,Exam 1 Review Guide: Foundations of Nursing (NUR 155)
Galen College of Nursing | Latest Fall 2026
50 Original Exam-Preparation Questions, Answers & Detailed Rationales
CLINICAL JUDGMENT & NURSING PROCESS
Question 1
A nurse receives report on four clients. Which client should the nurse assess first?
A. A client requesting assistance to the bathroom
B. A client with chronic back pain rated 6/10
C. A client who has new inspiratory stridor after a procedure
D. A client awaiting discharge instructions
Correct Answer: C. A client who has new inspiratory stridor after a procedure
Rationale: Stridor indicates possible upper-airway obstruction and therefore threatens the client's ability to
breathe. Airway problems receive immediate priority using ABC principles. The other concerns require nursing
attention but are not as immediately life-threatening.
Keywords: priority; ABCs; airway; stridor
Clinical Pearl: A new airway sound should never be treated as a routine finding.
Exam Strategy: When one option threatens airway, breathing, or circulation, address it before comfort or
teaching needs.
Question 2
Which action represents the assessment phase of the nursing process?
A. Obtaining the client's blood pressure and pain rating
B. Administering an ordered analgesic
C. Developing a goal for pain reduction
D. Determining whether the analgesic relieved pain
Correct Answer: A. Obtaining the client's blood pressure and pain rating
Rationale: Assessment involves systematically collecting subjective and objective client data. Planning
establishes goals, implementation carries out interventions, and evaluation determines whether expected
outcomes were achieved.
Keywords: ADPIE; assessment; data collection
Clinical Pearl: Assessment occurs throughout care, not only at admission.
Exam Strategy: If the nurse is collecting information, think Assessment.
Question 3
,A client reports, “I feel dizzy every time I stand up.” How should the nurse classify this information?
A. Objective data
B. Diagnostic data
C. Subjective data
D. Secondary data
Correct Answer: C. Subjective data
Rationale: Subjective data are symptoms, perceptions, or experiences reported by the client and cannot be
directly measured by another person. Dizziness is known through the client's description. Objective data would
include measurable findings such as blood pressure or pulse.
Keywords: subjective data; symptoms; assessment
Clinical Pearl: Symptoms are subjective; signs are generally objective.
Exam Strategy: If the information comes from what the client says, classify it as subjective.
Question 4
Which statement best describes a nursing diagnosis?
A. It identifies the medical disease causing symptoms.
B. It describes the client's response to an actual or potential health problem.
C. It is written exclusively by the healthcare provider.
D. It replaces the need for assessment findings.
Correct Answer: B. It describes the client's response to an actual or potential health problem.
Rationale: Nursing diagnoses focus on human responses that nurses can address through nursing
interventions. Medical diagnoses identify diseases or pathologic processes. Nursing diagnoses are developed
from assessment data and guide individualized nursing care.
Keywords: nursing diagnosis; client response; care planning
Clinical Pearl: A medical diagnosis may remain the same while nursing diagnoses change as the client's
condition changes.
Exam Strategy: Nursing diagnosis = response to health condition, not the disease itself.
Question 5 — Nursing Process Flow
ASSESSMENT
↓
DIAGNOSIS
↓
PLANNING
↓
IMPLEMENTATION
,↓
EVALUATION
The nurse administers oxygen according to the care plan. Which phase is represented?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: D. Implementation
Rationale: Implementation is the phase in which planned nursing interventions are carried out. Giving
oxygen is an action performed to address an identified client need. Evaluation would determine the client's
response after the intervention.
Keywords: implementation; ADPIE; intervention
Clinical Pearl: Implementation includes both independent and provider-prescribed nursing actions.
Exam Strategy: If the nurse is doing the planned intervention, select implementation.
Question 6
The nurse establishes the goal, “Client will report pain at 3/10 or less within 1 hour.” Which characteristic
makes this a strong expected outcome?
A. It is measurable and time limited.
B. It focuses on nursing activity.
C. It guarantees a specific medication response.
D. It avoids identifying a time frame.
Correct Answer: A. It is measurable and time limited.
Rationale: Effective outcomes are client-centered, observable or measurable, realistic, and associated with
a time frame. A numerical pain rating and one-hour target allow the nurse to determine objectively whether
the outcome was achieved.
Keywords: expected outcome; SMART goal; planning
Clinical Pearl: Outcomes should describe what the client will achieve, not what the nurse will do.
Exam Strategy: Look for a goal that includes a specific result plus a time frame.
Question 7
Which nursing action occurs during the evaluation phase?
A. Comparing the client's current pain score with the established goal
B. Identifying impaired mobility
,C. Teaching the client how to use a walker
D. Obtaining the initial health history
Correct Answer: A. Comparing the client's current pain score with the established goal
Rationale: Evaluation determines whether expected outcomes have been met by comparing current client
responses with planned goals. Findings may lead the nurse to continue, modify, or discontinue parts of the care
plan.
Keywords: evaluation; outcomes; nursing process
Clinical Pearl: Evaluation closes the nursing-process loop and often leads back to reassessment.
Exam Strategy: “Did it work?” = Evaluation.
Question 8
A nurse notices a client is confused, restless, and repeatedly trying to remove oxygen tubing. What should the
nurse do first?
A. Apply restraints immediately.
B. Document noncompliance.
C. Assess oxygenation and possible causes of the behavior.
D. Call security.
Correct Answer: C. Assess oxygenation and possible causes of the behavior.
Rationale: New confusion and restlessness may indicate hypoxia, pain, infection, medication effects, or
another physiologic problem. Assessment should precede restrictive interventions whenever immediate danger
does not require otherwise. Restraints do not treat the underlying cause.
Keywords: clinical judgment; confusion; hypoxia; assessment first
Clinical Pearl: Acute behavior changes can be the first sign of physiologic deterioration.
Exam Strategy: Before treating behavior, assess why it is occurring.
Question 9
Which client outcome requires the nurse to revise the care plan?
A. Goal met exactly as expected
B. Client demonstrates improved understanding
C. Expected outcome is not achieved despite interventions
D. Client requests written teaching material
Correct Answer: C. Expected outcome is not achieved despite interventions
, Rationale: When an outcome is not met, the nurse reassesses the client and determines whether the
diagnosis, goal, or intervention needs modification. Nursing care is dynamic and should change when the
client's response differs from what was expected.
Keywords: evaluation; care-plan revision; reassessment
Clinical Pearl: An unmet goal does not automatically mean the client “failed”; the plan may need
adjustment.
Exam Strategy: Outcome not met → reassess and revise.
Question 10
Which action best demonstrates clinical judgment?
A. Following every routine exactly the same for all clients
B. Recognizing relevant cues and selecting an intervention based on the client's current condition
C. Performing tasks only after another nurse confirms them
D. Ignoring minor changes until the next scheduled assessment
Correct Answer: B. Recognizing relevant cues and selecting an intervention based on the client's current
condition
Rationale: Clinical judgment requires nurses to recognize cues, analyze their meaning, prioritize concerns,
take action, and evaluate results. It is individualized and responsive rather than simply following routines
without considering the client's condition.
Keywords: clinical judgment; cue recognition; prioritization
Clinical Pearl: Good clinical judgment combines knowledge, assessment, context, and client response.
Exam Strategy: Choose the option showing cue recognition + appropriate decision-making.
HEALTH HISTORY, ASSESSMENT & DATA COLLECTION
Question 11
Which source is considered the primary source of health information whenever the client is alert and capable
of communication?
A. The client's family member
B. The medical record
C. The client
D. The healthcare provider
Correct Answer: C. The client
, Rationale: The client is the preferred primary source because they can directly describe symptoms,
concerns, history, and perceptions. Family members and records are secondary sources used when additional
information is needed or the client cannot provide reliable information.
Keywords: primary source; assessment; health history
Clinical Pearl: Always obtain the client's account first when the client is able to participate.
Exam Strategy: Alert, competent client = primary information source.
Question 12
Which finding is objective?
A. “My pain feels sharp.”
B. Respiratory rate 28/min
C. “I feel weak.”
D. “I slept poorly.”
Correct Answer: B. Respiratory rate 28/min
Rationale: Objective data are observable or measurable findings obtained through examination,
monitoring, or diagnostic testing. Respiratory rate can be counted directly. Pain quality, weakness, and sleep
quality are subjective experiences reported by the client.
Keywords: objective data; vital signs; assessment
Clinical Pearl: Objective does not mean “more important”; both data types are essential.
Exam Strategy: If it can be measured or observed, it is objective.
Question 13
Which technique should the nurse generally use first when performing a physical assessment of the abdomen?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation after deep palpation
Correct Answer: A. Inspection
Rationale: The nurse begins abdominal assessment with inspection, followed by auscultation before
percussion and palpation. Manipulating the abdomen before auscultation can alter bowel sounds and reduce
the accuracy of findings.
Keywords: abdominal assessment; inspection; auscultation
Clinical Pearl: The abdomen is the important exception to the usual inspection-palpation-percussion-
auscultation sequence.
, Exam Strategy: For the abdomen remember: Inspect → Auscultate → Percuss → Palpate.
Question 14
A client suddenly reports dizziness when standing. Which additional assessment is most appropriate?
A. Apical pulse while sleeping
B. Orthostatic vital signs
C. Abdominal girth
D. Visual acuity only
Correct Answer: B. Orthostatic vital signs
Rationale: Dizziness with position change may result from orthostatic hypotension. Comparing blood
pressure and pulse in different positions helps determine whether significant positional cardiovascular changes
are occurring.
Keywords: orthostatic hypotension; dizziness; vital signs
Clinical Pearl: Safety precautions are important during orthostatic assessment because the client may
become faint.
Exam Strategy: Symptoms with standing → think orthostatic measurements.
Question 15 — Data Classification Table
Finding Data Type
“I feel nauseated.” Subjective
Temperature 38.4°C Objective
“My chest feels tight.” Subjective
Oxygen saturation 89% Objective
Which finding requires the most immediate follow-up?
A. “I feel nauseated.”
B. Temperature 38.4°C
C. “My chest feels tight.”
D. Oxygen saturation 89%
Correct Answer: D. Oxygen saturation 89%
Rationale: An oxygen saturation of 89% indicates impaired oxygenation and may represent an immediate
breathing problem. Fever, nausea, and chest symptoms also require assessment, but significant hypoxemia
poses the most urgent physiologic threat.
Keywords: oxygen saturation; priority; assessment data
, Clinical Pearl: Always interpret data in terms of potential threats to airway, breathing, and circulation.
Exam Strategy: When several findings compete, prioritize the one indicating oxygenation failure.
Question 16
Which technique is used when the nurse taps the body surface to assess underlying density?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Correct Answer: C. Percussion
Rationale: Percussion produces sounds and vibrations that help estimate whether underlying structures
contain air, fluid, or solid tissue. Palpation uses touch, auscultation uses hearing, and inspection relies on
observation.
Keywords: percussion; physical assessment; examination
Clinical Pearl: Percussion findings are interpreted together with other assessment techniques.
Exam Strategy: Tapping the body = percussion.
Question 17
When measuring blood pressure manually, using a cuff that is too small may produce which result?
A. Falsely low reading
B. Falsely high reading
C. No effect
D. Accurate systolic but inaccurate diastolic pressure only
Correct Answer: B. Falsely high reading
Rationale: A cuff that is too small requires greater pressure to compress the artery and can falsely elevate
the measured blood pressure. Correct cuff size is essential for reliable assessment and clinical decision-making.
Keywords: blood pressure; cuff size; measurement error
Clinical Pearl: Technique errors can create abnormal findings that are not truly present.
Exam Strategy: Small cuff → falsely high; large cuff → potentially falsely low.
Question 18
Which finding should the nurse document as an assessment finding rather than an interpretation?
A. “Client appears to have pneumonia.”
B. “Client is noncompliant.”
,C. “Crackles heard in bilateral lower lung fields.”
D. “Client probably has fluid overload.”
Correct Answer: C. “Crackles heard in bilateral lower lung fields.”
Rationale: Documentation should describe observable and measurable findings objectively. “Crackles
heard” reports what the nurse actually assessed. Statements assigning a diagnosis or judgment without
supporting data introduce interpretation rather than factual observation.
Keywords: objective documentation; assessment; charting
Clinical Pearl: Chart what you observe, hear, measure, or are told.
Exam Strategy: Choose the option that describes facts without labels or assumptions.
COMMUNICATION & PATIENT TEACHING
Question 19
A client begins crying after receiving a new diagnosis. Which response by the nurse is most therapeutic?
A. “You shouldn't cry; everything will be fine.”
B. “Tell me what is going through your mind right now.”
C. “I know exactly how you feel.”
D. “You need to stay positive.”
Correct Answer: B. “Tell me what is going through your mind right now.”
Rationale: An open-ended invitation allows the client to express feelings and concerns without judgment.
False reassurance, minimizing emotions, and claiming to know exactly how the client feels can block
communication.
Keywords: therapeutic communication; open-ended question; empathy
Clinical Pearl: Therapeutic communication creates space for the client rather than directing how they
should feel.
Exam Strategy: Favor responses that invite expression rather than reassure, judge, or advise.
Question 20
Which statement by the nurse is an example of clarification?
A. “Why would you do that?”
B. “Everything will be okay.”
C. “When you say you feel strange, can you describe what you mean?”
D. “I understand exactly.”
Correct Answer: C. “When you say you feel strange, can you describe what you mean?”
Galen College of Nursing | Latest Fall 2026
50 Original Exam-Preparation Questions, Answers & Detailed Rationales
CLINICAL JUDGMENT & NURSING PROCESS
Question 1
A nurse receives report on four clients. Which client should the nurse assess first?
A. A client requesting assistance to the bathroom
B. A client with chronic back pain rated 6/10
C. A client who has new inspiratory stridor after a procedure
D. A client awaiting discharge instructions
Correct Answer: C. A client who has new inspiratory stridor after a procedure
Rationale: Stridor indicates possible upper-airway obstruction and therefore threatens the client's ability to
breathe. Airway problems receive immediate priority using ABC principles. The other concerns require nursing
attention but are not as immediately life-threatening.
Keywords: priority; ABCs; airway; stridor
Clinical Pearl: A new airway sound should never be treated as a routine finding.
Exam Strategy: When one option threatens airway, breathing, or circulation, address it before comfort or
teaching needs.
Question 2
Which action represents the assessment phase of the nursing process?
A. Obtaining the client's blood pressure and pain rating
B. Administering an ordered analgesic
C. Developing a goal for pain reduction
D. Determining whether the analgesic relieved pain
Correct Answer: A. Obtaining the client's blood pressure and pain rating
Rationale: Assessment involves systematically collecting subjective and objective client data. Planning
establishes goals, implementation carries out interventions, and evaluation determines whether expected
outcomes were achieved.
Keywords: ADPIE; assessment; data collection
Clinical Pearl: Assessment occurs throughout care, not only at admission.
Exam Strategy: If the nurse is collecting information, think Assessment.
Question 3
,A client reports, “I feel dizzy every time I stand up.” How should the nurse classify this information?
A. Objective data
B. Diagnostic data
C. Subjective data
D. Secondary data
Correct Answer: C. Subjective data
Rationale: Subjective data are symptoms, perceptions, or experiences reported by the client and cannot be
directly measured by another person. Dizziness is known through the client's description. Objective data would
include measurable findings such as blood pressure or pulse.
Keywords: subjective data; symptoms; assessment
Clinical Pearl: Symptoms are subjective; signs are generally objective.
Exam Strategy: If the information comes from what the client says, classify it as subjective.
Question 4
Which statement best describes a nursing diagnosis?
A. It identifies the medical disease causing symptoms.
B. It describes the client's response to an actual or potential health problem.
C. It is written exclusively by the healthcare provider.
D. It replaces the need for assessment findings.
Correct Answer: B. It describes the client's response to an actual or potential health problem.
Rationale: Nursing diagnoses focus on human responses that nurses can address through nursing
interventions. Medical diagnoses identify diseases or pathologic processes. Nursing diagnoses are developed
from assessment data and guide individualized nursing care.
Keywords: nursing diagnosis; client response; care planning
Clinical Pearl: A medical diagnosis may remain the same while nursing diagnoses change as the client's
condition changes.
Exam Strategy: Nursing diagnosis = response to health condition, not the disease itself.
Question 5 — Nursing Process Flow
ASSESSMENT
↓
DIAGNOSIS
↓
PLANNING
↓
IMPLEMENTATION
,↓
EVALUATION
The nurse administers oxygen according to the care plan. Which phase is represented?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: D. Implementation
Rationale: Implementation is the phase in which planned nursing interventions are carried out. Giving
oxygen is an action performed to address an identified client need. Evaluation would determine the client's
response after the intervention.
Keywords: implementation; ADPIE; intervention
Clinical Pearl: Implementation includes both independent and provider-prescribed nursing actions.
Exam Strategy: If the nurse is doing the planned intervention, select implementation.
Question 6
The nurse establishes the goal, “Client will report pain at 3/10 or less within 1 hour.” Which characteristic
makes this a strong expected outcome?
A. It is measurable and time limited.
B. It focuses on nursing activity.
C. It guarantees a specific medication response.
D. It avoids identifying a time frame.
Correct Answer: A. It is measurable and time limited.
Rationale: Effective outcomes are client-centered, observable or measurable, realistic, and associated with
a time frame. A numerical pain rating and one-hour target allow the nurse to determine objectively whether
the outcome was achieved.
Keywords: expected outcome; SMART goal; planning
Clinical Pearl: Outcomes should describe what the client will achieve, not what the nurse will do.
Exam Strategy: Look for a goal that includes a specific result plus a time frame.
Question 7
Which nursing action occurs during the evaluation phase?
A. Comparing the client's current pain score with the established goal
B. Identifying impaired mobility
,C. Teaching the client how to use a walker
D. Obtaining the initial health history
Correct Answer: A. Comparing the client's current pain score with the established goal
Rationale: Evaluation determines whether expected outcomes have been met by comparing current client
responses with planned goals. Findings may lead the nurse to continue, modify, or discontinue parts of the care
plan.
Keywords: evaluation; outcomes; nursing process
Clinical Pearl: Evaluation closes the nursing-process loop and often leads back to reassessment.
Exam Strategy: “Did it work?” = Evaluation.
Question 8
A nurse notices a client is confused, restless, and repeatedly trying to remove oxygen tubing. What should the
nurse do first?
A. Apply restraints immediately.
B. Document noncompliance.
C. Assess oxygenation and possible causes of the behavior.
D. Call security.
Correct Answer: C. Assess oxygenation and possible causes of the behavior.
Rationale: New confusion and restlessness may indicate hypoxia, pain, infection, medication effects, or
another physiologic problem. Assessment should precede restrictive interventions whenever immediate danger
does not require otherwise. Restraints do not treat the underlying cause.
Keywords: clinical judgment; confusion; hypoxia; assessment first
Clinical Pearl: Acute behavior changes can be the first sign of physiologic deterioration.
Exam Strategy: Before treating behavior, assess why it is occurring.
Question 9
Which client outcome requires the nurse to revise the care plan?
A. Goal met exactly as expected
B. Client demonstrates improved understanding
C. Expected outcome is not achieved despite interventions
D. Client requests written teaching material
Correct Answer: C. Expected outcome is not achieved despite interventions
, Rationale: When an outcome is not met, the nurse reassesses the client and determines whether the
diagnosis, goal, or intervention needs modification. Nursing care is dynamic and should change when the
client's response differs from what was expected.
Keywords: evaluation; care-plan revision; reassessment
Clinical Pearl: An unmet goal does not automatically mean the client “failed”; the plan may need
adjustment.
Exam Strategy: Outcome not met → reassess and revise.
Question 10
Which action best demonstrates clinical judgment?
A. Following every routine exactly the same for all clients
B. Recognizing relevant cues and selecting an intervention based on the client's current condition
C. Performing tasks only after another nurse confirms them
D. Ignoring minor changes until the next scheduled assessment
Correct Answer: B. Recognizing relevant cues and selecting an intervention based on the client's current
condition
Rationale: Clinical judgment requires nurses to recognize cues, analyze their meaning, prioritize concerns,
take action, and evaluate results. It is individualized and responsive rather than simply following routines
without considering the client's condition.
Keywords: clinical judgment; cue recognition; prioritization
Clinical Pearl: Good clinical judgment combines knowledge, assessment, context, and client response.
Exam Strategy: Choose the option showing cue recognition + appropriate decision-making.
HEALTH HISTORY, ASSESSMENT & DATA COLLECTION
Question 11
Which source is considered the primary source of health information whenever the client is alert and capable
of communication?
A. The client's family member
B. The medical record
C. The client
D. The healthcare provider
Correct Answer: C. The client
, Rationale: The client is the preferred primary source because they can directly describe symptoms,
concerns, history, and perceptions. Family members and records are secondary sources used when additional
information is needed or the client cannot provide reliable information.
Keywords: primary source; assessment; health history
Clinical Pearl: Always obtain the client's account first when the client is able to participate.
Exam Strategy: Alert, competent client = primary information source.
Question 12
Which finding is objective?
A. “My pain feels sharp.”
B. Respiratory rate 28/min
C. “I feel weak.”
D. “I slept poorly.”
Correct Answer: B. Respiratory rate 28/min
Rationale: Objective data are observable or measurable findings obtained through examination,
monitoring, or diagnostic testing. Respiratory rate can be counted directly. Pain quality, weakness, and sleep
quality are subjective experiences reported by the client.
Keywords: objective data; vital signs; assessment
Clinical Pearl: Objective does not mean “more important”; both data types are essential.
Exam Strategy: If it can be measured or observed, it is objective.
Question 13
Which technique should the nurse generally use first when performing a physical assessment of the abdomen?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation after deep palpation
Correct Answer: A. Inspection
Rationale: The nurse begins abdominal assessment with inspection, followed by auscultation before
percussion and palpation. Manipulating the abdomen before auscultation can alter bowel sounds and reduce
the accuracy of findings.
Keywords: abdominal assessment; inspection; auscultation
Clinical Pearl: The abdomen is the important exception to the usual inspection-palpation-percussion-
auscultation sequence.
, Exam Strategy: For the abdomen remember: Inspect → Auscultate → Percuss → Palpate.
Question 14
A client suddenly reports dizziness when standing. Which additional assessment is most appropriate?
A. Apical pulse while sleeping
B. Orthostatic vital signs
C. Abdominal girth
D. Visual acuity only
Correct Answer: B. Orthostatic vital signs
Rationale: Dizziness with position change may result from orthostatic hypotension. Comparing blood
pressure and pulse in different positions helps determine whether significant positional cardiovascular changes
are occurring.
Keywords: orthostatic hypotension; dizziness; vital signs
Clinical Pearl: Safety precautions are important during orthostatic assessment because the client may
become faint.
Exam Strategy: Symptoms with standing → think orthostatic measurements.
Question 15 — Data Classification Table
Finding Data Type
“I feel nauseated.” Subjective
Temperature 38.4°C Objective
“My chest feels tight.” Subjective
Oxygen saturation 89% Objective
Which finding requires the most immediate follow-up?
A. “I feel nauseated.”
B. Temperature 38.4°C
C. “My chest feels tight.”
D. Oxygen saturation 89%
Correct Answer: D. Oxygen saturation 89%
Rationale: An oxygen saturation of 89% indicates impaired oxygenation and may represent an immediate
breathing problem. Fever, nausea, and chest symptoms also require assessment, but significant hypoxemia
poses the most urgent physiologic threat.
Keywords: oxygen saturation; priority; assessment data
, Clinical Pearl: Always interpret data in terms of potential threats to airway, breathing, and circulation.
Exam Strategy: When several findings compete, prioritize the one indicating oxygenation failure.
Question 16
Which technique is used when the nurse taps the body surface to assess underlying density?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Correct Answer: C. Percussion
Rationale: Percussion produces sounds and vibrations that help estimate whether underlying structures
contain air, fluid, or solid tissue. Palpation uses touch, auscultation uses hearing, and inspection relies on
observation.
Keywords: percussion; physical assessment; examination
Clinical Pearl: Percussion findings are interpreted together with other assessment techniques.
Exam Strategy: Tapping the body = percussion.
Question 17
When measuring blood pressure manually, using a cuff that is too small may produce which result?
A. Falsely low reading
B. Falsely high reading
C. No effect
D. Accurate systolic but inaccurate diastolic pressure only
Correct Answer: B. Falsely high reading
Rationale: A cuff that is too small requires greater pressure to compress the artery and can falsely elevate
the measured blood pressure. Correct cuff size is essential for reliable assessment and clinical decision-making.
Keywords: blood pressure; cuff size; measurement error
Clinical Pearl: Technique errors can create abnormal findings that are not truly present.
Exam Strategy: Small cuff → falsely high; large cuff → potentially falsely low.
Question 18
Which finding should the nurse document as an assessment finding rather than an interpretation?
A. “Client appears to have pneumonia.”
B. “Client is noncompliant.”
,C. “Crackles heard in bilateral lower lung fields.”
D. “Client probably has fluid overload.”
Correct Answer: C. “Crackles heard in bilateral lower lung fields.”
Rationale: Documentation should describe observable and measurable findings objectively. “Crackles
heard” reports what the nurse actually assessed. Statements assigning a diagnosis or judgment without
supporting data introduce interpretation rather than factual observation.
Keywords: objective documentation; assessment; charting
Clinical Pearl: Chart what you observe, hear, measure, or are told.
Exam Strategy: Choose the option that describes facts without labels or assumptions.
COMMUNICATION & PATIENT TEACHING
Question 19
A client begins crying after receiving a new diagnosis. Which response by the nurse is most therapeutic?
A. “You shouldn't cry; everything will be fine.”
B. “Tell me what is going through your mind right now.”
C. “I know exactly how you feel.”
D. “You need to stay positive.”
Correct Answer: B. “Tell me what is going through your mind right now.”
Rationale: An open-ended invitation allows the client to express feelings and concerns without judgment.
False reassurance, minimizing emotions, and claiming to know exactly how the client feels can block
communication.
Keywords: therapeutic communication; open-ended question; empathy
Clinical Pearl: Therapeutic communication creates space for the client rather than directing how they
should feel.
Exam Strategy: Favor responses that invite expression rather than reassure, judge, or advise.
Question 20
Which statement by the nurse is an example of clarification?
A. “Why would you do that?”
B. “Everything will be okay.”
C. “When you say you feel strange, can you describe what you mean?”
D. “I understand exactly.”
Correct Answer: C. “When you say you feel strange, can you describe what you mean?”
