TESTBANK FOR HEALTH ASSESSMENT IN NURSING, 7TH EDITION
, PREMIUM TABLE OF CONTENTS
Complete Chapters 1–34 | Updated 2026–2027
UNIT 1 — Nursing Data Collection, Documentation, and Analysis
Chapter 1: The Nurse’s Role in Health Assessment
Chapter 2: Collecting Subjective Data: The Interview and Health History
Chapter 3: Collecting Objective Data: The Physical Examination
Chapter 4: Validating and Documenting Data
Chapter 5: Thinking Critically to Analyze Data to Make Informed Clinical Judgments
UNIT 2 — Integrative Holistic Nursing Assessment
Chapter 6: Assessing Mental Status Including Risk for Substance Abuse
Chapter 7: Assessing Psychosocial, Cognitive, and Moral Development
Chapter 8: Assessing General Health Status and Vital Signs
Chapter 9: Assessing Pain
Chapter 10: Assessing for Violence
Chapter 11: Assessing Culture
Chapter 12: Assessing Spirituality and Religious Practices
Chapter 13: Assessing Nutritional Status
UNIT 3 — Nursing Assessment of Physical Systems
Chapter 14: Assessing Skin, Hair, and Nails
Chapter 15: Assessing Head and Neck
Chapter 16: Assessing Eyes
Chapter 17: Assessing Ears
Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses
Chapter 19: Assessing Thorax and Lungs
Chapter 20: Assessing Breasts and Lymphatic System
Chapter 21: Assessing Heart and Neck Vessels
Chapter 22: Assessing Peripheral Vascular System
Chapter 23: Assessing Abdomen
Chapter 24: Assessing Musculoskeletal System
Chapter 25: Assessing Neurologic System
Chapter 26: Assessing Male Genitalia and Rectum
Chapter 27: Assessing Female Genitalia, Anus, and Rectum
Chapter 28: Pulling It All Together: Integrated Head-to-Toe Assessment
UNIT 4 — Nursing Assessment of Special Groups
Chapter 29: Assessing Childbearing Women
Chapter 30: Assessing Newborns and Infants
,Chapter 31: Assessing Children and Adolescents
Chapter 32: Assessing Older Adults
Chapter 33: Assessing Families
Chapter 34: Assessing Communities
Premium Exam Bank Features
• Comprehensive coverage of all 34 chapters
• 700+ challenging nursing assessment questions
• Four-option multiple-choice format (A–D)
• Deliberately varied and unpredictable answer distributions
• Detailed evidence-based rationales
• Explanation of high-priority clinical findings
• Clinical Pearl included throughout
• Exam Strategy included throughout
• Priority, safety, delegation, and clinical-judgment emphasis
• Integrated head-to-toe and multisystem assessment scenarios
• Special-population assessment questions
• NCLEX-style clinical reasoning and cue-clustering concepts
• Updated 2026–2027 exam-preparation presentation
• Suitable for nursing students, instructors, review courses, and independent study
Comprehensive Coverage
Unit 1: Data Collection, Documentation & Clinical Judgment
Unit 2: Holistic, Psychosocial & Health Status Assessment
Unit 3: Complete Physical Systems Assessment
Unit 4: Maternal, Pediatric, Geriatric, Family & Community Assessment
UNIT 1 — Nursing Data Collection, Documentation, and Analysis
Chapter 1: The Nurse’s Role in Health Assessment
Question 1
During the initial assessment of an adult admitted with worsening shortness of breath, the client repeatedly
states, “I’m just tired,” while the nurse observes nasal flaring, difficulty completing sentences, and an oxygen
saturation of 88%. Which nursing action best demonstrates the nurse’s role in health assessment?
,A. Document the client's statement and wait for the provider to evaluate the respiratory findings
B. Integrate the subjective and objective findings and initiate appropriate nursing intervention
C. Give priority to the client's description because subjective data are the primary source of assessment
information
D. Complete the remaining health history before determining the significance of the respiratory findings
Correct Answer: B
Rationale: Health assessment requires the nurse to collect, validate, interpret, and integrate both subjective
and objective data. An SpO₂ of 88%, nasal flaring, and difficulty speaking indicate significant respiratory
compromise despite the client's relatively mild description. The nurse should recognize these cues, prioritize
oxygenation, and initiate appropriate interventions rather than simply continuing routine data collection.
Why the other options are less appropriate:
• A: Delaying action could allow respiratory deterioration.
• C: Subjective data are important but must be interpreted together with objective findings.
• D: An immediate physiological threat takes priority over completing a comprehensive history.
Exam Strategy: When assessment reveals an immediate ABC problem, prioritize recognition and
intervention over routine data collection.
Question 2
A client denies using any medications during a health history. Several minutes later, the nurse notices
nitroglycerin tablets and an antihypertensive medication in the client's belongings. What is the most
appropriate response?
A. Record that the client provided unreliable information
B. Assume the medications belong to another family member
C. Clarify the discrepancy with the client using nonjudgmental questioning
D. Add the medications to the medication record without further discussion
Correct Answer: C
Rationale: Conflicting assessment information should be validated before it becomes part of the clinical
database. A nonjudgmental question allows the nurse to determine whether the client misunderstood the
original question, forgot the medications, uses them only occasionally, or has another explanation.
Why the other options are less appropriate:
• A: Labeling the client unreliable is premature and judgmental.
• B: The nurse should not make assumptions about ownership.
• D: Medication information must be verified before documentation.
,Clinical Pearl: Validation improves the accuracy of assessment data and helps prevent clinical decisions based
on incorrect information.
Question 3
Following a focused assessment of a postoperative client, which finding requires the nurse's most
immediate attention?
A. Incisional pain rated 6/10
B. Temperature of 37.6°C (99.7°F)
C. No bowel movement since the day before surgery
D. New confusion accompanied by a respiratory rate of 8/min
Correct Answer: D
Rationale: New confusion combined with significant respiratory depression may indicate hypoxemia, opioid-
related respiratory suppression, or another acute deterioration. Using priority frameworks such as airway,
breathing, and circulation, this finding requires immediate assessment and intervention.
Why the other options are less appropriate:
• A: Pain requires treatment but is secondary to respiratory compromise.
• B: This temperature does not indicate a significant postoperative emergency.
• C: Temporary decreased bowel activity can occur after surgery.
Exam Strategy: A change in mental status can be an early sign of impaired oxygenation.
Question 4
Rather than immediately beginning a head-to-toe examination, the nurse first observes a newly admitted
client's posture, breathing pattern, facial expression, hygiene, and interaction with family. What component
of assessment is being performed?
A. General survey
B. Review of systems
C. Functional assessment
D. Diagnostic evaluation
Correct Answer: A
Rationale: The general survey begins with the nurse's first encounter with the client and includes overall
appearance, behavior, mobility, body structure, and obvious signs of distress. These observations provide an
initial impression that helps guide subsequent assessment.
Why the other options are less appropriate:
, • B: Review of systems systematically explores symptoms by body system.
• C: Functional assessment evaluates activities and ability to perform daily tasks.
• D: Diagnostic evaluation involves identifying or confirming disease processes.
Question 5
While assessing a client with abdominal pain, the nurse obtains a blood pressure of 82/50 mmHg, heart rate
of 126/min, and cool, clammy skin. The client reports feeling “a little dizzy.” Which interpretation is most
appropriate?
A. The subjective symptom should be documented before analyzing objective findings
B. The findings are expected consequences of abdominal discomfort
C. A complete gastrointestinal history should be obtained before intervention
D. The clustered findings suggest possible circulatory compromise requiring immediate action
Correct Answer: D
Rationale: Hypotension, tachycardia, cool clammy skin, and dizziness form a clinically significant cluster
suggesting decreased tissue perfusion or shock. Assessment involves recognizing relationships among findings
rather than treating each piece of information independently.
Clinical Pearl: Clustering related cues is fundamental to sound clinical judgment.
Question 6
When interviewing an older adult, the nurse receives most answers from the client's daughter even though
the client is alert, oriented, and able to communicate. Which approach is best?
A. Continue interviewing the daughter because family members generally provide more reliable information
B. Ask the daughter to leave immediately
C. Direct questions primarily to the client while appropriately incorporating supplementary information from
the daughter
D. Obtain the entire history from both individuals simultaneously
Correct Answer: C
Rationale: The client should remain the primary source of information whenever capable of communicating.
Family members can provide valuable supplementary information, but relying unnecessarily on them may
undermine autonomy and potentially distort the client's perspective.
Exam Strategy: Competent clients remain the primary source of subjective health information.
Question 7
,Before administering an antihypertensive medication, the nurse reassesses a client's blood pressure and
discovers it has fallen substantially since the previous measurement. Which principle of nursing assessment
does this best illustrate?
A. Comprehensive assessments replace focused assessments
B. Assessment is continuous and directly influences nursing decisions
C. Objective findings should always override subjective information
D. Reassessment is necessary only when a client reports new symptoms
Correct Answer: B
Rationale: Assessment is an ongoing component of nursing practice. Client conditions can change rapidly, and
reassessment provides current information needed to determine whether an intervention remains appropriate
and safe.
Question 8
Minutes after receiving an opioid analgesic, a client becomes increasingly difficult to arouse. Which
assessment should the nurse perform first?
A. Pain intensity
B. Bowel sounds
C. Peripheral pulses
D. Respiratory rate, depth, and oxygenation status
Correct Answer: D
Rationale: Opioids can suppress the central respiratory drive. Decreased responsiveness following opioid
administration therefore requires immediate assessment of breathing and oxygenation. Airway and breathing
threats supersede other assessment priorities.
Clinical Pearl: A sudden decrease in consciousness after an opioid should trigger immediate respiratory
assessment.
Question 9
A nurse documents, “Client appears depressed and uncooperative.” Which revision provides the most
appropriate assessment documentation?
A. “Client has major depressive behavior.”
B. “Client demonstrates inappropriate emotional responses.”
C. “Client speaks softly, maintains minimal eye contact, and declined breakfast and morning hygiene.”
D. “Client appears emotionally unstable and unwilling to cooperate.”
Correct Answer: C
,Rationale: High-quality documentation is objective, specific, observable, and measurable. Describing exactly
what the nurse observed avoids unsupported interpretation and allows other clinicians to independently
evaluate the findings.
Exam Strategy: In documentation questions, prefer observable behavior over labels or conclusions.
Question 10
During an assessment, a client says, “My chest feels like an elephant is sitting on it.” What should the nurse
do first?
A. Immediately assess characteristics of the discomfort and evaluate cardiovascular and respiratory status
B. Ask the client to finish describing the past medical history
C. Document the statement and complete the interview
D. Explain that anxiety commonly causes chest pressure
Correct Answer: A
Rationale: New pressure-like chest discomfort can indicate myocardial ischemia or another potentially life-
threatening cardiopulmonary condition. The nurse should immediately transition from routine assessment to
focused assessment of the symptom and physiological stability.
Question 11
A client reports severe dizziness when standing. Which additional assessment finding would most strongly
support orthostatic hypotension?
A. Increased blood pressure after standing
B. Significant blood pressure decrease accompanied by an increased pulse after standing
C. Unchanged blood pressure and pulse
D. Decreased respiratory rate while standing
Correct Answer: B
Rationale: Orthostatic hypotension involves a clinically meaningful reduction in blood pressure after assuming
an upright position and may be accompanied by compensatory tachycardia and symptoms such as dizziness or
weakness.
Question 12
During a health interview, the client states, “I haven't been eating much lately.” Which response best
facilitates further assessment?
A. “You need to make sure you eat three meals every day.”
B. “Have you lost exactly ten pounds?”
,C. “Tell me more about the changes you've noticed in your appetite and eating.”
D. “Is your appetite poor because you are depressed?”
Correct Answer: C
Rationale: Open-ended questions encourage clients to describe experiences in their own words and reduce the
risk of leading the response. This approach can uncover onset, contributing factors, associated symptoms, and
effects on nutritional status.
Question 13
Shortly after receiving shift report, the nurse must determine which client needs assessment first. Which
client has the highest priority?
A. A client requesting medication for chronic back pain rated 7/10
B. A client awaiting discharge instructions
C. A client requesting assistance to the bathroom
D. A client with newly developed inspiratory stridor following neck surgery
Correct Answer: D
Rationale: Inspiratory stridor indicates upper-airway narrowing and can precede complete airway obstruction.
Following ABC priorities, the nurse must immediately assess and intervene for this client.
Exam Strategy: New airway sounds such as stridor are high-priority findings.
Question 14
An experienced nurse notices that a client who was previously conversational has become unusually quiet
and restless despite vital signs remaining within the documented reference range. What is the best nursing
response?
A. Perform a focused reassessment to investigate the change from baseline
B. Wait until vital signs become abnormal
C. Attribute the behavior to hospitalization-related anxiety
D. Document the behavior for the next shift
Correct Answer: A
Rationale: Changes from an individual's baseline may indicate deterioration before conventional vital signs
become abnormal. Restlessness can be associated with hypoxia, pain, neurological changes, anxiety, or other
physiological problems and warrants focused reassessment.
Question 15
, Before beginning a comprehensive physical examination, which action most effectively improves the
accuracy of the information collected?
A. Ask only closed-ended questions
B. Establish rapport and explain the purpose and sequence of the assessment
C. Perform the examination before obtaining subjective information
D. Avoid discussing sensitive concerns until discharge
Correct Answer: B
Rationale: Rapport, privacy, clear explanations, and therapeutic communication increase trust and improve the
likelihood that clients will provide complete and accurate information.
Question 16
During medication reconciliation, a client says, “I take a little white blood-pressure pill every morning.”
Which nursing action provides the safest assessment?
A. Record “unknown antihypertensive medication” and continue
B. Select the most commonly prescribed antihypertensive from the medication list
C. Seek additional information to verify the medication name, dose, route, and frequency
D. Ask the provider to prescribe a replacement medication
Correct Answer: C
Rationale: Medication reconciliation requires accurate identification of medications, including prescription
drugs, OTC products, supplements, dosage, route, and frequency. Guessing creates a significant risk for
medication errors and adverse interactions.
Clinical Pearl: Unverified medication information should be clarified rather than assumed.
Question 17
Following an intervention for acute respiratory distress, which nursing action best evaluates whether the
intervention was effective?
A. Complete the original health history
B. Ask another nurse whether the intervention was appropriate
C. Document the intervention without additional assessment
D. Reassess the client's respiratory findings and compare them with baseline and expected outcomes
Correct Answer: D
Rationale: Evaluation depends on reassessment. Comparing post-intervention findings with baseline data and
desired outcomes allows the nurse to determine whether the client's condition improved, remained
unchanged, or worsened.
, PREMIUM TABLE OF CONTENTS
Complete Chapters 1–34 | Updated 2026–2027
UNIT 1 — Nursing Data Collection, Documentation, and Analysis
Chapter 1: The Nurse’s Role in Health Assessment
Chapter 2: Collecting Subjective Data: The Interview and Health History
Chapter 3: Collecting Objective Data: The Physical Examination
Chapter 4: Validating and Documenting Data
Chapter 5: Thinking Critically to Analyze Data to Make Informed Clinical Judgments
UNIT 2 — Integrative Holistic Nursing Assessment
Chapter 6: Assessing Mental Status Including Risk for Substance Abuse
Chapter 7: Assessing Psychosocial, Cognitive, and Moral Development
Chapter 8: Assessing General Health Status and Vital Signs
Chapter 9: Assessing Pain
Chapter 10: Assessing for Violence
Chapter 11: Assessing Culture
Chapter 12: Assessing Spirituality and Religious Practices
Chapter 13: Assessing Nutritional Status
UNIT 3 — Nursing Assessment of Physical Systems
Chapter 14: Assessing Skin, Hair, and Nails
Chapter 15: Assessing Head and Neck
Chapter 16: Assessing Eyes
Chapter 17: Assessing Ears
Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses
Chapter 19: Assessing Thorax and Lungs
Chapter 20: Assessing Breasts and Lymphatic System
Chapter 21: Assessing Heart and Neck Vessels
Chapter 22: Assessing Peripheral Vascular System
Chapter 23: Assessing Abdomen
Chapter 24: Assessing Musculoskeletal System
Chapter 25: Assessing Neurologic System
Chapter 26: Assessing Male Genitalia and Rectum
Chapter 27: Assessing Female Genitalia, Anus, and Rectum
Chapter 28: Pulling It All Together: Integrated Head-to-Toe Assessment
UNIT 4 — Nursing Assessment of Special Groups
Chapter 29: Assessing Childbearing Women
Chapter 30: Assessing Newborns and Infants
,Chapter 31: Assessing Children and Adolescents
Chapter 32: Assessing Older Adults
Chapter 33: Assessing Families
Chapter 34: Assessing Communities
Premium Exam Bank Features
• Comprehensive coverage of all 34 chapters
• 700+ challenging nursing assessment questions
• Four-option multiple-choice format (A–D)
• Deliberately varied and unpredictable answer distributions
• Detailed evidence-based rationales
• Explanation of high-priority clinical findings
• Clinical Pearl included throughout
• Exam Strategy included throughout
• Priority, safety, delegation, and clinical-judgment emphasis
• Integrated head-to-toe and multisystem assessment scenarios
• Special-population assessment questions
• NCLEX-style clinical reasoning and cue-clustering concepts
• Updated 2026–2027 exam-preparation presentation
• Suitable for nursing students, instructors, review courses, and independent study
Comprehensive Coverage
Unit 1: Data Collection, Documentation & Clinical Judgment
Unit 2: Holistic, Psychosocial & Health Status Assessment
Unit 3: Complete Physical Systems Assessment
Unit 4: Maternal, Pediatric, Geriatric, Family & Community Assessment
UNIT 1 — Nursing Data Collection, Documentation, and Analysis
Chapter 1: The Nurse’s Role in Health Assessment
Question 1
During the initial assessment of an adult admitted with worsening shortness of breath, the client repeatedly
states, “I’m just tired,” while the nurse observes nasal flaring, difficulty completing sentences, and an oxygen
saturation of 88%. Which nursing action best demonstrates the nurse’s role in health assessment?
,A. Document the client's statement and wait for the provider to evaluate the respiratory findings
B. Integrate the subjective and objective findings and initiate appropriate nursing intervention
C. Give priority to the client's description because subjective data are the primary source of assessment
information
D. Complete the remaining health history before determining the significance of the respiratory findings
Correct Answer: B
Rationale: Health assessment requires the nurse to collect, validate, interpret, and integrate both subjective
and objective data. An SpO₂ of 88%, nasal flaring, and difficulty speaking indicate significant respiratory
compromise despite the client's relatively mild description. The nurse should recognize these cues, prioritize
oxygenation, and initiate appropriate interventions rather than simply continuing routine data collection.
Why the other options are less appropriate:
• A: Delaying action could allow respiratory deterioration.
• C: Subjective data are important but must be interpreted together with objective findings.
• D: An immediate physiological threat takes priority over completing a comprehensive history.
Exam Strategy: When assessment reveals an immediate ABC problem, prioritize recognition and
intervention over routine data collection.
Question 2
A client denies using any medications during a health history. Several minutes later, the nurse notices
nitroglycerin tablets and an antihypertensive medication in the client's belongings. What is the most
appropriate response?
A. Record that the client provided unreliable information
B. Assume the medications belong to another family member
C. Clarify the discrepancy with the client using nonjudgmental questioning
D. Add the medications to the medication record without further discussion
Correct Answer: C
Rationale: Conflicting assessment information should be validated before it becomes part of the clinical
database. A nonjudgmental question allows the nurse to determine whether the client misunderstood the
original question, forgot the medications, uses them only occasionally, or has another explanation.
Why the other options are less appropriate:
• A: Labeling the client unreliable is premature and judgmental.
• B: The nurse should not make assumptions about ownership.
• D: Medication information must be verified before documentation.
,Clinical Pearl: Validation improves the accuracy of assessment data and helps prevent clinical decisions based
on incorrect information.
Question 3
Following a focused assessment of a postoperative client, which finding requires the nurse's most
immediate attention?
A. Incisional pain rated 6/10
B. Temperature of 37.6°C (99.7°F)
C. No bowel movement since the day before surgery
D. New confusion accompanied by a respiratory rate of 8/min
Correct Answer: D
Rationale: New confusion combined with significant respiratory depression may indicate hypoxemia, opioid-
related respiratory suppression, or another acute deterioration. Using priority frameworks such as airway,
breathing, and circulation, this finding requires immediate assessment and intervention.
Why the other options are less appropriate:
• A: Pain requires treatment but is secondary to respiratory compromise.
• B: This temperature does not indicate a significant postoperative emergency.
• C: Temporary decreased bowel activity can occur after surgery.
Exam Strategy: A change in mental status can be an early sign of impaired oxygenation.
Question 4
Rather than immediately beginning a head-to-toe examination, the nurse first observes a newly admitted
client's posture, breathing pattern, facial expression, hygiene, and interaction with family. What component
of assessment is being performed?
A. General survey
B. Review of systems
C. Functional assessment
D. Diagnostic evaluation
Correct Answer: A
Rationale: The general survey begins with the nurse's first encounter with the client and includes overall
appearance, behavior, mobility, body structure, and obvious signs of distress. These observations provide an
initial impression that helps guide subsequent assessment.
Why the other options are less appropriate:
, • B: Review of systems systematically explores symptoms by body system.
• C: Functional assessment evaluates activities and ability to perform daily tasks.
• D: Diagnostic evaluation involves identifying or confirming disease processes.
Question 5
While assessing a client with abdominal pain, the nurse obtains a blood pressure of 82/50 mmHg, heart rate
of 126/min, and cool, clammy skin. The client reports feeling “a little dizzy.” Which interpretation is most
appropriate?
A. The subjective symptom should be documented before analyzing objective findings
B. The findings are expected consequences of abdominal discomfort
C. A complete gastrointestinal history should be obtained before intervention
D. The clustered findings suggest possible circulatory compromise requiring immediate action
Correct Answer: D
Rationale: Hypotension, tachycardia, cool clammy skin, and dizziness form a clinically significant cluster
suggesting decreased tissue perfusion or shock. Assessment involves recognizing relationships among findings
rather than treating each piece of information independently.
Clinical Pearl: Clustering related cues is fundamental to sound clinical judgment.
Question 6
When interviewing an older adult, the nurse receives most answers from the client's daughter even though
the client is alert, oriented, and able to communicate. Which approach is best?
A. Continue interviewing the daughter because family members generally provide more reliable information
B. Ask the daughter to leave immediately
C. Direct questions primarily to the client while appropriately incorporating supplementary information from
the daughter
D. Obtain the entire history from both individuals simultaneously
Correct Answer: C
Rationale: The client should remain the primary source of information whenever capable of communicating.
Family members can provide valuable supplementary information, but relying unnecessarily on them may
undermine autonomy and potentially distort the client's perspective.
Exam Strategy: Competent clients remain the primary source of subjective health information.
Question 7
,Before administering an antihypertensive medication, the nurse reassesses a client's blood pressure and
discovers it has fallen substantially since the previous measurement. Which principle of nursing assessment
does this best illustrate?
A. Comprehensive assessments replace focused assessments
B. Assessment is continuous and directly influences nursing decisions
C. Objective findings should always override subjective information
D. Reassessment is necessary only when a client reports new symptoms
Correct Answer: B
Rationale: Assessment is an ongoing component of nursing practice. Client conditions can change rapidly, and
reassessment provides current information needed to determine whether an intervention remains appropriate
and safe.
Question 8
Minutes after receiving an opioid analgesic, a client becomes increasingly difficult to arouse. Which
assessment should the nurse perform first?
A. Pain intensity
B. Bowel sounds
C. Peripheral pulses
D. Respiratory rate, depth, and oxygenation status
Correct Answer: D
Rationale: Opioids can suppress the central respiratory drive. Decreased responsiveness following opioid
administration therefore requires immediate assessment of breathing and oxygenation. Airway and breathing
threats supersede other assessment priorities.
Clinical Pearl: A sudden decrease in consciousness after an opioid should trigger immediate respiratory
assessment.
Question 9
A nurse documents, “Client appears depressed and uncooperative.” Which revision provides the most
appropriate assessment documentation?
A. “Client has major depressive behavior.”
B. “Client demonstrates inappropriate emotional responses.”
C. “Client speaks softly, maintains minimal eye contact, and declined breakfast and morning hygiene.”
D. “Client appears emotionally unstable and unwilling to cooperate.”
Correct Answer: C
,Rationale: High-quality documentation is objective, specific, observable, and measurable. Describing exactly
what the nurse observed avoids unsupported interpretation and allows other clinicians to independently
evaluate the findings.
Exam Strategy: In documentation questions, prefer observable behavior over labels or conclusions.
Question 10
During an assessment, a client says, “My chest feels like an elephant is sitting on it.” What should the nurse
do first?
A. Immediately assess characteristics of the discomfort and evaluate cardiovascular and respiratory status
B. Ask the client to finish describing the past medical history
C. Document the statement and complete the interview
D. Explain that anxiety commonly causes chest pressure
Correct Answer: A
Rationale: New pressure-like chest discomfort can indicate myocardial ischemia or another potentially life-
threatening cardiopulmonary condition. The nurse should immediately transition from routine assessment to
focused assessment of the symptom and physiological stability.
Question 11
A client reports severe dizziness when standing. Which additional assessment finding would most strongly
support orthostatic hypotension?
A. Increased blood pressure after standing
B. Significant blood pressure decrease accompanied by an increased pulse after standing
C. Unchanged blood pressure and pulse
D. Decreased respiratory rate while standing
Correct Answer: B
Rationale: Orthostatic hypotension involves a clinically meaningful reduction in blood pressure after assuming
an upright position and may be accompanied by compensatory tachycardia and symptoms such as dizziness or
weakness.
Question 12
During a health interview, the client states, “I haven't been eating much lately.” Which response best
facilitates further assessment?
A. “You need to make sure you eat three meals every day.”
B. “Have you lost exactly ten pounds?”
,C. “Tell me more about the changes you've noticed in your appetite and eating.”
D. “Is your appetite poor because you are depressed?”
Correct Answer: C
Rationale: Open-ended questions encourage clients to describe experiences in their own words and reduce the
risk of leading the response. This approach can uncover onset, contributing factors, associated symptoms, and
effects on nutritional status.
Question 13
Shortly after receiving shift report, the nurse must determine which client needs assessment first. Which
client has the highest priority?
A. A client requesting medication for chronic back pain rated 7/10
B. A client awaiting discharge instructions
C. A client requesting assistance to the bathroom
D. A client with newly developed inspiratory stridor following neck surgery
Correct Answer: D
Rationale: Inspiratory stridor indicates upper-airway narrowing and can precede complete airway obstruction.
Following ABC priorities, the nurse must immediately assess and intervene for this client.
Exam Strategy: New airway sounds such as stridor are high-priority findings.
Question 14
An experienced nurse notices that a client who was previously conversational has become unusually quiet
and restless despite vital signs remaining within the documented reference range. What is the best nursing
response?
A. Perform a focused reassessment to investigate the change from baseline
B. Wait until vital signs become abnormal
C. Attribute the behavior to hospitalization-related anxiety
D. Document the behavior for the next shift
Correct Answer: A
Rationale: Changes from an individual's baseline may indicate deterioration before conventional vital signs
become abnormal. Restlessness can be associated with hypoxia, pain, neurological changes, anxiety, or other
physiological problems and warrants focused reassessment.
Question 15
, Before beginning a comprehensive physical examination, which action most effectively improves the
accuracy of the information collected?
A. Ask only closed-ended questions
B. Establish rapport and explain the purpose and sequence of the assessment
C. Perform the examination before obtaining subjective information
D. Avoid discussing sensitive concerns until discharge
Correct Answer: B
Rationale: Rapport, privacy, clear explanations, and therapeutic communication increase trust and improve the
likelihood that clients will provide complete and accurate information.
Question 16
During medication reconciliation, a client says, “I take a little white blood-pressure pill every morning.”
Which nursing action provides the safest assessment?
A. Record “unknown antihypertensive medication” and continue
B. Select the most commonly prescribed antihypertensive from the medication list
C. Seek additional information to verify the medication name, dose, route, and frequency
D. Ask the provider to prescribe a replacement medication
Correct Answer: C
Rationale: Medication reconciliation requires accurate identification of medications, including prescription
drugs, OTC products, supplements, dosage, route, and frequency. Guessing creates a significant risk for
medication errors and adverse interactions.
Clinical Pearl: Unverified medication information should be clarified rather than assumed.
Question 17
Following an intervention for acute respiratory distress, which nursing action best evaluates whether the
intervention was effective?
A. Complete the original health history
B. Ask another nurse whether the intervention was appropriate
C. Document the intervention without additional assessment
D. Reassess the client's respiratory findings and compare them with baseline and expected outcomes
Correct Answer: D
Rationale: Evaluation depends on reassessment. Comparing post-intervention findings with baseline data and
desired outcomes allows the nurse to determine whether the client's condition improved, remained
unchanged, or worsened.
