Q&A
1. Which statement accurately describes the purpose of a nursing health assessment?
A) To diagnose medical diseases and prescribe treatment
B) To collect holistic subjective and objective data to determine a client's overall level of
functioning
C) To replace the need for laboratory and diagnostic testing
D) To evaluate the effectiveness of medical interventions
Correct Answer: To collect holistic subjective and objective data to determine a client's
overall level of functioning
Rationale: The purpose of a nursing health assessment is to collect holistic subjective and
objective data to determine a client's overall level of functioning in order to make a
professional clinical judgment (nursing diagnosis). It does not diagnose medical diseases
or prescribe treatment; those are medical functions.
2. What is the correct order of the four phases of a nursing interview?
A) Introductory, Working, Preintroducory, Summary/Closing
B) Preintroducory, Introductory, Working, Summary/Closing
C) Working, Preintroducory, Introductory, Summary/Closing
D) Preintroducory, Working, Introductory, Summary/Closing
Correct Answer: Preintroducory, Introductory, Working, Summary/Closing
Rationale: The four phases of a nursing interview occur in this specific order: the
preintroducory phase (reviewing the medical chart), the introductory phase (introducing
,oneself and stating the purpose), the working phase (collecting information through
questions), and the summary/closing phase (reviewing the information obtained).
3. A client reports feeling "short of breath" and "dizzy." This information is classified as:
A) Objective data
B) Secondary data
C) Subjective data
D) Primary data
Correct Answer: Subjective data
Rationale: Subjective data is information reported by the client, including their
perceptions, feelings, and sensations. Shortness of breath and dizziness cannot be directly
observed or measured by the nurse, making them subjective findings. Objective data is
directly observed or measured.
4. A nurse observes that a client's skin is pale and their respiratory rate is 24 breaths per
minute. These findings are classified as:
A) Subjective data
B) Objective data
C) Primary data
D) Secondary data
Correct Answer: Objective data
Rationale: Objective data is information gathered through direct observation and physical
examination, such as vital signs and skin color. It is measurable and observable. Subjective
data is reported by the client and cannot be directly measured.
, 5. An initial comprehensive assessment is typically performed:
A) When a client is about to be discharged
B) When a client first enters the healthcare system
C) During every shift change
D) Only when a client is in critical condition
Correct Answer: When a client first enters the healthcare system
Rationale: An initial comprehensive assessment is performed when a client first enters the
healthcare system to establish a baseline of data against which future changes can be
measured. It includes a full health history and physical examination.
6. The correct order of assessment techniques for a general physical examination is:
A) Palpation, Percussion, Inspection, Auscultation
B) Inspection, Palpation, Percussion, Auscultation
C) Inspection, Auscultation, Palpation, Percussion
D) Auscultation, Inspection, Palpation, Percussion
Correct Answer: Inspection, Palpation, Percussion, Auscultation
Rationale: The standard order for a general physical examination is inspection, palpation,
percussion, and auscultation. This sequence prevents alteration of findings before they are
assessed. The abdomen is the exception, where auscultation precedes palpation and
percussion.
7. What is the modified order of assessment techniques for the abdomen?
A) Inspection, Palpation, Percussion, Auscultation