2026 Nursing Health Assessment
Documentation Study Guide Practice
Questions Answer Explanations Subjective
Objective Findings Charting Patient History
Clinical Records
SECTION 1: SUBJECTIVE DATA DOCUMENTATION (Questions 1–20)
Question 1. A nurse is documenting a client's health history. Which information is
considered subjective data?
A. Blood pressure of 140/90 mm Hg
B. Client's report of "sharp chest pain when I breathe deeply"
C. Respiratory rate of 24/min
D. Oxygen saturation of 92% on room air
Rationale: Subjective data includes information the client reports, such as
symptoms, feelings, and perceptions. The client's description of chest pain is
subjective data that cannot be measured or observed by the nurse. Blood pressure,
respiratory rate, and oxygen saturation are objective data that the nurse measures.
Question 2. A nurse is documenting a client's chief complaint. Which entry is
most appropriate?
A. "Client is sick."
B. "Client reports, 'I have had crushing chest pain for 2 hours.'"
C. "Client has chest pain."
D. "Chest pain."
Rationale: The chief complaint should be documented using the client's own
words in quotation marks when possible. "Client reports, 'I have had crushing chest
pain for 2 hours'" captures the client's exact words and the duration of the
symptom. Vague entries such as "Client is sick" or "Chest pain" lack specificity.
,Question 3. A nurse is documenting a client's pain assessment. Which entry is
most appropriate?
A. "Client in pain."
B. "Client reports pain of 8/10 in lower back, sharp, radiating to left leg,
started 2 hours ago."
C. "Client has severe pain."
D. "Client uncomfortable."
Rationale: Pain documentation should include the location, intensity (using a
standardized scale), quality, radiation, and timing. "Client reports pain of 8/10 in
lower back, sharp, radiating to left leg, started 2 hours ago" includes all essential
components of a comprehensive pain assessment.
Question 4. A nurse is documenting a client's past medical history. Which
information is most important to include?
A. The client's occupation
B. Chronic illnesses, surgeries, and hospitalizations
C. The client's marital status
D. The client's birthplace
Rationale: Past medical history should include chronic illnesses, previous
surgeries, hospitalizations, and significant injuries. This information helps identify
risk factors and guide current care. Occupation, marital status, and birthplace are
part of the social history, not the past medical history.
Question 5. A nurse is documenting a client's medication history. Which entry is
most comprehensive?
A. "Client takes medications for blood pressure."
B. "Client reports taking lisinopril 10 mg daily, metformin 500 mg twice daily,
and over-the-counter ibuprofen 200 mg as needed for headaches."
C. "Client takes blood pressure and diabetes medications."
D. "Client takes several medications."
Rationale: A comprehensive medication history includes all prescription
medications, over-the-counter drugs, herbal supplements, and vitamins, along with
doses and frequencies. "Client reports taking lisinopril 10 mg daily, metformin 500
mg twice daily, and over-the-counter ibuprofen 200 mg as needed for headaches"
includes specific drug names, doses, and frequencies.
,Question 6. A nurse is documenting a client's family history. Which entry is most
appropriate?
A. "Family history is positive."
B. "Father died at age 62 from myocardial infarction; mother has type 2
diabetes; sister has breast cancer."
C. "Family has health problems."
D. "Family history unknown."
Rationale: Family history documentation should include the age and cause of
death of immediate family members, as well as any chronic diseases that may
indicate genetic risk factors. "Father died at age 62 from myocardial infarction;
mother has type 2 diabetes; sister has breast cancer" provides specific, relevant
information.
Question 7. A nurse is documenting a client's social history. Which information is
most important to include?
A. The client's favorite hobbies
B. Tobacco, alcohol, and substance use; occupation; living situation; and
functional status
C. The client's pet ownership
D. The client's television preferences
Rationale: Social history should include tobacco, alcohol, and substance use;
occupation; living situation; and functional status, as these factors can significantly
impact health and treatment planning.
Question 8. A nurse is documenting a client's review of systems. Which entry is
most appropriate for the cardiovascular system?
A. "Heart is fine."
B. "Client denies chest pain, palpitations, syncope, or edema. Reports
occasional shortness of breath with exertion."
C. "No heart problems."
D. "Cardiovascular system normal."
Rationale: Review of systems documentation should include both positive and
negative findings for each body system. "Client denies chest pain, palpitations,
syncope, or edema. Reports occasional shortness of breath with exertion" includes
both pertinent negatives and positives.
, Question 9. A nurse is documenting a client's history of present illness. Which
information is most important to include?
A. Only the client's current symptoms
B. Onset, location, duration, characteristics, aggravating and alleviating
factors, radiation, and timing (OLDCART)
C. Only the client's past medical history
D. Only the client's family history
Rationale: The history of present illness should include the OLDCART
mnemonic: Onset, Location, Duration, Characteristics, Aggravating factors,
Relieving factors, Radiation, and Timing. This comprehensive approach ensures
complete symptom characterization.
Question 10. A nurse is documenting a client's report of nausea. Which entry is
most appropriate?
A. "Client is nauseated."
B. "Client reports nausea, started 1 hour ago, rated 6/10, worse when moving,
better when lying still."
C. "Client feels sick to stomach."
D. "Nausea present."
Rationale: Symptom documentation should include onset, duration, severity, and
aggravating/alleviating factors. "Client reports nausea, started 1 hour ago, rated
6/10, worse when moving, better when lying still" provides comprehensive
information.
Question 11. A nurse is documenting a client's health history. Which information
is considered subjective?
A. Heart rate of 88 bpm
B. Client's report of dizziness upon standing
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 18/min
Rationale: Subjective data includes information the client reports, such as
symptoms, feelings, and perceptions. Dizziness is a symptom the client
experiences and reports.
Question 12. A nurse is documenting a client's allergy history. Which entry is
most appropriate?
Documentation Study Guide Practice
Questions Answer Explanations Subjective
Objective Findings Charting Patient History
Clinical Records
SECTION 1: SUBJECTIVE DATA DOCUMENTATION (Questions 1–20)
Question 1. A nurse is documenting a client's health history. Which information is
considered subjective data?
A. Blood pressure of 140/90 mm Hg
B. Client's report of "sharp chest pain when I breathe deeply"
C. Respiratory rate of 24/min
D. Oxygen saturation of 92% on room air
Rationale: Subjective data includes information the client reports, such as
symptoms, feelings, and perceptions. The client's description of chest pain is
subjective data that cannot be measured or observed by the nurse. Blood pressure,
respiratory rate, and oxygen saturation are objective data that the nurse measures.
Question 2. A nurse is documenting a client's chief complaint. Which entry is
most appropriate?
A. "Client is sick."
B. "Client reports, 'I have had crushing chest pain for 2 hours.'"
C. "Client has chest pain."
D. "Chest pain."
Rationale: The chief complaint should be documented using the client's own
words in quotation marks when possible. "Client reports, 'I have had crushing chest
pain for 2 hours'" captures the client's exact words and the duration of the
symptom. Vague entries such as "Client is sick" or "Chest pain" lack specificity.
,Question 3. A nurse is documenting a client's pain assessment. Which entry is
most appropriate?
A. "Client in pain."
B. "Client reports pain of 8/10 in lower back, sharp, radiating to left leg,
started 2 hours ago."
C. "Client has severe pain."
D. "Client uncomfortable."
Rationale: Pain documentation should include the location, intensity (using a
standardized scale), quality, radiation, and timing. "Client reports pain of 8/10 in
lower back, sharp, radiating to left leg, started 2 hours ago" includes all essential
components of a comprehensive pain assessment.
Question 4. A nurse is documenting a client's past medical history. Which
information is most important to include?
A. The client's occupation
B. Chronic illnesses, surgeries, and hospitalizations
C. The client's marital status
D. The client's birthplace
Rationale: Past medical history should include chronic illnesses, previous
surgeries, hospitalizations, and significant injuries. This information helps identify
risk factors and guide current care. Occupation, marital status, and birthplace are
part of the social history, not the past medical history.
Question 5. A nurse is documenting a client's medication history. Which entry is
most comprehensive?
A. "Client takes medications for blood pressure."
B. "Client reports taking lisinopril 10 mg daily, metformin 500 mg twice daily,
and over-the-counter ibuprofen 200 mg as needed for headaches."
C. "Client takes blood pressure and diabetes medications."
D. "Client takes several medications."
Rationale: A comprehensive medication history includes all prescription
medications, over-the-counter drugs, herbal supplements, and vitamins, along with
doses and frequencies. "Client reports taking lisinopril 10 mg daily, metformin 500
mg twice daily, and over-the-counter ibuprofen 200 mg as needed for headaches"
includes specific drug names, doses, and frequencies.
,Question 6. A nurse is documenting a client's family history. Which entry is most
appropriate?
A. "Family history is positive."
B. "Father died at age 62 from myocardial infarction; mother has type 2
diabetes; sister has breast cancer."
C. "Family has health problems."
D. "Family history unknown."
Rationale: Family history documentation should include the age and cause of
death of immediate family members, as well as any chronic diseases that may
indicate genetic risk factors. "Father died at age 62 from myocardial infarction;
mother has type 2 diabetes; sister has breast cancer" provides specific, relevant
information.
Question 7. A nurse is documenting a client's social history. Which information is
most important to include?
A. The client's favorite hobbies
B. Tobacco, alcohol, and substance use; occupation; living situation; and
functional status
C. The client's pet ownership
D. The client's television preferences
Rationale: Social history should include tobacco, alcohol, and substance use;
occupation; living situation; and functional status, as these factors can significantly
impact health and treatment planning.
Question 8. A nurse is documenting a client's review of systems. Which entry is
most appropriate for the cardiovascular system?
A. "Heart is fine."
B. "Client denies chest pain, palpitations, syncope, or edema. Reports
occasional shortness of breath with exertion."
C. "No heart problems."
D. "Cardiovascular system normal."
Rationale: Review of systems documentation should include both positive and
negative findings for each body system. "Client denies chest pain, palpitations,
syncope, or edema. Reports occasional shortness of breath with exertion" includes
both pertinent negatives and positives.
, Question 9. A nurse is documenting a client's history of present illness. Which
information is most important to include?
A. Only the client's current symptoms
B. Onset, location, duration, characteristics, aggravating and alleviating
factors, radiation, and timing (OLDCART)
C. Only the client's past medical history
D. Only the client's family history
Rationale: The history of present illness should include the OLDCART
mnemonic: Onset, Location, Duration, Characteristics, Aggravating factors,
Relieving factors, Radiation, and Timing. This comprehensive approach ensures
complete symptom characterization.
Question 10. A nurse is documenting a client's report of nausea. Which entry is
most appropriate?
A. "Client is nauseated."
B. "Client reports nausea, started 1 hour ago, rated 6/10, worse when moving,
better when lying still."
C. "Client feels sick to stomach."
D. "Nausea present."
Rationale: Symptom documentation should include onset, duration, severity, and
aggravating/alleviating factors. "Client reports nausea, started 1 hour ago, rated
6/10, worse when moving, better when lying still" provides comprehensive
information.
Question 11. A nurse is documenting a client's health history. Which information
is considered subjective?
A. Heart rate of 88 bpm
B. Client's report of dizziness upon standing
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 18/min
Rationale: Subjective data includes information the client reports, such as
symptoms, feelings, and perceptions. Dizziness is a symptom the client
experiences and reports.
Question 12. A nurse is documenting a client's allergy history. Which entry is
most appropriate?
