NUR 245 Exam 1: Health Assessment and Promotion –
Questions & Answers with Rationale
TABLE OF CONTENTS
1. Foundations of Health Assessment
2. Health History and Interviewing
3. Communication and Therapeutic Interviewing
4. Physical Examination Techniques
5. Vital Signs and Pain Assessment
6. Cardiovascular Assessment
7. Respiratory Assessment
8. Neurologic Assessment
9. Abdominal, Gastrointestinal, and Genitourinary Assessment
10.Musculoskeletal and Skin Assessment
11.Health Promotion and Disease Prevention
12.Cultural, Psychosocial, and Older-Adult Assessment
13.Integrated Clinical Judgment
SECTION 1: FOUNDATIONS OF HEALTH ASSESSMENT
Question 1
What is the primary purpose of a comprehensive health assessment?
A. To establish a medical diagnosis
B. To collect information about the client's health status
C. To prescribe treatment
D. To determine insurance eligibility
,Answer: B. To collect information about the client's health status
Rationale: A nursing health assessment systematically collects subjective and
objective information about the client's physical, psychological, social,
developmental, and functional status. Diagnosis and treatment decisions may
follow, but assessment itself focuses on data collection and interpretation.
Question 2
Which finding is considered subjective data?
A. Blood pressure of 148/88 mmHg
B. Temperature of 38.2°C
C. Client reports feeling dizzy
D. Respiratory rate of 24/min
Answer: C. Client reports feeling dizzy
Rationale: Subjective data are symptoms or experiences reported by the
client. Blood pressure, temperature, and respiratory rate are measurable
findings and therefore represent objective data.
Question 3
Which is an example of objective data?
A. "My stomach hurts."
B. "I feel tired."
C. "I am nauseated."
D. Respiratory rate of 28 breaths/minute
Answer: D. Respiratory rate of 28 breaths/minute
Rationale: Objective data can be observed, measured, or verified by the
healthcare professional. Respiratory rate is directly measurable.
Question 4
,Which action should the nurse perform first when beginning a health
assessment?
A. Begin palpating the abdomen
B. Review the medication list
C. Introduce self and verify the client's identity
D. Obtain the client's blood pressure
Answer: C. Introduce self and verify the client's identity
Rationale: Establishing identity and introducing oneself promote safety, trust,
and professional communication before assessment begins.
Question 5
Why is establishing a baseline assessment important?
A. It eliminates the need for future assessments
B. It provides a reference for detecting changes
C. It replaces diagnostic testing
D. It determines the client's insurance status
Answer: B. It provides a reference for detecting changes
Rationale: Baseline findings provide a point of comparison for subsequent
assessments. Changes from baseline may indicate improvement,
deterioration, or a new health problem.
Question 6
Which factor is particularly important when interpreting health assessment
findings?
A. The client's age and developmental stage
B. The nurse's personal preferences
C. The client's room number
D. The nurse's work schedule
Answer: A. The client's age and developmental stage
, Rationale: Normal findings vary according to age and developmental stage.
Assessment findings must be interpreted in the context of the individual
client.
Question 7
Which assessment finding requires the nurse to compare both sides of the
body?
A. Blood glucose
B. Bilateral peripheral pulses
C. Temperature
D. Pain rating
Answer: B. Bilateral peripheral pulses
Rationale: Comparing corresponding areas bilaterally can reveal asymmetry,
differences in strength, swelling, movement, or circulation.
Question 8
Which nursing action best promotes accurate assessment findings?
A. Make assumptions based on the client's diagnosis
B. Use a systematic approach
C. Skip normal findings
D. Assess only the client's chief complaint
Answer: B. Use a systematic approach
Rationale: A systematic assessment reduces omissions and helps the nurse
consistently collect relevant information.
Question 9
A client reports a symptom that seems inconsistent with the nurse's initial
observations. What should the nurse do?
A. Ignore the report
B. Tell the client the symptom is unlikely
Questions & Answers with Rationale
TABLE OF CONTENTS
1. Foundations of Health Assessment
2. Health History and Interviewing
3. Communication and Therapeutic Interviewing
4. Physical Examination Techniques
5. Vital Signs and Pain Assessment
6. Cardiovascular Assessment
7. Respiratory Assessment
8. Neurologic Assessment
9. Abdominal, Gastrointestinal, and Genitourinary Assessment
10.Musculoskeletal and Skin Assessment
11.Health Promotion and Disease Prevention
12.Cultural, Psychosocial, and Older-Adult Assessment
13.Integrated Clinical Judgment
SECTION 1: FOUNDATIONS OF HEALTH ASSESSMENT
Question 1
What is the primary purpose of a comprehensive health assessment?
A. To establish a medical diagnosis
B. To collect information about the client's health status
C. To prescribe treatment
D. To determine insurance eligibility
,Answer: B. To collect information about the client's health status
Rationale: A nursing health assessment systematically collects subjective and
objective information about the client's physical, psychological, social,
developmental, and functional status. Diagnosis and treatment decisions may
follow, but assessment itself focuses on data collection and interpretation.
Question 2
Which finding is considered subjective data?
A. Blood pressure of 148/88 mmHg
B. Temperature of 38.2°C
C. Client reports feeling dizzy
D. Respiratory rate of 24/min
Answer: C. Client reports feeling dizzy
Rationale: Subjective data are symptoms or experiences reported by the
client. Blood pressure, temperature, and respiratory rate are measurable
findings and therefore represent objective data.
Question 3
Which is an example of objective data?
A. "My stomach hurts."
B. "I feel tired."
C. "I am nauseated."
D. Respiratory rate of 28 breaths/minute
Answer: D. Respiratory rate of 28 breaths/minute
Rationale: Objective data can be observed, measured, or verified by the
healthcare professional. Respiratory rate is directly measurable.
Question 4
,Which action should the nurse perform first when beginning a health
assessment?
A. Begin palpating the abdomen
B. Review the medication list
C. Introduce self and verify the client's identity
D. Obtain the client's blood pressure
Answer: C. Introduce self and verify the client's identity
Rationale: Establishing identity and introducing oneself promote safety, trust,
and professional communication before assessment begins.
Question 5
Why is establishing a baseline assessment important?
A. It eliminates the need for future assessments
B. It provides a reference for detecting changes
C. It replaces diagnostic testing
D. It determines the client's insurance status
Answer: B. It provides a reference for detecting changes
Rationale: Baseline findings provide a point of comparison for subsequent
assessments. Changes from baseline may indicate improvement,
deterioration, or a new health problem.
Question 6
Which factor is particularly important when interpreting health assessment
findings?
A. The client's age and developmental stage
B. The nurse's personal preferences
C. The client's room number
D. The nurse's work schedule
Answer: A. The client's age and developmental stage
, Rationale: Normal findings vary according to age and developmental stage.
Assessment findings must be interpreted in the context of the individual
client.
Question 7
Which assessment finding requires the nurse to compare both sides of the
body?
A. Blood glucose
B. Bilateral peripheral pulses
C. Temperature
D. Pain rating
Answer: B. Bilateral peripheral pulses
Rationale: Comparing corresponding areas bilaterally can reveal asymmetry,
differences in strength, swelling, movement, or circulation.
Question 8
Which nursing action best promotes accurate assessment findings?
A. Make assumptions based on the client's diagnosis
B. Use a systematic approach
C. Skip normal findings
D. Assess only the client's chief complaint
Answer: B. Use a systematic approach
Rationale: A systematic assessment reduces omissions and helps the nurse
consistently collect relevant information.
Question 9
A client reports a symptom that seems inconsistent with the nurse's initial
observations. What should the nurse do?
A. Ignore the report
B. Tell the client the symptom is unlikely
