Health Assessment (2026-2027) /Actual
Questions & Answers
1. When documenting subjective data for the cardiovascular system, the nurse would include which of
the following?
A. Vital signs
B. Peripheral pulses
C. Chest pain
D. Heart sounds
Correct Answer: C. Chest pain
Expert Rationale: Subjective data are symptoms or information reported by the patient. Chest pain is
something the patient experiences and reports, whereas vital signs, pulses, and heart sounds are
objective findings obtained through assessment.
2. When responding to questions asked during a review of systems, the client reports having a sore
throat which "happens all the time." The nurse should ask which question next?
A. When did this sore throat begin?
B. What do you mean you have sore throats all the time?
C. Did you also have sore throats as a child?
D. Did you ever take antibiotics?
Correct Answer: A. When did this sore throat begin?
,Expert Rationale: The nurse should clarify the symptom by determining its onset and gathering specific
information about the patient's current problem. Questions about onset help establish the history and
progression of the symptom.
3. The nurse is gathering present health data during the health history assessment. The nurse asks the
client about alcohol use. The client angrily asks, "Why do you need to know?" What is the nurse's best
response?
A. If you consume alcohol then I will need to provide alcohol counseling.
B. I need to know because alcohol can interact with many medications.
C. You are very defensive. This suggests you probably have an alcohol problem.
D. I can make a referral to alcohol self-help groups for you.
Correct Answer: B. I need to know because alcohol can interact with many medications.
Expert Rationale: The nurse should explain why sensitive health information is necessary. Alcohol can
affect health and interact with medications, so obtaining this information is clinically relevant.
4. Prior to obtaining data for a health history, the nurse should take which action?
A. Introduce self to client and position client comfortably in a chair.
B. Bring in a family member to verify all data.
C. Review medical record to validate client information.
D. Tape record client information to avoid omissions.
Correct Answer: A. Introduce self to client and position client comfortably in a chair.
Expert Rationale: The nurse should establish rapport, introduce themselves, and provide a comfortable
environment before beginning the health history.
5. Which question would the nurse ask to gather information about the client's health beliefs?
A. What is the name of the clinic you usually attend?
B. Can you tell me about your current abdominal pain?
C. What do you think it means to be healthy?
,D. What type of health insurance do you have?
Correct Answer: C. What do you think it means to be healthy?
Expert Rationale: Open-ended questions about the patient's definition of health help the nurse
understand the patient's health beliefs, values, and perceptions.
6. The nurse is performing a physical assessment and is unable to palpate a pulse. What is the best
action to take next?
A. Ask another nurse to check for a pulse.
B. Notify the healthcare provider about the finding.
C. Page the nursing supervisor to palpate the pulse.
D. Verify the finding with a Doppler ultrasound.
Correct Answer: A. Ask another nurse to check for a pulse.
Expert Rationale: When an unexpected assessment finding occurs, the nurse should first verify the
finding. Having another qualified nurse assess the pulse helps determine whether the finding is accurate
before escalating the situation.
7. To assess vibration during a physical assessment, the nurse would use which part of the hand?
A. Fingertips
B. Finger pads
C. Ulnar aspect
D. Dorsal surface
Correct Answer: C. Ulnar aspect
Expert Rationale: The ulnar surface of the hand is sensitive to vibrations and is used to assess tactile
fremitus and vibrations during physical assessment.
8. Upon completion of the physical examination of a client, the nurse should take which action?
A. Have another nurse confirm all findings.
, B. Notify the healthcare provider of all findings.
C. Inform the client of the findings.
D. Verify all findings with client.
Correct Answer: D. Verify all findings with client.
Expert Rationale: The nurse should communicate relevant findings to the client and verify information
obtained during the assessment when appropriate.
9. A client who is mildly anxious is to undergo a physical assessment. Which of the following is the
most appropriate action for the nurse to take?
A. Stay with the client at all times to provide assistance.
B. Use an unhurried manner and reassure client as necessary.
C. Proceed with the exam by completing the most invasive aspects first.
D. Ask for a consult to assess the extent of the anxiety.
Correct Answer: B. Use an unhurried manner and reassure client as necessary.
Expert Rationale: An unhurried, calm approach can decrease anxiety and promote cooperation during
the physical examination.
10. During a cardiovascular assessment, the nurse finds a bluish tinge on the client's lips, fingers, and
toes. What is the appropriate documentation for this?
A. Central cyanosis
B. Peripheral cyanosis
C. Cyanosis
D. Central and peripheral cyanosis
Correct Answer: D. Central and peripheral cyanosis
Expert Rationale: Bluish discoloration of the lips indicates central cyanosis, while discoloration of the
fingers and toes indicates peripheral cyanosis. When both are present, the finding can be documented
as central and peripheral cyanosis.