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 68-year-old man arrives for a routine clinic visit for
diabetes follow-up. During the history he mentions new fatigue
and increased thirst over the last month. Which nursing action
best reflects the nurse’s primary role in health assessment at
this visit?
A. Order laboratory tests for glucose and electrolytes.
B. Perform focused assessment related to diabetes and report
findings to the provider.
C. Diagnose uncontrolled diabetes and start insulin
adjustments.
D. Provide detailed dietary counseling and set caloric limits.
,Correct answer: B
Rationale — Correct: Performing a focused assessment and
reporting findings is within the nurse’s role: it gathers relevant
subjective and objective data to inform clinical decision-making.
This action uses assessment skills to identify changes (fatigue,
polydipsia) and communicates findings for medical
management.
Rationale — Incorrect:
A. Ordering labs is a provider/advanced practice action and not
within typical RN scope without protocol.
C. Making a medical diagnosis and changing medications
exceeds the nurse’s assessment role and scope.
D. Providing general education may be appropriate but does not
prioritize assessment and communication of new symptoms.
Teaching point: Nurses gather and interpret assessment data
and report abnormal findings for collaborative management.
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 — Types of Assessments
(Comprehensive vs Focused)
Stem: A 2-day postoperative patient develops sudden shortness
of breath and pleuritic chest pain. The nurse should perform
which type of assessment first?
A. Comprehensive head-to-toe admission assessment.
,B. Focused problem-oriented assessment of respiratory and
cardiovascular systems.
C. Standard postoperative pain assessment only.
D. Full medication reconciliation and allergy review.
Correct answer: B
Rationale — Correct: A focused problem-oriented assessment
targets the systems related to the new symptoms
(respiratory/cardiovascular), rapidly gathering data to detect
potential complications (e.g., pulmonary embolism, atelectasis).
This is appropriate and time-sensitive.
Rationale — Incorrect:
A. A comprehensive assessment is thorough but not timely for
acute respiratory symptoms.
C. Pain assessment alone is insufficient to evaluate respiratory
compromise.
D. Medication reconciliation is important but secondary to
assessing acute respiratory status.
Teaching point: Use focused assessments to evaluate new,
urgent symptoms promptly.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — Clinical Judgment & Prioritization in
Assessment
Stem: While completing a home-visit assessment, the nurse
, notes a client with chronic heart failure has 3+ pitting edema to
the knees, weight gain of 4 kg in 4 days, and increased
shortness of breath at rest. What is the nurse’s highest-priority
action?
A. Document findings in the electronic health record.
B. Teach dietary sodium restriction and encourage leg elevation.
C. Contact the provider to report findings and recommend
immediate evaluation.
D. Schedule the patient for routine clinic follow-up next week.
Correct answer: C
Rationale — Correct: These findings indicate acute
decompensated heart failure and require prompt
communication with the provider for possible urgent
intervention. Prioritization of clinical deterioration and
escalation is essential in nursing assessment.
Rationale — Incorrect:
A. Documentation is necessary but should not delay escalation
for potentially life-threatening findings.
B. Teaching is useful but insufficient when immediate medical
evaluation may be required.
D. Routine follow-up is unsafe given rapid weight gain and
dyspnea.
Teaching point: Escalate promptly for signs of acute
decompensation (rapid weight gain, dyspnea, significant
edema).
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
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 68-year-old man arrives for a routine clinic visit for
diabetes follow-up. During the history he mentions new fatigue
and increased thirst over the last month. Which nursing action
best reflects the nurse’s primary role in health assessment at
this visit?
A. Order laboratory tests for glucose and electrolytes.
B. Perform focused assessment related to diabetes and report
findings to the provider.
C. Diagnose uncontrolled diabetes and start insulin
adjustments.
D. Provide detailed dietary counseling and set caloric limits.
,Correct answer: B
Rationale — Correct: Performing a focused assessment and
reporting findings is within the nurse’s role: it gathers relevant
subjective and objective data to inform clinical decision-making.
This action uses assessment skills to identify changes (fatigue,
polydipsia) and communicates findings for medical
management.
Rationale — Incorrect:
A. Ordering labs is a provider/advanced practice action and not
within typical RN scope without protocol.
C. Making a medical diagnosis and changing medications
exceeds the nurse’s assessment role and scope.
D. Providing general education may be appropriate but does not
prioritize assessment and communication of new symptoms.
Teaching point: Nurses gather and interpret assessment data
and report abnormal findings for collaborative management.
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 — Types of Assessments
(Comprehensive vs Focused)
Stem: A 2-day postoperative patient develops sudden shortness
of breath and pleuritic chest pain. The nurse should perform
which type of assessment first?
A. Comprehensive head-to-toe admission assessment.
,B. Focused problem-oriented assessment of respiratory and
cardiovascular systems.
C. Standard postoperative pain assessment only.
D. Full medication reconciliation and allergy review.
Correct answer: B
Rationale — Correct: A focused problem-oriented assessment
targets the systems related to the new symptoms
(respiratory/cardiovascular), rapidly gathering data to detect
potential complications (e.g., pulmonary embolism, atelectasis).
This is appropriate and time-sensitive.
Rationale — Incorrect:
A. A comprehensive assessment is thorough but not timely for
acute respiratory symptoms.
C. Pain assessment alone is insufficient to evaluate respiratory
compromise.
D. Medication reconciliation is important but secondary to
assessing acute respiratory status.
Teaching point: Use focused assessments to evaluate new,
urgent symptoms promptly.
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
3.
Reference: Ch. 1 — Clinical Judgment & Prioritization in
Assessment
Stem: While completing a home-visit assessment, the nurse
, notes a client with chronic heart failure has 3+ pitting edema to
the knees, weight gain of 4 kg in 4 days, and increased
shortness of breath at rest. What is the nurse’s highest-priority
action?
A. Document findings in the electronic health record.
B. Teach dietary sodium restriction and encourage leg elevation.
C. Contact the provider to report findings and recommend
immediate evaluation.
D. Schedule the patient for routine clinic follow-up next week.
Correct answer: C
Rationale — Correct: These findings indicate acute
decompensated heart failure and require prompt
communication with the provider for possible urgent
intervention. Prioritization of clinical deterioration and
escalation is essential in nursing assessment.
Rationale — Incorrect:
A. Documentation is necessary but should not delay escalation
for potentially life-threatening findings.
B. Teaching is useful but insufficient when immediate medical
evaluation may be required.
D. Routine follow-up is unsafe given rapid weight gain and
dyspnea.
Teaching point: Escalate promptly for signs of acute
decompensation (rapid weight gain, dyspnea, significant
edema).
Citation: Weber, J. R., & Kelley-Landaeta, J. H. (2025). Health
Assessment in Nursing (8th ed.). Ch. 1.
