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 and
Scope of Nursing Assessment
Stem
A 68-year-old male with diabetes is admitted for cellulitis of the
lower leg. During initial assessment, he reports increasing
shortness of breath on exertion and new ankle swelling. The
nurse’s admission notes show oxygen saturation 92% on room
air and audible bibasilar crackles on lung auscultation that were
not present in the ED triage notes. What is the nurse’s best
immediate action?
,A. Document findings in the admission note and continue
routine skin assessment.
B. Notify the primary provider and request an order for chest x-
ray and diuretic therapy.
C. Reassess vital signs and lung sounds, place the patient in
upright position, and notify the provider of potential volume
overload.
D. Start contact precautions and escalate antibiotic therapy for
cellulitis.
Correct Answer: C
Rationale — Correct (C)
Reassessing and implementing immediate nursing measures
(upright position) to improve ventilation, then notifying the
provider with updated, accurate assessment data follows
assessment → intervention → communication. Bibasilar
crackles with new dyspnea and peripheral edema suggest fluid
overload or evolving heart failure; prompt nursing reassessment
clarifies urgency before initiating provider-level therapies. This
aligns with the chapter’s focus on ongoing data collection,
recognizing change, and appropriate sequencing of actions.
Rationales — Incorrect
A. Documentation without immediate reassessment and
intervention risks missing a deteriorating cardiopulmonary
state; not acceptable when findings are acute.
B. Jumping to specific orders (diuretic, chest x-ray) without
nurse-led reassessment and communication may be premature;
,nurse should provide current assessment data first.
D. Contact precautions and antibiotic escalation target
infection, not the acute cardiopulmonary signs; misprioritizes
problems given the new pulmonary findings.
Teaching Point
Reassess, implement basic interventions, then communicate
clear, current data to the provider.
Citation
Weber, J. R., & Kelley-Landaeta, J. H. (2024). Health Assessment
in Nursing (8th ed.). Ch. 1.
2
Reference
Ch. 1 — The Nurse’s Role in Health Assessment — Clinical
Reasoning and Prioritization
Stem
During a home visit, a 78-year-old woman’s daughter reports
the patient has become more forgetful and has had two falls in
the past month. The nurse finds orthostatic blood pressure drop
from 132/72 to 104/60 mm Hg, pulse increases from 78 to 110
bpm on standing, and the patient complains of
lightheadedness. Which conclusion and next step best reflect
clinical reasoning?
A. Cognitive decline is causing falls; arrange neuropsychological
testing next week.
, B. Orthostatic hypotension likely explains falls; implement fall
precautions, review medications, and notify provider today.
C. Normal age-related blood pressure changes account for
findings; document and continue routine care.
D. Dehydration is unlikely; encourage ambulation and monitor
for improvement.
Correct Answer: B
Rationale — Correct (B)
A significant orthostatic drop with compensatory tachycardia
explains syncope/falls and requires immediate nursing
interventions (fall precautions), medication review
(antihypertensives, diuretics), and prompt provider notification.
This demonstrates prioritization and linking assessment data to
likely causes consistent with Chapter 1 emphasis on clinical
reasoning and safety.
Rationales — Incorrect
A. Cognitive testing may be appropriate later but misses the
immediate physiologic cause of falls and delays safety
measures.
C. These changes exceed expected age-related variability and
are clinically significant; treating them as normal risks harm.
D. Dehydration could be contributory but dismissing
intervention (encourage ambulation) is unsafe given orthostasis
and fall risk.
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 and
Scope of Nursing Assessment
Stem
A 68-year-old male with diabetes is admitted for cellulitis of the
lower leg. During initial assessment, he reports increasing
shortness of breath on exertion and new ankle swelling. The
nurse’s admission notes show oxygen saturation 92% on room
air and audible bibasilar crackles on lung auscultation that were
not present in the ED triage notes. What is the nurse’s best
immediate action?
,A. Document findings in the admission note and continue
routine skin assessment.
B. Notify the primary provider and request an order for chest x-
ray and diuretic therapy.
C. Reassess vital signs and lung sounds, place the patient in
upright position, and notify the provider of potential volume
overload.
D. Start contact precautions and escalate antibiotic therapy for
cellulitis.
Correct Answer: C
Rationale — Correct (C)
Reassessing and implementing immediate nursing measures
(upright position) to improve ventilation, then notifying the
provider with updated, accurate assessment data follows
assessment → intervention → communication. Bibasilar
crackles with new dyspnea and peripheral edema suggest fluid
overload or evolving heart failure; prompt nursing reassessment
clarifies urgency before initiating provider-level therapies. This
aligns with the chapter’s focus on ongoing data collection,
recognizing change, and appropriate sequencing of actions.
Rationales — Incorrect
A. Documentation without immediate reassessment and
intervention risks missing a deteriorating cardiopulmonary
state; not acceptable when findings are acute.
B. Jumping to specific orders (diuretic, chest x-ray) without
nurse-led reassessment and communication may be premature;
,nurse should provide current assessment data first.
D. Contact precautions and antibiotic escalation target
infection, not the acute cardiopulmonary signs; misprioritizes
problems given the new pulmonary findings.
Teaching Point
Reassess, implement basic interventions, then communicate
clear, current data to the provider.
Citation
Weber, J. R., & Kelley-Landaeta, J. H. (2024). Health Assessment
in Nursing (8th ed.). Ch. 1.
2
Reference
Ch. 1 — The Nurse’s Role in Health Assessment — Clinical
Reasoning and Prioritization
Stem
During a home visit, a 78-year-old woman’s daughter reports
the patient has become more forgetful and has had two falls in
the past month. The nurse finds orthostatic blood pressure drop
from 132/72 to 104/60 mm Hg, pulse increases from 78 to 110
bpm on standing, and the patient complains of
lightheadedness. Which conclusion and next step best reflect
clinical reasoning?
A. Cognitive decline is causing falls; arrange neuropsychological
testing next week.
, B. Orthostatic hypotension likely explains falls; implement fall
precautions, review medications, and notify provider today.
C. Normal age-related blood pressure changes account for
findings; document and continue routine care.
D. Dehydration is unlikely; encourage ambulation and monitor
for improvement.
Correct Answer: B
Rationale — Correct (B)
A significant orthostatic drop with compensatory tachycardia
explains syncope/falls and requires immediate nursing
interventions (fall precautions), medication review
(antihypertensives, diuretics), and prompt provider notification.
This demonstrates prioritization and linking assessment data to
likely causes consistent with Chapter 1 emphasis on clinical
reasoning and safety.
Rationales — Incorrect
A. Cognitive testing may be appropriate later but misses the
immediate physiologic cause of falls and delays safety
measures.
C. These changes exceed expected age-related variability and
are clinically significant; treating them as normal risks harm.
D. Dehydration could be contributory but dismissing
intervention (encourage ambulation) is unsafe given orthostasis
and fall risk.
