SDSU NURS 206 (Health Assessment) – Unit Exam 1
Latest 2026/2027 | Newly Released
Guaranteed Pass | Graded A +
50 Questions with Verified Answers and Detailed Rationales
Q1. A nurse is preparing to interview a patient who arrives 20 minutes late, appears disheveled,
and reeks of alcohol. The patient slurs speech and admits to drinking "a few beers" before the
appointment. Which of the following is the nurse's priority action?
A. Reschedule the appointment and provide resources for substance use treatment
B. Proceed with the interview while documenting the behavior
C. Confront the patient about the inappropriate behavior
D. Call security to remove the patient from the clinic
Correct Answer: A
Rationale: Correct because a patient who is visibly intoxicated cannot provide reliable health
history information or give informed consent for examination; rescheduling ensures accurate
assessment while offering substance use resources demonstrates compassionate, patient-
centered care. Pathophysiology of alcohol intoxication involves central nervous system
depression impairing judgment, memory, and coordination, which compromises the validity of
subjective health data. The clinical presentation is consistent with professional nursing
boundaries where safety, accuracy, and therapeutic referral take priority over completing the
scheduled appointment.
Q2. During a general survey, a nurse observes a patient sitting upright with shoulders hunched,
hands clasped tightly, and eyes darting around the room. The patient's respiratory rate is 24
breaths/min. Which of the following nursing interpretations is most accurate?
A. The patient is experiencing acute respiratory distress
B. The patient is displaying signs of anxiety or psychological distress
C. The patient is demonstrating normal attention to surroundings
D. The patient is preparing to leave against medical advice
Correct Answer: B
,Rationale: Correct because the combination of guarded body posture, hypervigilance
(scanning), and mild tachypnea without other respiratory symptoms is characteristic of anxiety
or psychological distress rather than organic respiratory pathology. Pathophysiology of anxiety
involves sympathetic nervous system activation causing increased respiratory rate, muscle
tension, and hyperarousal that manifests in nonverbal behavior. The clinical presentation is
consistent with holistic health assessment where general survey observations of posture,
movement, and affect provide critical clues to emotional state before verbal communication
begins.
Q3. A nurse is assessing a patient's vital signs after 30 minutes of bed rest. Temperature is
36.8°C orally, pulse 72 beats/min and regular, respirations 14 breaths/min, blood pressure
128/78 mmHg, and SpO₂ 97% on room air. Which of the following is the correct documentation
of these findings?
A. The blood pressure indicates stage 1 hypertension
B. The temperature suggests hypothermia
C. All vital signs are within normal limits for a resting adult
D. The respiratory rate indicates bradypnea
Correct Answer: C
Rationale: Correct because all documented values fall within accepted normal ranges for a
resting adult: oral temperature 36.5–37.5°C, pulse 60–100 beats/min, respirations 12–20
breaths/min, blood pressure <130/80 mmHg per ACC/AHA guidelines, and SpO₂ ≥95% on room
air. Pathophysiology of vital sign interpretation involves understanding normal variations by age,
activity level, and measurement site; accurate documentation requires comparing values to
evidence-based norms rather than isolated thresholds. The clinical presentation is consistent
with baseline health assessment where recognizing normal findings is as important as
identifying abnormalities.
Q4. A 78-year-old patient is being assessed for nutritional status. The nurse notes that the
patient's dentures are ill-fitting, there are multiple expired medications in the home, and the
refrigerator contains only condiments. Which social determinant of health most directly impacts
this patient's nutritional status?
A. Healthcare access
B. Food security
, C. Social isolation
D. Health literacy
Correct Answer: D
Rationale: Correct because the combination of ill-fitting dentures (impaired ability to chew),
expired medications (poor self-management), and absent fresh food suggests impaired health
literacy—the capacity to obtain, process, and understand basic health information needed to
make appropriate decisions. Pathophysiology of health literacy involves cognitive, social, and
cultural factors that affect comprehension of medical instructions, medication management,
and recognition of nutritional needs; older adults with limited literacy are at highest risk for
adverse outcomes. The clinical presentation is consistent with comprehensive health
assessment where environmental and functional indicators reveal underlying determinants that
standardized screening tools may miss.
Q5. A nurse is using the OLDCART mnemonic to assess a patient's chief complaint of chest pain.
The patient reports the pain "Started 2 hours ago while mowing the lawn, is pressure-like,
radiates to the left arm, gets worse with exertion, and is relieved by rest." Which element of
OLDCART is missing from this description?
A. Onset
B. Location
C. Character
D. Associated symptoms
Correct Answer: B
Rationale: Correct because the patient described onset (2 hours ago), character (pressure-like),
aggravating factors (exertion), relieving factors (rest), timing (while mowing), and radiation (left
arm), but did not specify the precise anatomical location of the pain within the chest.
Pathophysiology of structured symptom assessment involves systematic characterization to
differentiate cardiac, pulmonary, gastrointestinal, and musculoskeletal etiologies; location is
essential for anatomical localization and differential diagnosis. The clinical presentation is
consistent with thorough history-taking where the OLDCART framework ensures comprehensive
symptom documentation.
Q6. A nurse is preparing to measure a pediatric patient's blood pressure. The child is 6 years old
and anxious. Which technique will produce the most accurate reading?
Latest 2026/2027 | Newly Released
Guaranteed Pass | Graded A +
50 Questions with Verified Answers and Detailed Rationales
Q1. A nurse is preparing to interview a patient who arrives 20 minutes late, appears disheveled,
and reeks of alcohol. The patient slurs speech and admits to drinking "a few beers" before the
appointment. Which of the following is the nurse's priority action?
A. Reschedule the appointment and provide resources for substance use treatment
B. Proceed with the interview while documenting the behavior
C. Confront the patient about the inappropriate behavior
D. Call security to remove the patient from the clinic
Correct Answer: A
Rationale: Correct because a patient who is visibly intoxicated cannot provide reliable health
history information or give informed consent for examination; rescheduling ensures accurate
assessment while offering substance use resources demonstrates compassionate, patient-
centered care. Pathophysiology of alcohol intoxication involves central nervous system
depression impairing judgment, memory, and coordination, which compromises the validity of
subjective health data. The clinical presentation is consistent with professional nursing
boundaries where safety, accuracy, and therapeutic referral take priority over completing the
scheduled appointment.
Q2. During a general survey, a nurse observes a patient sitting upright with shoulders hunched,
hands clasped tightly, and eyes darting around the room. The patient's respiratory rate is 24
breaths/min. Which of the following nursing interpretations is most accurate?
A. The patient is experiencing acute respiratory distress
B. The patient is displaying signs of anxiety or psychological distress
C. The patient is demonstrating normal attention to surroundings
D. The patient is preparing to leave against medical advice
Correct Answer: B
,Rationale: Correct because the combination of guarded body posture, hypervigilance
(scanning), and mild tachypnea without other respiratory symptoms is characteristic of anxiety
or psychological distress rather than organic respiratory pathology. Pathophysiology of anxiety
involves sympathetic nervous system activation causing increased respiratory rate, muscle
tension, and hyperarousal that manifests in nonverbal behavior. The clinical presentation is
consistent with holistic health assessment where general survey observations of posture,
movement, and affect provide critical clues to emotional state before verbal communication
begins.
Q3. A nurse is assessing a patient's vital signs after 30 minutes of bed rest. Temperature is
36.8°C orally, pulse 72 beats/min and regular, respirations 14 breaths/min, blood pressure
128/78 mmHg, and SpO₂ 97% on room air. Which of the following is the correct documentation
of these findings?
A. The blood pressure indicates stage 1 hypertension
B. The temperature suggests hypothermia
C. All vital signs are within normal limits for a resting adult
D. The respiratory rate indicates bradypnea
Correct Answer: C
Rationale: Correct because all documented values fall within accepted normal ranges for a
resting adult: oral temperature 36.5–37.5°C, pulse 60–100 beats/min, respirations 12–20
breaths/min, blood pressure <130/80 mmHg per ACC/AHA guidelines, and SpO₂ ≥95% on room
air. Pathophysiology of vital sign interpretation involves understanding normal variations by age,
activity level, and measurement site; accurate documentation requires comparing values to
evidence-based norms rather than isolated thresholds. The clinical presentation is consistent
with baseline health assessment where recognizing normal findings is as important as
identifying abnormalities.
Q4. A 78-year-old patient is being assessed for nutritional status. The nurse notes that the
patient's dentures are ill-fitting, there are multiple expired medications in the home, and the
refrigerator contains only condiments. Which social determinant of health most directly impacts
this patient's nutritional status?
A. Healthcare access
B. Food security
, C. Social isolation
D. Health literacy
Correct Answer: D
Rationale: Correct because the combination of ill-fitting dentures (impaired ability to chew),
expired medications (poor self-management), and absent fresh food suggests impaired health
literacy—the capacity to obtain, process, and understand basic health information needed to
make appropriate decisions. Pathophysiology of health literacy involves cognitive, social, and
cultural factors that affect comprehension of medical instructions, medication management,
and recognition of nutritional needs; older adults with limited literacy are at highest risk for
adverse outcomes. The clinical presentation is consistent with comprehensive health
assessment where environmental and functional indicators reveal underlying determinants that
standardized screening tools may miss.
Q5. A nurse is using the OLDCART mnemonic to assess a patient's chief complaint of chest pain.
The patient reports the pain "Started 2 hours ago while mowing the lawn, is pressure-like,
radiates to the left arm, gets worse with exertion, and is relieved by rest." Which element of
OLDCART is missing from this description?
A. Onset
B. Location
C. Character
D. Associated symptoms
Correct Answer: B
Rationale: Correct because the patient described onset (2 hours ago), character (pressure-like),
aggravating factors (exertion), relieving factors (rest), timing (while mowing), and radiation (left
arm), but did not specify the precise anatomical location of the pain within the chest.
Pathophysiology of structured symptom assessment involves systematic characterization to
differentiate cardiac, pulmonary, gastrointestinal, and musculoskeletal etiologies; location is
essential for anatomical localization and differential diagnosis. The clinical presentation is
consistent with thorough history-taking where the OLDCART framework ensures comprehensive
symptom documentation.
Q6. A nurse is preparing to measure a pediatric patient's blood pressure. The child is 6 years old
and anxious. Which technique will produce the most accurate reading?
