Q&A | Health Assessment
1. A nurse is preparing to conduct a health history interview with a patient.
Which of the following is the priority action before beginning the interview?
A) Review the patient's medical record
B) Ensure the patient is in a supine position
C) Dim the lights for a calming effect
D) Ask the patient to complete a lengthy questionnaire
Correct Answer: Review the patient's medical record
Rationale: Before beginning a health history interview, the nurse should
review the patient's medical record to gather any existing data and avoid
redundancy. While creating a comfortable environment is important,
reviewing the record is the first step in the assessment process to establish a
baseline.
2. When assessing a patient, the nurse understands that subjective data
includes:
A) The patient's blood pressure reading
B) The patient's statement that they are experiencing pain
C) The presence of a skin rash
D) The patient's heart rate
Correct Answer: The patient's statement that they are experiencing pain
Rationale: Subjective data is what the patient says about themselves during
history taking. Pain is a subjective experience reported by the patient.
Objective data is what the healthcare professional observes by inspecting,
percussing, palpating, and auscultating.
,3. A nurse is performing a physical examination on a patient. Which of the
following is an example of objective data?
A) The patient reports feeling nauseous
B) The patient states they have a headache
C) The nurse observes a wound that is 3 cm in length
D) The patient describes their pain as "sharp"
Correct Answer: The nurse observes a wound that is 3 cm in length
Rationale: Objective data is what the health professional observes during the
physical examination. Measuring a wound is an observable and measurable
finding. The patient's reports of nausea, headache, and pain are subjective
data.
4. A patient is admitted to the emergency department after a motor vehicle
accident. Which type of health assessment is most appropriate in this
situation?
A) Complete assessment
B) Focused assessment
C) Emergency assessment
D) Follow-up assessment
Correct Answer: Emergency assessment
Rationale: An emergency assessment involves a rapid collection of data,
often obtained concurrently with lifesaving measures. This is appropriate for
a patient in an emergency situation. A complete assessment is a
comprehensive health history and physical exam.
,5. A nurse is admitting a patient to a long-term care facility. Which type of
health assessment is most appropriate?
A) Focused
B) Complete
C) Emergency
D) Follow-up
Correct Answer: Complete
Rationale: A complete database includes a complete health history and a full
physical examination; it describes the current and past health state and
forms a baseline against which all future changes can be measured. This is
appropriate for a new admission to a long-term care facility.
6. A patient presents to the clinic with a sore throat. The nurse performs an
examination limited to the throat and neck. This is an example of which type
of assessment?
A) Complete assessment
B) Focused assessment
C) Emergency assessment
D) Follow-up assessment
Correct Answer: Focused assessment
Rationale: A focused database is for a limited or short-term problem,
concerning mainly one problem, one cue complex, or one body system. A
sore throat is a focused problem that warrants a targeted assessment.
, 7. A nurse is caring for a patient with a chronic condition and is evaluating
the patient's progress at a regular interval. Which type of assessment is
being performed?
A) Complete assessment
B) Focused assessment
C) Emergency assessment
D) Follow-up assessment
Correct Answer: Follow-up assessment
Rationale: A follow-up database is used to follow up on short-term or chronic
health problems; the statuses of identified problems are evaluated at regular
and appropriate intervals.
8. Which of the following is the correct order of the nursing process?
A) Assessment, Planning, Diagnosis, Implementation, Evaluation
B) Assessment, Diagnosis, Planning, Implementation, Evaluation
C) Diagnosis, Assessment, Planning, Implementation, Evaluation
D) Assessment, Implementation, Diagnosis, Planning, Evaluation
Correct Answer: Assessment, Diagnosis, Planning, Implementation,
Evaluation
Rationale: The correct order of the nursing process is Assessment, Diagnosis,
Planning, Implementation, and Evaluation. This class focuses heavily on the
first step, Assessment.
9. A nurse is prioritizing care for a patient. Which of the following is an
example of a first-level priority problem?