Answers 2026/2027
1.** A nurse is performing a comprehensive health assessment on a new
client. The client reports a history of "heart trouble" but cannot recall specific
details. Which of the following actions by the nurse demonstrates the critical
thinking skill of **clinical reasoning**?
A) Documenting the client's statement verbatim and moving to the next
question
B) Asking the client to "think harder" about the specifics of their heart
condition
C) Exploring the client's statement by asking focused questions about
symptoms, treatments, and specialists seen
D) Assuming the client's "heart trouble" is likely hypertension due to their
age
**Correct Answer:** C) Exploring the client's statement by asking focused
questions about symptoms, treatments, and specialists seen
**Rationale:** Clinical reasoning involves the nurse's ability to gather and
analyze data, identify patterns, and formulate hypotheses. Option C
demonstrates this by seeking specific, relevant information to clarify the
client's vague report. Documenting verbatim (A) lacks analysis, assuming (D)
is a premature conclusion, and asking to "think harder" (B) is non-
therapeutic.
**2.** A nurse is using the "PQRST" mnemonic to assess a client's chest pain.
Which of the following questions is used to assess the "Quality" of the pain?
A) "What were you doing when the pain started?"
B) "Can you describe the pain? Is it sharp, dull, or crushing?"
C) "On a scale of 0 to 10, how would you rate the pain?"
,D) "Does the pain radiate to your arm or jaw?"
**Correct Answer:** B) "Can you describe the pain? Is it sharp, dull, or
crushing?"
**Rationale:** The "PQRST" mnemonic stands for Provocation/Palliation,
Quality, Region/Radiation, Severity, and Timing. Asking about the nature of
the pain (sharp, dull, crushing) assesses its quality. Option A assesses
provocation, C assesses severity, and D assesses radiation.
**3.** A nurse is formulating a differential diagnosis for a client presenting
with fatigue and weight loss. Which of the following steps is essential for the
nurse to take first?
A) Immediately order a comprehensive metabolic panel
B) Review the client's complete health history and current medications
C) Refer the client to a nutritionist
D) Schedule a follow-up appointment in one month
**Correct Answer:** B) Review the client's complete health history and
current medications
**Rationale:** Before forming a differential diagnosis, it is essential to gather
comprehensive data. A thorough review of the client's health history,
including medications, is the foundational step for identifying potential
causes of vague symptoms like fatigue and weight loss. Ordering tests (A)
should follow assessment, not precede it.
**4.** A nurse is conducting a health history interview. The client answers
questions with brief, monosyllabic responses. Which of the following
, communication techniques is most effective for obtaining detailed
information?
A) Using closed-ended questions to gather specific facts
B) Using open-ended questions and active listening
C) Completing the interview as quickly as possible
D) Repeating the same question in a louder voice
**Correct Answer:** B) Using open-ended questions and active listening
**Rationale:** Open-ended questions encourage the client to provide more
detailed, narrative responses. Active listening, including the use of non-
verbal cues, helps build rapport and facilitates the client's willingness to
share information. Closed-ended questions (A) typically elicit short, yes/no
answers.
**5.** A nurse is assessing a client's perception of their health status. The
client states, "I know I have diabetes, but I feel fine, so I don't really think I
need to check my blood sugar every day." This statement is an example of:
A) A health belief that may impact treatment adherence
B) A normal reaction to a chronic illness
C) An intentional non-compliance issue
D) A lack of intelligence
**Correct Answer:** A) A health belief that may impact treatment adherence
**Rationale:** The client's statement reflects their personal health beliefs.
Understanding these beliefs is crucial for the nurse to develop an effective,