,Exam 1 NSG121/NSG 121 Health Assessment |
1. A nurse is performing a health assessment on a client. Which action demonstrates the primary goal of
the nursing process in this context?
A) Establishing a therapeutic nurse-client relationship
B) Collecting comprehensive data to identify client needs
C) Documenting findings in the electronic health record
D) Implementing interventions based on medical orders
Correct Answer: B) Collecting comprehensive data to identify client needs
Rationale: The nursing process is a systematic method for client care, with assessment as its
foundational step. The primary goal of health assessment is to collect comprehensive data to identify
client needs, strengths, and potential health problems. While establishing relationships, documenting,
and implementing interventions are important nursing actions, they are not the primary goal of the
assessment phase itself.
2. A nurse is preparing to conduct an admission assessment on a client. Which type of assessment is
most appropriate for this situation?
A) Emergency assessment
B) Focused assessment
C) Comprehensive assessment
D) General survey
Correct Answer: C) Comprehensive assessment
Rationale: A comprehensive assessment includes a complete health history and physical examination,
assessing cognitive, emotional, and physical development. This is the standard for an initial admission to
identify expected growth patterns, variations, and deviations. An emergency assessment is for life-
threatening situations, a focused assessment is for specific issues, and a general survey is a brief
overview.
,3. A client is brought to the emergency department after a motor vehicle accident. The nurse's initial
assessment should follow which framework?
A) Functional assessment
B) Head-to-toe assessment
C) Body systems assessment
D) Emergency assessment (ABCDE)
Correct Answer: D) Emergency assessment (ABCDE)
Rationale: An emergency assessment is used for life-threatening or unstable situations and is based on
Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). This framework prioritizes the most
critical physiological needs. Functional, head-to-toe, and body systems assessments are more
appropriate for stable clients.
4. A nurse is assessing a client who reports knee pain after a fall. The nurse performs a detailed
examination of the knee, range of motion, and neurovascular status. This type of assessment is known
as:
A) Comprehensive assessment
B) Focused assessment
C) Emergency assessment
D) General survey
Correct Answer: B) Focused assessment
Rationale: A focused assessment is smaller in scope but has increased depth for a specific issue or body
system. It is conducted after a specific problem is identified, such as knee pain following a fall. A
comprehensive assessment is a full examination, while an emergency assessment is for life-threatening
situations.
5. A nurse is providing education to a community group about the importance of immunizations. This
activity is an example of which level of prevention?
A) Primary prevention
, B) Secondary prevention
C) Tertiary prevention
D) Health protection
Correct Answer: A) Primary prevention
Rationale: Primary prevention aims to promote health and prevent the development of disease through
activities such as immunization clinics, family planning services, and accident-prevention education.
Secondary prevention involves screening for early detection of disease, and tertiary prevention focuses
on rehabilitation and restoration.
6. A nurse is conducting a health screening for hypertension at a community health fair. This activity is
an example of which level of prevention?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Health promotion
Correct Answer: B) Secondary prevention
Rationale: Secondary prevention involves screening for early detection of disease with prompt diagnosis
and treatment. The goal is to identify illness early, reverse or reduce its severity, and return the client to
maximum health quickly. Hypertension screening aims to detect the condition early so that
interventions can begin.
7. A client who is motivated by a personal desire to increase well-being and health potential is
demonstrating:
A) Health protection
B) Health promotion
C) Secondary prevention
D) Tertiary prevention
1. A nurse is performing a health assessment on a client. Which action demonstrates the primary goal of
the nursing process in this context?
A) Establishing a therapeutic nurse-client relationship
B) Collecting comprehensive data to identify client needs
C) Documenting findings in the electronic health record
D) Implementing interventions based on medical orders
Correct Answer: B) Collecting comprehensive data to identify client needs
Rationale: The nursing process is a systematic method for client care, with assessment as its
foundational step. The primary goal of health assessment is to collect comprehensive data to identify
client needs, strengths, and potential health problems. While establishing relationships, documenting,
and implementing interventions are important nursing actions, they are not the primary goal of the
assessment phase itself.
2. A nurse is preparing to conduct an admission assessment on a client. Which type of assessment is
most appropriate for this situation?
A) Emergency assessment
B) Focused assessment
C) Comprehensive assessment
D) General survey
Correct Answer: C) Comprehensive assessment
Rationale: A comprehensive assessment includes a complete health history and physical examination,
assessing cognitive, emotional, and physical development. This is the standard for an initial admission to
identify expected growth patterns, variations, and deviations. An emergency assessment is for life-
threatening situations, a focused assessment is for specific issues, and a general survey is a brief
overview.
,3. A client is brought to the emergency department after a motor vehicle accident. The nurse's initial
assessment should follow which framework?
A) Functional assessment
B) Head-to-toe assessment
C) Body systems assessment
D) Emergency assessment (ABCDE)
Correct Answer: D) Emergency assessment (ABCDE)
Rationale: An emergency assessment is used for life-threatening or unstable situations and is based on
Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). This framework prioritizes the most
critical physiological needs. Functional, head-to-toe, and body systems assessments are more
appropriate for stable clients.
4. A nurse is assessing a client who reports knee pain after a fall. The nurse performs a detailed
examination of the knee, range of motion, and neurovascular status. This type of assessment is known
as:
A) Comprehensive assessment
B) Focused assessment
C) Emergency assessment
D) General survey
Correct Answer: B) Focused assessment
Rationale: A focused assessment is smaller in scope but has increased depth for a specific issue or body
system. It is conducted after a specific problem is identified, such as knee pain following a fall. A
comprehensive assessment is a full examination, while an emergency assessment is for life-threatening
situations.
5. A nurse is providing education to a community group about the importance of immunizations. This
activity is an example of which level of prevention?
A) Primary prevention
, B) Secondary prevention
C) Tertiary prevention
D) Health protection
Correct Answer: A) Primary prevention
Rationale: Primary prevention aims to promote health and prevent the development of disease through
activities such as immunization clinics, family planning services, and accident-prevention education.
Secondary prevention involves screening for early detection of disease, and tertiary prevention focuses
on rehabilitation and restoration.
6. A nurse is conducting a health screening for hypertension at a community health fair. This activity is
an example of which level of prevention?
A) Primary prevention
B) Secondary prevention
C) Tertiary prevention
D) Health promotion
Correct Answer: B) Secondary prevention
Rationale: Secondary prevention involves screening for early detection of disease with prompt diagnosis
and treatment. The goal is to identify illness early, reverse or reduce its severity, and return the client to
maximum health quickly. Hypertension screening aims to detect the condition early so that
interventions can begin.
7. A client who is motivated by a personal desire to increase well-being and health potential is
demonstrating:
A) Health protection
B) Health promotion
C) Secondary prevention
D) Tertiary prevention
