Nightingale College
001 · ISEH RUN
★ ★
N School of Nursing
EST. 2004
C O M M I T T E D T O E X C E L L E N C E I N N U R S I N G E D U C AT I O N
Nightingale College - Comprehensive Health Assessment
P H YS I C A L A SS E SS M E N T & N U RS I N G F U N DA M E N TA LS
INSTITUTION Nightingale College PROGRAM Bachelor of Science in Nursing
COURSE CODE NUR HESI COURSE TITLE Comprehensive Health
Assessment
ACADEMIC YEAR EXAM TITLE Nightingale College -
Comprehensive Health
Assessment
TOTAL QUESTIONS 100 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Physical assessment techniques, health history, and nursing interventions are all testable content.
▸ Clinical reasoning and priority-setting are emphasized.
▸ Correct answers and clinical rationales appear below each question for board review purposes.
▸ All clinical data reflects current evidence-based practice guidelines.
, SECTION I — COMPREHENSIVE HEALTH ASSESSMENT Questions 1 – 100
1. The nurse is performing an admission assessment for a client with pyelonephritis who has
urgency and burning while urinating. Which finding indicates an expected response when
the nurse percusses the costovertebral angle?
A. Audible thud without pain
B. Rigidity and firmness
C. Rebound tenderness
D. Sharp, severe pain
CORRECT ANSWER D — Sharp, severe pain
RATIONALE Costovertebral angle (CVA) tenderness is a classic sign of pyelonephritis.
Percussion of the CVA in a client with pyelonephritis typically elicits sharp, severe
pain due to kidney inflammation. This finding supports the diagnosis of
pyelonephritis.
2. In assessing a client's level of consciousness, what should the nurse assess first?
A. Motor response
B. Eye opening
C. Control Pane
D. Level of alertness
CORRECT ANSWER D — Level of alertness
RATIONALE The nurse should first assess the level of alertness and arousal (whether the client
is awake, responds to stimuli, etc.). Orientation to person, place, and time is
assessed after establishing that the client is alert and responsive. Level of
consciousness is the most basic and essential assessment.
,3. In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which
assessment provides the nurse with the information needed to evaluate the effects of this
condition?
A. Observe chest and upper neck for a rash
B. Perform a hearing test
C. Evaluate for a loss of peripheral vision
D. Assess deep tendon reflexes
CORRECT ANSWER B — Perform a hearing test
RATIONALE Tinnitus is a symptom of hearing impairment characterized by ringing, buzzing, or
roaring in the ears. A hearing test (audiometry) provides objective data to
evaluate the effects of this condition and assess for hearing loss.
4. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A. Perform passive range of motion and compare the findings
B. Compare measured circumferences of each extremity joint
C. Instruct client to walk across room and observe the gait
D. Measure the length of each leg and document the findings
CORRECT ANSWER D — Measure the length of each leg and document the findings
RATIONALE Asymmetrical legs require measurement of each leg from the anterior superior
iliac spine to the medial malleolus to determine if a true leg length discrepancy
exists. This objective measurement provides accurate data for documentation
and further evaluation.
, 5. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctivae. Which question should the nurse ask first?
"Have you..."
A. "ever had problems with your blood sugar?"
B. "been sleeping well?"
C. "had anything to eat in the last 24 hours?"
D. "been depressed lately?"
CORRECT ANSWER B — "been sleeping well?"
RATIONALE Expressionless facial affect, slurred speech, and red conjunctivae may indicate
sleep deprivation or fatigue. Asking about sleep patterns is a non-threatening way
to begin the assessment and gather information about potential causes of these
findings.
6. The nurse observes an older adult client walking aimlessly in the hallway and staring
straight ahead with a blank expression. How should the nurse enter documentation of this
finding in the client's electronic medical record (EMR)?
A. Appears confused and depressed
B. Demonstrates signs of early dementia
C. Ambulatory and disoriented to place
D. Wandering behavior with flat affect
CORRECT ANSWER D — Wandering behavior with flat affect
RATIONALE Objective documentation should describe the behavior observed without making
diagnostic assumptions. "Wandering behavior with flat affect" accurately
describes the observed behavior (aimless walking, blank expression) without
implying a diagnosis or subjective interpretation.
001 · ISEH RUN
★ ★
N School of Nursing
EST. 2004
C O M M I T T E D T O E X C E L L E N C E I N N U R S I N G E D U C AT I O N
Nightingale College - Comprehensive Health Assessment
P H YS I C A L A SS E SS M E N T & N U RS I N G F U N DA M E N TA LS
INSTITUTION Nightingale College PROGRAM Bachelor of Science in Nursing
COURSE CODE NUR HESI COURSE TITLE Comprehensive Health
Assessment
ACADEMIC YEAR EXAM TITLE Nightingale College -
Comprehensive Health
Assessment
TOTAL QUESTIONS 100 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Physical assessment techniques, health history, and nursing interventions are all testable content.
▸ Clinical reasoning and priority-setting are emphasized.
▸ Correct answers and clinical rationales appear below each question for board review purposes.
▸ All clinical data reflects current evidence-based practice guidelines.
, SECTION I — COMPREHENSIVE HEALTH ASSESSMENT Questions 1 – 100
1. The nurse is performing an admission assessment for a client with pyelonephritis who has
urgency and burning while urinating. Which finding indicates an expected response when
the nurse percusses the costovertebral angle?
A. Audible thud without pain
B. Rigidity and firmness
C. Rebound tenderness
D. Sharp, severe pain
CORRECT ANSWER D — Sharp, severe pain
RATIONALE Costovertebral angle (CVA) tenderness is a classic sign of pyelonephritis.
Percussion of the CVA in a client with pyelonephritis typically elicits sharp, severe
pain due to kidney inflammation. This finding supports the diagnosis of
pyelonephritis.
2. In assessing a client's level of consciousness, what should the nurse assess first?
A. Motor response
B. Eye opening
C. Control Pane
D. Level of alertness
CORRECT ANSWER D — Level of alertness
RATIONALE The nurse should first assess the level of alertness and arousal (whether the client
is awake, responds to stimuli, etc.). Orientation to person, place, and time is
assessed after establishing that the client is alert and responsive. Level of
consciousness is the most basic and essential assessment.
,3. In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which
assessment provides the nurse with the information needed to evaluate the effects of this
condition?
A. Observe chest and upper neck for a rash
B. Perform a hearing test
C. Evaluate for a loss of peripheral vision
D. Assess deep tendon reflexes
CORRECT ANSWER B — Perform a hearing test
RATIONALE Tinnitus is a symptom of hearing impairment characterized by ringing, buzzing, or
roaring in the ears. A hearing test (audiometry) provides objective data to
evaluate the effects of this condition and assess for hearing loss.
4. While assessing a client, the nurse notices that the client's legs are asymmetrical. Which
additional physical data should the nurse collect?
A. Perform passive range of motion and compare the findings
B. Compare measured circumferences of each extremity joint
C. Instruct client to walk across room and observe the gait
D. Measure the length of each leg and document the findings
CORRECT ANSWER D — Measure the length of each leg and document the findings
RATIONALE Asymmetrical legs require measurement of each leg from the anterior superior
iliac spine to the medial malleolus to determine if a true leg length discrepancy
exists. This objective measurement provides accurate data for documentation
and further evaluation.
, 5. The nurse is performing an initial assessment of a client who has an expressionless facial
affect, slurred speech, and red conjunctivae. Which question should the nurse ask first?
"Have you..."
A. "ever had problems with your blood sugar?"
B. "been sleeping well?"
C. "had anything to eat in the last 24 hours?"
D. "been depressed lately?"
CORRECT ANSWER B — "been sleeping well?"
RATIONALE Expressionless facial affect, slurred speech, and red conjunctivae may indicate
sleep deprivation or fatigue. Asking about sleep patterns is a non-threatening way
to begin the assessment and gather information about potential causes of these
findings.
6. The nurse observes an older adult client walking aimlessly in the hallway and staring
straight ahead with a blank expression. How should the nurse enter documentation of this
finding in the client's electronic medical record (EMR)?
A. Appears confused and depressed
B. Demonstrates signs of early dementia
C. Ambulatory and disoriented to place
D. Wandering behavior with flat affect
CORRECT ANSWER D — Wandering behavior with flat affect
RATIONALE Objective documentation should describe the behavior observed without making
diagnostic assumptions. "Wandering behavior with flat affect" accurately
describes the observed behavior (aimless walking, blank expression) without
implying a diagnosis or subjective interpretation.
