NUR 304 Health Assessment ATI EXAM 1 Questions
and Answers Complete Solution
Section I: Foundations of Health Assessment & Nursing Process
1. A nurse is preparing to conduct a comprehensive health assessment. Which of
the following best describes the primary purpose of the health assessment?
A) To establish a medical diagnosis
B) To collect subjective and objective data to form a nursing database
C) To determine the client's insurance coverage
D) To evaluate the effectiveness of medical treatment
B) To collect subjective and objective data to form a nursing database
Rationale: The primary purpose of health assessment is to collect
subjective and objective data that form the foundation of the nursing database,
which is then used to identify nursing diagnoses and plan care.
2. A nurse is differentiating between subjective and objective data. Which of the
following is an example of subjective data?
A) Blood pressure 138/86 mm Hg
B) Client reports "I feel dizzy when I stand up"
C) Temperature 38.2°C
D) Rash noted on the client's abdomen
B) Client reports "I feel dizzy when I stand up"
Rationale: Subjective data are information the client reports, such as
symptoms, feelings, and perceptions. "I feel dizzy" is a symptom the client
experiences and reports.
3. A nurse is preparing for a comprehensive assessment. Before entering the
client's room, which action should the nurse take first?
A) Gather assessment equipment
B) Review the client's medical record and gather information
,C) Introduce herself to the client
D) Perform hand hygiene
B) Review the client's medical record and gather information
Rationale: Before entering the client's room, the nurse should review the
client's medical record to gather existing information, which helps focus the
assessment and avoid unnecessary repetition of questions.
4. Which of the following are the four major steps of health assessment? (SATA)
A) Collection of subjective data
B) Collection of objective data
C) Validation of data
D) Documentation of data
E) Ordering laboratory tests
A, B, C, D
Rationale: The four major steps of health assessment are: collection of
subjective data, collection of objective data, validation of data, and
documentation of data. Ordering laboratory tests is a medical provider function,
not a nursing assessment step.
5. A nurse is performing an initial comprehensive assessment on a newly admitted
client. Which type of assessment is this?
A) Focused assessment
B) Emergency assessment
C) Initial comprehensive assessment
D) Ongoing partial assessment
C) Initial comprehensive assessment
Rationale: An initial comprehensive assessment is performed upon
admission and includes collection of subjective data about the client's perception
of health of all body parts or systems, past medical history, family history, and
lifestyle and health practices.
,6. A nurse is assessing a client who is experiencing acute chest pain. Which type of
assessment should the nurse perform?
A) Initial comprehensive assessment
B) Focused or problem-oriented assessment
C) Ongoing partial assessment
D) Emergency assessment
D) Emergency assessment
Rationale: An emergency assessment is performed when a client is
experiencing an acute life-threatening situation. Chest pain requires immediate
focused assessment to determine the nature and severity of the problem.
7. The nurse is applying the nursing process. Which step immediately follows
assessment?
A) Planning
B) Implementation
C) Analysis
D) Evaluation
C) Analysis
Rationale: The nursing process steps are: Assessment, Analysis (diagnosis),
Planning, Implementation, and Evaluation. Analysis follows assessment and
involves interpreting the collected data to identify nursing diagnoses.
8. Which of the following are components of critical thinking in nursing? (SATA)
A) Contextual awareness
B) Analyzing assumptions
C) Exploring alternatives
D) Using credible sources
E) Reflecting and deciding
A, B, C, D, E
, Rationale: All five are components of critical thinking. Critical thinking in
nursing involves contextual awareness, analyzing assumptions, exploring
alternatives, using credible sources, and reflecting and deciding.
9. A nurse is collecting data and notes that the client's blood pressure is 180/110
mm Hg. What action should the nurse take?
A) Document the finding and continue with the assessment
B) Report the unexpected finding immediately
C) Recheck the blood pressure in one hour
D) Ask the client if they usually have high blood pressure
B) Report the unexpected finding immediately
Rationale: A blood pressure of 180/110 mm Hg is a hypertensive crisis
requiring immediate reporting. The nurse should take action for unexpected
findings rather than simply documenting and continuing.
10. Which ethical principle refers to the nurse's obligation to do no harm?
A) Beneficence
B) Nonmaleficence
C) Autonomy
D) Justice
B) Nonmaleficence
Rationale: Nonmaleficence is the ethical principle of doing no harm.
Beneficence refers to doing good, autonomy respects the client's right to self-
determination, and justice refers to fairness.
11. A nurse respects a client's right to refuse a physical examination. Which
ethical principle is the nurse demonstrating?
A) Nonmaleficence
B) Beneficence
C) Autonomy
D) Confidentiality
C) Autonomy
and Answers Complete Solution
Section I: Foundations of Health Assessment & Nursing Process
1. A nurse is preparing to conduct a comprehensive health assessment. Which of
the following best describes the primary purpose of the health assessment?
A) To establish a medical diagnosis
B) To collect subjective and objective data to form a nursing database
C) To determine the client's insurance coverage
D) To evaluate the effectiveness of medical treatment
B) To collect subjective and objective data to form a nursing database
Rationale: The primary purpose of health assessment is to collect
subjective and objective data that form the foundation of the nursing database,
which is then used to identify nursing diagnoses and plan care.
2. A nurse is differentiating between subjective and objective data. Which of the
following is an example of subjective data?
A) Blood pressure 138/86 mm Hg
B) Client reports "I feel dizzy when I stand up"
C) Temperature 38.2°C
D) Rash noted on the client's abdomen
B) Client reports "I feel dizzy when I stand up"
Rationale: Subjective data are information the client reports, such as
symptoms, feelings, and perceptions. "I feel dizzy" is a symptom the client
experiences and reports.
3. A nurse is preparing for a comprehensive assessment. Before entering the
client's room, which action should the nurse take first?
A) Gather assessment equipment
B) Review the client's medical record and gather information
,C) Introduce herself to the client
D) Perform hand hygiene
B) Review the client's medical record and gather information
Rationale: Before entering the client's room, the nurse should review the
client's medical record to gather existing information, which helps focus the
assessment and avoid unnecessary repetition of questions.
4. Which of the following are the four major steps of health assessment? (SATA)
A) Collection of subjective data
B) Collection of objective data
C) Validation of data
D) Documentation of data
E) Ordering laboratory tests
A, B, C, D
Rationale: The four major steps of health assessment are: collection of
subjective data, collection of objective data, validation of data, and
documentation of data. Ordering laboratory tests is a medical provider function,
not a nursing assessment step.
5. A nurse is performing an initial comprehensive assessment on a newly admitted
client. Which type of assessment is this?
A) Focused assessment
B) Emergency assessment
C) Initial comprehensive assessment
D) Ongoing partial assessment
C) Initial comprehensive assessment
Rationale: An initial comprehensive assessment is performed upon
admission and includes collection of subjective data about the client's perception
of health of all body parts or systems, past medical history, family history, and
lifestyle and health practices.
,6. A nurse is assessing a client who is experiencing acute chest pain. Which type of
assessment should the nurse perform?
A) Initial comprehensive assessment
B) Focused or problem-oriented assessment
C) Ongoing partial assessment
D) Emergency assessment
D) Emergency assessment
Rationale: An emergency assessment is performed when a client is
experiencing an acute life-threatening situation. Chest pain requires immediate
focused assessment to determine the nature and severity of the problem.
7. The nurse is applying the nursing process. Which step immediately follows
assessment?
A) Planning
B) Implementation
C) Analysis
D) Evaluation
C) Analysis
Rationale: The nursing process steps are: Assessment, Analysis (diagnosis),
Planning, Implementation, and Evaluation. Analysis follows assessment and
involves interpreting the collected data to identify nursing diagnoses.
8. Which of the following are components of critical thinking in nursing? (SATA)
A) Contextual awareness
B) Analyzing assumptions
C) Exploring alternatives
D) Using credible sources
E) Reflecting and deciding
A, B, C, D, E
, Rationale: All five are components of critical thinking. Critical thinking in
nursing involves contextual awareness, analyzing assumptions, exploring
alternatives, using credible sources, and reflecting and deciding.
9. A nurse is collecting data and notes that the client's blood pressure is 180/110
mm Hg. What action should the nurse take?
A) Document the finding and continue with the assessment
B) Report the unexpected finding immediately
C) Recheck the blood pressure in one hour
D) Ask the client if they usually have high blood pressure
B) Report the unexpected finding immediately
Rationale: A blood pressure of 180/110 mm Hg is a hypertensive crisis
requiring immediate reporting. The nurse should take action for unexpected
findings rather than simply documenting and continuing.
10. Which ethical principle refers to the nurse's obligation to do no harm?
A) Beneficence
B) Nonmaleficence
C) Autonomy
D) Justice
B) Nonmaleficence
Rationale: Nonmaleficence is the ethical principle of doing no harm.
Beneficence refers to doing good, autonomy respects the client's right to self-
determination, and justice refers to fairness.
11. A nurse respects a client's right to refuse a physical examination. Which
ethical principle is the nurse demonstrating?
A) Nonmaleficence
B) Beneficence
C) Autonomy
D) Confidentiality
C) Autonomy
