Nur 325 - Health Assessment Exam 3 questions and
answers 2025/2026 update
The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining
of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of
which condition?
a. Ischemia
b. Pneumonia
c. Myocardial infarction
d. Peptic ulcer disease - ✔✔ANS C (Fatigue is an atypical symptom of myocardial infarction in
women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of
breath. Peptic ulcer disease is associated with pain and intestinal discomfort.)
A patient is questioning the nurse about circulation and perfusion. What is the nurse's best
response?
a. Perfusion assists the body by preventing clots and increasing stamina.
b. Perfusion assists the cell by delivering oxygen and removing waste products.
c. Perfusion assists the heart by increasing the cardiac output.
d. Perfusion assists the brain by increasing mental alertness. - ✔✔ANS B (Perfusion delivers
much needed oxygen to the cells of the body and then helps to remove waste products.
Perfusion does not prevent clots, does not increase cardiac output, and does not increase
mental alertness.)
A 72-year-old man presents to the emergency room. The patient appears diaphoretic and
anxious, and has noted peripheral edema. The patient's vital signs are blood pressure of 100/40,
heart rate of 130 and irregular, and respiratory rate of 26. How does the nurse interpret these
findings?
a. The patient is having a myocardial infarction.
b. The patient has impaired central perfusion.
c. The patient has a virus.
,rate. Pain management is not indicated for patients who do not present with pain. Also, the
question is asking what assessment the nurse has made, and is not asking about interventions.)
The nurse knows that including teaching on modifiable risk factors for impaired perfusion in the
patient's plan of care includes which of the following:
a. Impaired perfusion increases with age.
b. Genetics play a role in impaired perfusion.
c. Exercise should be kept at a minimum to prevent a myocardial infarction.
d. A smoking cessation plan should be in place. - ✔✔ANS D (The importance of distinguishing
between modifiable versus nonmodifiable risk factors is imperative when determining what sort
of lifestyle changes can be discussed when formulating the patient's plan of care. Impaired
perfusion can affect all people and age groups regardless of gender, race, or economic status.
Smoking cessation is an example of a modifiable risk factor for impaired perfusion that can be
included in the patient's plan of care. Modifiable risk factors can be changed by the patient
through teaching from the nurse. Although impaired perfusion can increase with age, this is an
example of an unmodifiable risk factor (something that the patient cannot change). Genetics is
an example of an unmodifiable risk factor for impaired perfusion. A sedentary lifestyle can lead
to obesity, which would then become a modifiable risk factor for impaired perfusion.)
The nurse knows that primary prevention strategies to prevent impaired perfusion in the patient
include which of the following recommendations by the American Heart Association (AHA):
a. Routine blood pressure monitoring
b. Administering furosemide (Lasix) to a patient with active congestive heart failure (CHF)
symptoms
c. Eating a healthy diet and exercising most days of the week
d. Monitoring routine serum lipids - ✔✔ANS C (Primary prevention strategies include measures
that promote health and prevent disease from developing. The American Heart Association
recommends eating a heart-healthy diet, exercising most days of the week, taking a low-dose
aspirin, and not smoking. Routine blood pressure monitoring is considered secondary
prevention, which also includes screening and early diagnosis of health issues.Although
administering a diuretic such as furosemide to a patient who presents with active CHF
symptoms is considered an optimal treatment of symptoms, this is not considered a primary
prevention strategy. Testing for routine serum lipids is considered secondary prevention.)
,b. The pain indicates a muscle spasm.
c. The patient is having a myocardial infarction.
d. The pain is due to over-exertion during morning care. - ✔✔ANS A (Impaired perfusion often
results in leg pain as related to peripheral arterial disease (PAD). PAD leg pain is often relieved
with rest and worsens with walking. Leg pain that is relieved with rest is called intermittent
claudication and means that there is an inadequate supply of blood being transported to the
muscles. Edema also develops from the obstruction of venous blood flow.Although pain is
common during a muscle spasm, it is usually not relieved with rest. During a myocardial
infarction, pain is often felt in the chest and not in the lower extremities.Although pain may
occur from exercise, acute leg pain with the presence of edema indicates a perfusion problem
and warrants further investigation.)
A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like
symptoms. The client suddenly complains of chest pain. Which of the following questions would
best help a nurse to discriminate pain caused by a non-cardiac problem?
a. "Have you ever had this pain before?"
b. "Can you describe the pain to me?"
c. "Does the pain get worse when you breathe in?"
d. "Can you rate the pain on a scale of 1-10, with 10 being the worst?" - ✔✔ANS C (Chest pain is
assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may
not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on
inspiration.)
You read in Mr. Smith's medical record that he was diagnosed with stage 1 hypertension and
started on a diuretic. Which statement defines stage 1 hypertension?
a. A systolic reading of less than 120 mm Hg, and a diastolic reading of less than 80 mm Hg
b. A systolic reading of 120-139 mm Hg, or a diastolic reading of 80-89 mm Hg
c. A systolic reading of 140-159 mm Hg, or a diastolic reading of 90-99 mm Hg
d. A systolic reading of 160 mm Hg or greater, or a diastolic reading of 100 mm Hg or greater -
✔✔ANS C
A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction
who was admitted 2 days ago. The nurse would plan to do which of the following next?
, d. Order daily weights starting the following morning - ✔✔ANS A (Edema, the accumulation of
excess fluid in the interstitial spaces, can be measured by intake greater than output and by a
sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid
nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.)
For all persons without a normal blood pressure, treatment recommendations vary by blood
pressure classification. Blood pressure classification should be based on:
a. an average of two or more blood pressure readings taken at one healthcare visit
b. an average of two or more blood pressure readings taken at each of two healthcare visits
c. the highest pressure over a week
d. the lowest pressure over a week - ✔✔ANS B (Blood pressure classification should be made
on the basis of average blood pressure readings (two or more) obtained at each of two separate
healthcare visits.)
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees
no electrocardiogram complexes on the screen. The first action of the nurse is to:
a. Check the client status and lead placement
b. Press the recorder button on the electrocardiogram console
c. Call the physician
d. Call a code blue - ✔✔ANS A (Sudden loss of electrocardiogram complexes indicates
ventricular asystole or possible electrode displacement. Accurate assessment of the client and
equipment is necessary to determine the cause and identify the appropriate intervention.)
Which assessment is indicated to evaluate a patients' leg circulation?
a. Carotid arteries for bruits
b. Pedal and tibial pulses for presence and quality
c. Orthostatic blood pressure readings - ✔✔ANS B
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of
answers 2025/2026 update
The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining
of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of
which condition?
a. Ischemia
b. Pneumonia
c. Myocardial infarction
d. Peptic ulcer disease - ✔✔ANS C (Fatigue is an atypical symptom of myocardial infarction in
women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of
breath. Peptic ulcer disease is associated with pain and intestinal discomfort.)
A patient is questioning the nurse about circulation and perfusion. What is the nurse's best
response?
a. Perfusion assists the body by preventing clots and increasing stamina.
b. Perfusion assists the cell by delivering oxygen and removing waste products.
c. Perfusion assists the heart by increasing the cardiac output.
d. Perfusion assists the brain by increasing mental alertness. - ✔✔ANS B (Perfusion delivers
much needed oxygen to the cells of the body and then helps to remove waste products.
Perfusion does not prevent clots, does not increase cardiac output, and does not increase
mental alertness.)
A 72-year-old man presents to the emergency room. The patient appears diaphoretic and
anxious, and has noted peripheral edema. The patient's vital signs are blood pressure of 100/40,
heart rate of 130 and irregular, and respiratory rate of 26. How does the nurse interpret these
findings?
a. The patient is having a myocardial infarction.
b. The patient has impaired central perfusion.
c. The patient has a virus.
,rate. Pain management is not indicated for patients who do not present with pain. Also, the
question is asking what assessment the nurse has made, and is not asking about interventions.)
The nurse knows that including teaching on modifiable risk factors for impaired perfusion in the
patient's plan of care includes which of the following:
a. Impaired perfusion increases with age.
b. Genetics play a role in impaired perfusion.
c. Exercise should be kept at a minimum to prevent a myocardial infarction.
d. A smoking cessation plan should be in place. - ✔✔ANS D (The importance of distinguishing
between modifiable versus nonmodifiable risk factors is imperative when determining what sort
of lifestyle changes can be discussed when formulating the patient's plan of care. Impaired
perfusion can affect all people and age groups regardless of gender, race, or economic status.
Smoking cessation is an example of a modifiable risk factor for impaired perfusion that can be
included in the patient's plan of care. Modifiable risk factors can be changed by the patient
through teaching from the nurse. Although impaired perfusion can increase with age, this is an
example of an unmodifiable risk factor (something that the patient cannot change). Genetics is
an example of an unmodifiable risk factor for impaired perfusion. A sedentary lifestyle can lead
to obesity, which would then become a modifiable risk factor for impaired perfusion.)
The nurse knows that primary prevention strategies to prevent impaired perfusion in the patient
include which of the following recommendations by the American Heart Association (AHA):
a. Routine blood pressure monitoring
b. Administering furosemide (Lasix) to a patient with active congestive heart failure (CHF)
symptoms
c. Eating a healthy diet and exercising most days of the week
d. Monitoring routine serum lipids - ✔✔ANS C (Primary prevention strategies include measures
that promote health and prevent disease from developing. The American Heart Association
recommends eating a heart-healthy diet, exercising most days of the week, taking a low-dose
aspirin, and not smoking. Routine blood pressure monitoring is considered secondary
prevention, which also includes screening and early diagnosis of health issues.Although
administering a diuretic such as furosemide to a patient who presents with active CHF
symptoms is considered an optimal treatment of symptoms, this is not considered a primary
prevention strategy. Testing for routine serum lipids is considered secondary prevention.)
,b. The pain indicates a muscle spasm.
c. The patient is having a myocardial infarction.
d. The pain is due to over-exertion during morning care. - ✔✔ANS A (Impaired perfusion often
results in leg pain as related to peripheral arterial disease (PAD). PAD leg pain is often relieved
with rest and worsens with walking. Leg pain that is relieved with rest is called intermittent
claudication and means that there is an inadequate supply of blood being transported to the
muscles. Edema also develops from the obstruction of venous blood flow.Although pain is
common during a muscle spasm, it is usually not relieved with rest. During a myocardial
infarction, pain is often felt in the chest and not in the lower extremities.Although pain may
occur from exercise, acute leg pain with the presence of edema indicates a perfusion problem
and warrants further investigation.)
A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like
symptoms. The client suddenly complains of chest pain. Which of the following questions would
best help a nurse to discriminate pain caused by a non-cardiac problem?
a. "Have you ever had this pain before?"
b. "Can you describe the pain to me?"
c. "Does the pain get worse when you breathe in?"
d. "Can you rate the pain on a scale of 1-10, with 10 being the worst?" - ✔✔ANS C (Chest pain is
assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may
not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on
inspiration.)
You read in Mr. Smith's medical record that he was diagnosed with stage 1 hypertension and
started on a diuretic. Which statement defines stage 1 hypertension?
a. A systolic reading of less than 120 mm Hg, and a diastolic reading of less than 80 mm Hg
b. A systolic reading of 120-139 mm Hg, or a diastolic reading of 80-89 mm Hg
c. A systolic reading of 140-159 mm Hg, or a diastolic reading of 90-99 mm Hg
d. A systolic reading of 160 mm Hg or greater, or a diastolic reading of 100 mm Hg or greater -
✔✔ANS C
A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction
who was admitted 2 days ago. The nurse would plan to do which of the following next?
, d. Order daily weights starting the following morning - ✔✔ANS A (Edema, the accumulation of
excess fluid in the interstitial spaces, can be measured by intake greater than output and by a
sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid
nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.)
For all persons without a normal blood pressure, treatment recommendations vary by blood
pressure classification. Blood pressure classification should be based on:
a. an average of two or more blood pressure readings taken at one healthcare visit
b. an average of two or more blood pressure readings taken at each of two healthcare visits
c. the highest pressure over a week
d. the lowest pressure over a week - ✔✔ANS B (Blood pressure classification should be made
on the basis of average blood pressure readings (two or more) obtained at each of two separate
healthcare visits.)
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees
no electrocardiogram complexes on the screen. The first action of the nurse is to:
a. Check the client status and lead placement
b. Press the recorder button on the electrocardiogram console
c. Call the physician
d. Call a code blue - ✔✔ANS A (Sudden loss of electrocardiogram complexes indicates
ventricular asystole or possible electrode displacement. Accurate assessment of the client and
equipment is necessary to determine the cause and identify the appropriate intervention.)
Which assessment is indicated to evaluate a patients' leg circulation?
a. Carotid arteries for bruits
b. Pedal and tibial pulses for presence and quality
c. Orthostatic blood pressure readings - ✔✔ANS B
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of
