HEALTH ASSESSMENT IN NURSING
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Purpose & Scope of Assessment
Stem: A 58-year-old man admitted for congestive heart failure
has a recent history documented by EMS. The nurse plans the
initial assessment. Which nursing approach best reflects the
primary purpose of the comprehensive health assessment on
admission?
A. Confirm the physician’s admitting diagnosis by ordering
diagnostic tests.
B. Collect baseline data to identify actual and potential health
problems and plan individualized care.
C. Complete only a focused exam of the cardiovascular system
,because that is the admitting problem.
D. Delegate the assessment to the UAP and review the findings
later.
Correct answer: B.
Rationale — Correct: Comprehensive admission assessment
collects baseline subjective and objective data to identify actual
and potential problems and to individualize the plan of nursing
care; it’s foundational to nursing practice. It emphasizes holistic
data collection beyond the admitting diagnosis.
Rationale — A: Incorrect — Nurses do not order tests to
confirm medical diagnoses; they collect data and collaborate
with the team.
Rationale — C: Incorrect — A focused exam is appropriate for
specific concerns, but on admission a comprehensive baseline is
required.
Rationale — D: Incorrect — Delegating the initial
comprehensive assessment to unlicensed assistive personnel
(UAP) is unsafe and outside scope; UAP can assist with basic
tasks only.
Teaching point: Admission assessments establish baseline data
to identify current and potential nursing problems.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
2.
,Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Subjective vs Objective Data
Stem: A nurse documents a patient’s complaint of “shortness of
breath at rest” and observes the patient sitting upright,
speaking in short phrases, and respiratory rate 28. Which
statement best describes the documentation?
A. The nurse documented only subjective data and omitted
objective findings.
B. The nurse correctly documented both subjective (symptom)
and objective (sign) data.
C. The nurse should convert the subjective report into an
objective finding.
D. The nurse must avoid documenting the patient’s
statements—only measurable data are allowed.
Correct answer: B.
Rationale — Correct: Documenting the patient’s report
(“shortness of breath”) is subjective data, while observations—
position, respiratory rate—are objective data; both are
appropriate and necessary.
Rationale — A: Incorrect — The nurse included objective
observations (respiratory rate, posture).
Rationale — C: Incorrect — Subjective reports should be
recorded verbatim or paraphrased, not converted into objective
data.
Rationale — D: Incorrect — Patient statements are essential
and required; documentation should include both subjective
and objective information.
, Teaching point: Record both subjective symptoms and objective
signs; quote or paraphrase patient words for accuracy.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Sources of Data & Validation
Stem: During a home visit, the patient’s daughter reports poor
appetite for 2 weeks, but the patient says appetite is “fine.”
Vital signs are normal and weight has decreased by 3 kg in two
weeks. What is the nurse’s best next action?
A. Accept the patient’s statement and document “appetite
fine.”
B. Record both reports and seek additional corroborating data
(food intake records, weight trend) to validate the discrepancy.
C. Confront the daughter for contradicting the patient.
D. Discharge the patient from follow-up because vitals are
normal.
Correct answer: B.
Rationale — Correct: When sources conflict, the nurse
documents both perspectives and seeks objective data (weight
trends, intake records) to validate and clarify discrepancies for
accurate assessment and planning.
Rationale — A: Incorrect — Accepting one report without
validation risks missing a real problem.
8TH EDITION
• AUTHOR(S)JANET R. WEBER, JANE
HARMON KELLEY-LANDAETA
TEST BANK
1.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Purpose & Scope of Assessment
Stem: A 58-year-old man admitted for congestive heart failure
has a recent history documented by EMS. The nurse plans the
initial assessment. Which nursing approach best reflects the
primary purpose of the comprehensive health assessment on
admission?
A. Confirm the physician’s admitting diagnosis by ordering
diagnostic tests.
B. Collect baseline data to identify actual and potential health
problems and plan individualized care.
C. Complete only a focused exam of the cardiovascular system
,because that is the admitting problem.
D. Delegate the assessment to the UAP and review the findings
later.
Correct answer: B.
Rationale — Correct: Comprehensive admission assessment
collects baseline subjective and objective data to identify actual
and potential problems and to individualize the plan of nursing
care; it’s foundational to nursing practice. It emphasizes holistic
data collection beyond the admitting diagnosis.
Rationale — A: Incorrect — Nurses do not order tests to
confirm medical diagnoses; they collect data and collaborate
with the team.
Rationale — C: Incorrect — A focused exam is appropriate for
specific concerns, but on admission a comprehensive baseline is
required.
Rationale — D: Incorrect — Delegating the initial
comprehensive assessment to unlicensed assistive personnel
(UAP) is unsafe and outside scope; UAP can assist with basic
tasks only.
Teaching point: Admission assessments establish baseline data
to identify current and potential nursing problems.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
2.
,Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Subjective vs Objective Data
Stem: A nurse documents a patient’s complaint of “shortness of
breath at rest” and observes the patient sitting upright,
speaking in short phrases, and respiratory rate 28. Which
statement best describes the documentation?
A. The nurse documented only subjective data and omitted
objective findings.
B. The nurse correctly documented both subjective (symptom)
and objective (sign) data.
C. The nurse should convert the subjective report into an
objective finding.
D. The nurse must avoid documenting the patient’s
statements—only measurable data are allowed.
Correct answer: B.
Rationale — Correct: Documenting the patient’s report
(“shortness of breath”) is subjective data, while observations—
position, respiratory rate—are objective data; both are
appropriate and necessary.
Rationale — A: Incorrect — The nurse included objective
observations (respiratory rate, posture).
Rationale — C: Incorrect — Subjective reports should be
recorded verbatim or paraphrased, not converted into objective
data.
Rationale — D: Incorrect — Patient statements are essential
and required; documentation should include both subjective
and objective information.
, Teaching point: Record both subjective symptoms and objective
signs; quote or paraphrase patient words for accuracy.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — The Nurse’s Role in Health Assessment —
Sources of Data & Validation
Stem: During a home visit, the patient’s daughter reports poor
appetite for 2 weeks, but the patient says appetite is “fine.”
Vital signs are normal and weight has decreased by 3 kg in two
weeks. What is the nurse’s best next action?
A. Accept the patient’s statement and document “appetite
fine.”
B. Record both reports and seek additional corroborating data
(food intake records, weight trend) to validate the discrepancy.
C. Confront the daughter for contradicting the patient.
D. Discharge the patient from follow-up because vitals are
normal.
Correct answer: B.
Rationale — Correct: When sources conflict, the nurse
documents both perspectives and seeks objective data (weight
trends, intake records) to validate and clarify discrepancies for
accurate assessment and planning.
Rationale — A: Incorrect — Accepting one report without
validation risks missing a real problem.
