This observation is part of the
assessment of:
A) Vital signs
B) General appearance and behavior
C) Neurological function
D) Nutritional status
Correct Answer: General appearance and behavior
,Rationale: The general survey includes observations of physical appearance,
body structure, mobility, and behavior. Grooming, eye contact, speech, and
emotional state are key behavioral indicators that provide valuable data
about the patient's overall status, including signs of distress, pain, or mental
health concerns.
3. A nurse is assessing a patient's level of consciousness using the Glasgow
Coma Scale (GCS). Which of the following components is evaluated in the
GCS?
A) Eye opening, verbal response, and motor response
B) Orientation to person, place, and time
C) Memory, attention, and language
D) Mood, affect, and behavior
Correct Answer: Eye opening, verbal response, and motor response
Rationale: The Glasgow Coma Scale (GCS) is a standardized tool used to
assess level of consciousness by evaluating three components: eye opening
(scored 1-4), verbal response (scored 1-5), and motor response (scored 1-6).
The total score ranges from 3 to 15, with lower scores indicating a decreased
level of consciousness.
4. A nurse is assessing a patient's orientation and asks, "What is today's
date?" and "Where are you right now?" These questions assess the patient's:
A) Attention and concentration
B) Orientation to time, place, and person
C) Memory
D) Abstract reasoning
Correct Answer: Orientation to time, place, and person
,Rationale: Orientation is the awareness of one's self in relation to time (date,
season), place (location), and person (who they are and who the examiner
is). Asking about the date and location specifically assesses orientation to
time and place, which are key components of the mental status examination.
A patient who is oriented to all four domains is documented as "alert and
oriented x 4" (A&O x 4).
5. A nurse is performing a mental status examination and asks the patient to
repeat three unrelated words immediately and again after five minutes. This
tests which aspect of cognitive function?
A) Attention
B) Memory
C) Language
D) Executive function
Correct Answer: Memory
Rationale: Asking the patient to repeat three words immediately tests
immediate recall (registration), while asking for recall after a delay (e.g., five
minutes) assesses short-term memory. This is a common component of
mental status examinations to screen for cognitive impairment, such as
dementia.
6. A nurse is using the SPICES tool to assess an older adult patient. What
does the "S" in SPICES represent?
A) Sleep disorders
B) Social isolation
C) Skin breakdown
D) Somatic complaints
, Correct Answer: Sleep disorders
Rationale: The SPICES tool is a screening instrument for common geriatric
syndromes. The acronym stands for **S**leep disorders, **P**roblems with
eating/feeding, **I**ncontinence, **C**onfusion, **E**vidence of falls, and
**S**kin breakdown. It helps nurses identify key areas of concern in the
elderly population.
7. A nurse is assessing a patient's risk for falls. Which of the following is a
key component of a comprehensive fall risk assessment?
A) Assessing the patient's gait and balance
B) Reviewing the patient's medication list for side effects such as dizziness
C) Evaluating the patient's vision and environmental factors
D) All of the above
Correct Answer: All of the above
Rationale: A comprehensive fall risk assessment includes evaluating the
patient's gait and balance, reviewing medications that may cause dizziness
or hypotension, and assessing vision and environmental factors. All these
components contribute to identifying an individual's risk for falls and guide
prevention strategies.
8. A nurse is assessing a patient's pain. Which of the following is considered
the most reliable indicator of pain?
A) The patient's self-report
B) The nurse's observation of behavior
C) The patient's vital signs
D) The patient's facial expression
