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 of Health Assessment & Scope
Stem: A 72-year-old man arrives for a routine clinic visit with
controlled hypertension on two medications. During the health
assessment, he reports occasional dizziness on standing and a
history of falls last winter. As the nurse collecting data, which
action is the best next step to prioritize?
A. Document the dizziness as “occasional” and schedule follow-
up in 6 months.
B. Perform orthostatic vital signs now and ask about timing of
dizziness relative to medication dosing.
C. Teach the patient fall-prevention strategies and provide
written handouts.
,D. Notify the provider immediately to request discontinuation
of antihypertensive medications.
Correct Answer: B
Rationale — Correct (B): Orthostatic vital signs directly assess a
likely cause of dizziness and prior falls in an older adult on
antihypertensives. Measuring lying, sitting, and standing blood
pressures and heart rate provides objective data to guide
medication timing or dose adjustments and immediate safety
planning. This is an evidence-based, assessment-first nursing
action.
Rationale — Incorrect (A): Delaying assessment risks missing
orthostatic hypotension and further falls; documentation alone
is insufficient.
Rationale — Incorrect (C): Teaching is important but secondary;
without identifying orthostatic changes, teaching alone may not
prevent imminent risk.
Rationale — Incorrect (D): Immediate medication
discontinuation is a medical decision; nursing role is to gather
data and communicate findings.
Teaching Point: Always obtain orthostatic vitals when older
adults report dizziness or falls.
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 —
Types of Data (Subjective vs Objective)
Stem: A 5-year-old child presents with fever and cough. The
parent reports decreased oral intake and that the child “seems
more sleepy.” On exam the nurse notes dry mucous
membranes, decreased skin turgor, and capillary refill of 4
seconds. Which interpretation and immediate nursing action
best aligns with accurate data analysis?
A. Rely on parental report; document “child appears sleepy”
and schedule reassessment tomorrow.
B. Classify the parent’s report as subjective data and the dry
mucous membranes, decreased turgor, and prolonged capillary
refill as objective signs of volume depletion; initiate oral
rehydration if tolerated and notify provider.
C. Treat the findings as normal for fever and advise increased
fluids at home without notifying provider.
D. Record all findings but defer any interventions until
laboratory tests are available.
Correct Answer: B
Rationale — Correct (B): The nurse appropriately differentiates
subjective (parental report) from objective findings
(dehydration signs), recognizes clinical significance (possible
hypovolemia), initiates immediate supportive measures (oral
rehydration if safe), and communicates with the provider—
consistent with nursing assessment scope.
Rationale — Incorrect (A): Sole reliance on subjective report
, without acting on objective dehydration is unsafe.
Rationale — Incorrect (C): Prolonged capillary refill and poor
turgor are abnormal and require more than routine at-home
advice.
Rationale — Incorrect (D): Waiting for labs delays needed initial
nursing interventions and communication.
Teaching Point: Distinguish subjective vs objective data; act
promptly on objective dehydration signs.
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 —
Cultural Considerations in Data Collection
Stem: A 28-year-old female refugee who speaks limited English
is admitted for a prenatal visit. She declines a standard pelvic
exam and appears anxious. As the admitting nurse, which
approach best upholds culturally responsive assessment while
ensuring safety?
A. Force the pelvic exam to follow protocol and document
refusal only if she resists.
B. Use a professional medical interpreter, explain the purpose
and components of the exam, explore cultural concerns, and
offer a female examiner if preferred.
C. Skip the pelvic exam and mark it as permanently
contraindicated due to cultural beliefs.
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 of Health Assessment & Scope
Stem: A 72-year-old man arrives for a routine clinic visit with
controlled hypertension on two medications. During the health
assessment, he reports occasional dizziness on standing and a
history of falls last winter. As the nurse collecting data, which
action is the best next step to prioritize?
A. Document the dizziness as “occasional” and schedule follow-
up in 6 months.
B. Perform orthostatic vital signs now and ask about timing of
dizziness relative to medication dosing.
C. Teach the patient fall-prevention strategies and provide
written handouts.
,D. Notify the provider immediately to request discontinuation
of antihypertensive medications.
Correct Answer: B
Rationale — Correct (B): Orthostatic vital signs directly assess a
likely cause of dizziness and prior falls in an older adult on
antihypertensives. Measuring lying, sitting, and standing blood
pressures and heart rate provides objective data to guide
medication timing or dose adjustments and immediate safety
planning. This is an evidence-based, assessment-first nursing
action.
Rationale — Incorrect (A): Delaying assessment risks missing
orthostatic hypotension and further falls; documentation alone
is insufficient.
Rationale — Incorrect (C): Teaching is important but secondary;
without identifying orthostatic changes, teaching alone may not
prevent imminent risk.
Rationale — Incorrect (D): Immediate medication
discontinuation is a medical decision; nursing role is to gather
data and communicate findings.
Teaching Point: Always obtain orthostatic vitals when older
adults report dizziness or falls.
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 —
Types of Data (Subjective vs Objective)
Stem: A 5-year-old child presents with fever and cough. The
parent reports decreased oral intake and that the child “seems
more sleepy.” On exam the nurse notes dry mucous
membranes, decreased skin turgor, and capillary refill of 4
seconds. Which interpretation and immediate nursing action
best aligns with accurate data analysis?
A. Rely on parental report; document “child appears sleepy”
and schedule reassessment tomorrow.
B. Classify the parent’s report as subjective data and the dry
mucous membranes, decreased turgor, and prolonged capillary
refill as objective signs of volume depletion; initiate oral
rehydration if tolerated and notify provider.
C. Treat the findings as normal for fever and advise increased
fluids at home without notifying provider.
D. Record all findings but defer any interventions until
laboratory tests are available.
Correct Answer: B
Rationale — Correct (B): The nurse appropriately differentiates
subjective (parental report) from objective findings
(dehydration signs), recognizes clinical significance (possible
hypovolemia), initiates immediate supportive measures (oral
rehydration if safe), and communicates with the provider—
consistent with nursing assessment scope.
Rationale — Incorrect (A): Sole reliance on subjective report
, without acting on objective dehydration is unsafe.
Rationale — Incorrect (C): Prolonged capillary refill and poor
turgor are abnormal and require more than routine at-home
advice.
Rationale — Incorrect (D): Waiting for labs delays needed initial
nursing interventions and communication.
Teaching Point: Distinguish subjective vs objective data; act
promptly on objective dehydration signs.
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 —
Cultural Considerations in Data Collection
Stem: A 28-year-old female refugee who speaks limited English
is admitted for a prenatal visit. She declines a standard pelvic
exam and appears anxious. As the admitting nurse, which
approach best upholds culturally responsive assessment while
ensuring safety?
A. Force the pelvic exam to follow protocol and document
refusal only if she resists.
B. Use a professional medical interpreter, explain the purpose
and components of the exam, explore cultural concerns, and
offer a female examiner if preferred.
C. Skip the pelvic exam and mark it as permanently
contraindicated due to cultural beliefs.
