,SET 1 (Questions 1–50) – Health Assessment V1
1. A nurse is performing a general survey on a newly admitted client.
Which finding is most indicative of a potential thyroid disorder?
A) Blood pressure 118/76 mm Hg
B) Heart rate 72 bpm
C) Fine tremor of the outstretched hands
D) Respiratory rate 16 breaths/min
Rationale: A fine tremor of the hands is a classic sign of
hyperthyroidism due to increased sympathetic nervous system
activity.
2. During an admission assessment, the nurse notes that a client’s
skin is warm, dry, and flushed. The client reports feeling hot. This
finding is most consistent with:
A) Hypothyroidism
B) Dehydration
C) Fever or hypermetabolic state
D) Peripheral vascular disease
Rationale: Warm, flushed skin occurs with fever, hyperthyroidism,
or early sepsis from peripheral vasodilation.
3. The nurse is assessing a client’s nutritional status. Which
laboratory value best reflects recent protein intake?
A) Hemoglobin
B) Prealbumin
,C) Albumin
D) Total protein
*Rationale: Prealbumin has a short half-life (2-3 days) and reflects
recent protein status; albumin reflects longer-term status.*
4. A client reports a sudden, severe headache described as “the worst
of my life.” The nurse’s priority action is to:
A) Administer acetaminophen
B) Assess neurologic status and vital signs
C) Encourage rest in a dark room
D) Apply a cold compress
Rationale: Thunderclap headache may indicate subarachnoid
hemorrhage; immediate neurologic and vital sign assessment is
critical.
5. The nurse is assessing a client’s pupillary response. Which finding
indicates dysfunction of cranial nerve III?
A) Bilateral miosis
B) Anisocoria that is stable and longstanding
C) A dilated pupil that does not constrict to light
D) Pinpoint pupils that react to light
Rationale: A dilated, nonreactive pupil suggests CN III compression
(oculomotor nerve).
6. A client has a blood pressure of 104/62 mm Hg in the supine
position. Upon standing, the blood pressure is 82/50 mm Hg, and the
, client reports dizziness. This finding is documented as:
A) Hypertension
B) Orthostatic hypotension
C) Normal response
D) Vasovagal response
Rationale: A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic
with symptoms upon standing indicates orthostatic hypotension.
7. The nurse is assessing a client’s jugular veins. The client is
positioned supine with the head of the bed elevated 30 degrees. The
nurse visualizes the jugular vein pulsation 4 cm above the sternal
angle. This indicates:
A) Normal finding
B) Elevated jugular venous pressure
C) Hypovolemia
D) Carotid artery pulsation
Rationale: Normal JVP is ≤3 cm above the sternal angle; >3 cm
suggests elevated right atrial pressure.
8. During a respiratory assessment, the nurse notes that a client has a
prolonged expiratory phase. This finding is most consistent with:
A) Pneumonia
B) Chronic obstructive pulmonary disease (COPD)
C) Pulmonary fibrosis
D) Pleural effusion
1. A nurse is performing a general survey on a newly admitted client.
Which finding is most indicative of a potential thyroid disorder?
A) Blood pressure 118/76 mm Hg
B) Heart rate 72 bpm
C) Fine tremor of the outstretched hands
D) Respiratory rate 16 breaths/min
Rationale: A fine tremor of the hands is a classic sign of
hyperthyroidism due to increased sympathetic nervous system
activity.
2. During an admission assessment, the nurse notes that a client’s
skin is warm, dry, and flushed. The client reports feeling hot. This
finding is most consistent with:
A) Hypothyroidism
B) Dehydration
C) Fever or hypermetabolic state
D) Peripheral vascular disease
Rationale: Warm, flushed skin occurs with fever, hyperthyroidism,
or early sepsis from peripheral vasodilation.
3. The nurse is assessing a client’s nutritional status. Which
laboratory value best reflects recent protein intake?
A) Hemoglobin
B) Prealbumin
,C) Albumin
D) Total protein
*Rationale: Prealbumin has a short half-life (2-3 days) and reflects
recent protein status; albumin reflects longer-term status.*
4. A client reports a sudden, severe headache described as “the worst
of my life.” The nurse’s priority action is to:
A) Administer acetaminophen
B) Assess neurologic status and vital signs
C) Encourage rest in a dark room
D) Apply a cold compress
Rationale: Thunderclap headache may indicate subarachnoid
hemorrhage; immediate neurologic and vital sign assessment is
critical.
5. The nurse is assessing a client’s pupillary response. Which finding
indicates dysfunction of cranial nerve III?
A) Bilateral miosis
B) Anisocoria that is stable and longstanding
C) A dilated pupil that does not constrict to light
D) Pinpoint pupils that react to light
Rationale: A dilated, nonreactive pupil suggests CN III compression
(oculomotor nerve).
6. A client has a blood pressure of 104/62 mm Hg in the supine
position. Upon standing, the blood pressure is 82/50 mm Hg, and the
, client reports dizziness. This finding is documented as:
A) Hypertension
B) Orthostatic hypotension
C) Normal response
D) Vasovagal response
Rationale: A drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic
with symptoms upon standing indicates orthostatic hypotension.
7. The nurse is assessing a client’s jugular veins. The client is
positioned supine with the head of the bed elevated 30 degrees. The
nurse visualizes the jugular vein pulsation 4 cm above the sternal
angle. This indicates:
A) Normal finding
B) Elevated jugular venous pressure
C) Hypovolemia
D) Carotid artery pulsation
Rationale: Normal JVP is ≤3 cm above the sternal angle; >3 cm
suggests elevated right atrial pressure.
8. During a respiratory assessment, the nurse notes that a client has a
prolonged expiratory phase. This finding is most consistent with:
A) Pneumonia
B) Chronic obstructive pulmonary disease (COPD)
C) Pulmonary fibrosis
D) Pleural effusion
