Health Assessment in Nursing Weber & Kelley 5th Edition
Test Bank Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
Section A: Foundations of Health Assessment & Nursing Process
(Q1–Q10)
Q1: A nursing student is preparing to complete a patient's admission assessment.
According to the nursing process (ADPIE), which step must always be completed first?
A. Planning
B. Evaluation
C. Assessment [CORRECT]
D. Implementation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process, providing the data
foundation for all diagnoses, planning, implementation, and evaluation. Planning,
implementation, and evaluation cannot be performed meaningfully without collected
assessment data.
Q2: During an interview, a patient tells the nurse, "I have a dull, aching pain in my lower
back that started two days ago." How should the nurse classify this information?
A. Objective data
B. Subjective data [CORRECT]
C. A secondary data source
D. A medical diagnosis
Correct Answer: B
Rationale: The patient's verbal report of pain is a symptom—subjective data perceptible
only to the patient. Objective data are observable and measurable findings such as vital
signs, and a verbal symptom report is not a diagnosis or a secondary source.
Q3: A patient arrives in the emergency department complaining of crushing chest pain
radiating to the left arm. Which type of assessment should the nurse perform?
A. Comprehensive assessment of all body systems
B. Ongoing assessment performed once per shift
,C. Emergency assessment limited to airway only
D. Focused assessment concentrated on the cardiovascular and respiratory systems
[CORRECT]
Correct Answer: D
Rationale: A focused assessment targets the systems related to the presenting
problem, here the cardiovascular and respiratory systems. A full comprehensive
assessment delays care, and an airway-only emergency assessment does not address
the presenting complaint.
Q4: When documenting the chief concern in the health history, the nurse should record
which of the following?
A. The reason the patient is seeking care, stated in the patient's own words [CORRECT]
B. The nurse's interpretation of the patient's most serious problem
C. The physician's admitting diagnosis
D. A complete list of the patient's prescribed medications
Correct Answer: A
Rationale: The chief concern is recorded as a brief, quoted statement in the patient's
own words describing why care is being sought. Nurse interpretations, medical
diagnoses, and medication lists belong in other sections of the record.
Q5: A patient who appears well and reports no distress has a pulse oximetry reading of
85%. What is the nurse's best action?
A. Document the value and continue with the assessment
B. Validate the finding by checking the probe placement, warming the hand, and
repeating the measurement [CORRECT]
C. Immediately begin chest compressions
D. Tell the patient the result is normal
Correct Answer: B
Rationale: A single abnormal finding inconsistent with the clinical picture must be
validated through recheck, probe repositioning, and equipment verification before
documentation. Ignoring the value risks missing hypoxemia, and falsely reassuring the
patient is unsafe.
Q6: A patient is unresponsive following a suspected stroke, and no health record is
immediately available. Which source is most appropriate for obtaining the health
history?
A. The patient's roommate in the waiting area
B. The nurse's physical examination alone
C. The patient's spouse, who can supply secondary history data [CORRECT]
D. Waiting to ask the patient when he wakes up
,Correct Answer: C
Rationale: When the patient cannot provide information, family members serve as valid
secondary data sources for history. A bystander roommate lacks reliable knowledge,
the exam cannot reveal history, and delaying collection postpones essential care.
Q7: What is the primary purpose of the review of systems (ROS) in the health history?
A. To document the physical examination findings of each body system
B. To record the patient's family medical diagnoses
C. To summarize the nurse's clinical judgments
D. To identify symptoms in each body system that the patient may not have
spontaneously reported [CORRECT]
Correct Answer: D
Rationale: The ROS is a systematic, question-by-question subjective screen designed to
uncover symptoms the patient omitted during the present illness. It does not record
objective exam findings, family history, or nursing conclusions.
Q8: A patient states, "I've been under a lot of stress lately." Which interviewer response
best encourages the patient to elaborate?
A. "Tell me more about the stress you've been experiencing." [CORRECT]
B. "Your stress is caused by your job, isn't it?"
C. "Why did you let things get this stressful?"
D. "You should just relax more often."
Correct Answer: A
Rationale: Open-ended questions facilitate the patient's full narrative without
constraining the answer. Leading, "why," and advice-giving responses close down
communication or place the patient on the defensive.
Q9: In the physical examination of most body systems, which sequence of assessment
techniques does the nurse follow?
A. Palpation, percussion, inspection, auscultation
B. Inspection, palpation, percussion, auscultation [CORRECT]
C. Auscultation, inspection, palpation, percussion
D. Percussion, auscultation, inspection, palpation
Correct Answer: B
Rationale: The standard sequence is inspection first, followed by palpation, percussion,
and auscultation, minimizing technique-induced changes before observation. The
abdomen is the exception, where auscultation precedes palpation and percussion.
Q10: While taking the health history, a patient's eyes fill with tears when discussing her
recent cancer diagnosis. What is the nurse's best response?
, A. Continue with the next question about family history
B. Hand the patient a tissue and leave the room
C. Pause, sit quietly with the patient, and say, "This seems very difficult for you."
[CORRECT]
D. Tell the patient that crying will not help the situation
Correct Answer: C
Rationale: Therapeutic use of silence with an empathic, acknowledging statement
supports the patient's expression of feelings. Ignoring the emotion, leaving, or
dismissing the tears obstructs the nurse–patient relationship and data collection.
Section B: General Survey, Vital Signs & Pain Assessment (Q11–Q20)
Q11: Which components are included in the general survey performed when first
encountering a patient?
A. Heart sounds, bowel sounds, and breath sounds
B. Deep tendon reflexes, muscle strength, and sensation
C. Pupil response, visual acuity, and hearing
D. Appearance, body structure, behavior, and measurements [CORRECT]
Correct Answer: D
Rationale: The general survey is the first observational impression, encompassing
appearance, body structure, behavior, and measurements such as height, weight, and
vital signs. The other options are specific system examinations, not the general survey.
Q12: A patient reports dizziness when standing. Which procedure should the nurse use
to assess for orthostatic hypotension?
A. Compare blood pressure in both arms in the sitting position
B. Measure blood pressure and pulse with the patient lying, then sitting, then standing,
noting a drop of 20 mm Hg systolic or 10 mm Hg diastolic [CORRECT]
C. Take a single blood pressure in each lower extremity
D. Measure blood pressure only after the patient walks the hallway
Correct Answer: B
Rationale: Orthostatic vital signs are taken in sequential lying, sitting, and standing
positions, with a drop of ≥20 systolic or ≥10 diastolic indicating orthostatic hypotension.
Single-arm comparison, leg pressures, and post-ambulation readings do not test
postural change.
Test Bank Actual Exam 2026/2027 – Complete Exam-Style
Questions with Detailed Rationales | 100% Verified | Pass
Guaranteed – A+ Graded
Section A: Foundations of Health Assessment & Nursing Process
(Q1–Q10)
Q1: A nursing student is preparing to complete a patient's admission assessment.
According to the nursing process (ADPIE), which step must always be completed first?
A. Planning
B. Evaluation
C. Assessment [CORRECT]
D. Implementation
Correct Answer: C
Rationale: Assessment is the first step of the nursing process, providing the data
foundation for all diagnoses, planning, implementation, and evaluation. Planning,
implementation, and evaluation cannot be performed meaningfully without collected
assessment data.
Q2: During an interview, a patient tells the nurse, "I have a dull, aching pain in my lower
back that started two days ago." How should the nurse classify this information?
A. Objective data
B. Subjective data [CORRECT]
C. A secondary data source
D. A medical diagnosis
Correct Answer: B
Rationale: The patient's verbal report of pain is a symptom—subjective data perceptible
only to the patient. Objective data are observable and measurable findings such as vital
signs, and a verbal symptom report is not a diagnosis or a secondary source.
Q3: A patient arrives in the emergency department complaining of crushing chest pain
radiating to the left arm. Which type of assessment should the nurse perform?
A. Comprehensive assessment of all body systems
B. Ongoing assessment performed once per shift
,C. Emergency assessment limited to airway only
D. Focused assessment concentrated on the cardiovascular and respiratory systems
[CORRECT]
Correct Answer: D
Rationale: A focused assessment targets the systems related to the presenting
problem, here the cardiovascular and respiratory systems. A full comprehensive
assessment delays care, and an airway-only emergency assessment does not address
the presenting complaint.
Q4: When documenting the chief concern in the health history, the nurse should record
which of the following?
A. The reason the patient is seeking care, stated in the patient's own words [CORRECT]
B. The nurse's interpretation of the patient's most serious problem
C. The physician's admitting diagnosis
D. A complete list of the patient's prescribed medications
Correct Answer: A
Rationale: The chief concern is recorded as a brief, quoted statement in the patient's
own words describing why care is being sought. Nurse interpretations, medical
diagnoses, and medication lists belong in other sections of the record.
Q5: A patient who appears well and reports no distress has a pulse oximetry reading of
85%. What is the nurse's best action?
A. Document the value and continue with the assessment
B. Validate the finding by checking the probe placement, warming the hand, and
repeating the measurement [CORRECT]
C. Immediately begin chest compressions
D. Tell the patient the result is normal
Correct Answer: B
Rationale: A single abnormal finding inconsistent with the clinical picture must be
validated through recheck, probe repositioning, and equipment verification before
documentation. Ignoring the value risks missing hypoxemia, and falsely reassuring the
patient is unsafe.
Q6: A patient is unresponsive following a suspected stroke, and no health record is
immediately available. Which source is most appropriate for obtaining the health
history?
A. The patient's roommate in the waiting area
B. The nurse's physical examination alone
C. The patient's spouse, who can supply secondary history data [CORRECT]
D. Waiting to ask the patient when he wakes up
,Correct Answer: C
Rationale: When the patient cannot provide information, family members serve as valid
secondary data sources for history. A bystander roommate lacks reliable knowledge,
the exam cannot reveal history, and delaying collection postpones essential care.
Q7: What is the primary purpose of the review of systems (ROS) in the health history?
A. To document the physical examination findings of each body system
B. To record the patient's family medical diagnoses
C. To summarize the nurse's clinical judgments
D. To identify symptoms in each body system that the patient may not have
spontaneously reported [CORRECT]
Correct Answer: D
Rationale: The ROS is a systematic, question-by-question subjective screen designed to
uncover symptoms the patient omitted during the present illness. It does not record
objective exam findings, family history, or nursing conclusions.
Q8: A patient states, "I've been under a lot of stress lately." Which interviewer response
best encourages the patient to elaborate?
A. "Tell me more about the stress you've been experiencing." [CORRECT]
B. "Your stress is caused by your job, isn't it?"
C. "Why did you let things get this stressful?"
D. "You should just relax more often."
Correct Answer: A
Rationale: Open-ended questions facilitate the patient's full narrative without
constraining the answer. Leading, "why," and advice-giving responses close down
communication or place the patient on the defensive.
Q9: In the physical examination of most body systems, which sequence of assessment
techniques does the nurse follow?
A. Palpation, percussion, inspection, auscultation
B. Inspection, palpation, percussion, auscultation [CORRECT]
C. Auscultation, inspection, palpation, percussion
D. Percussion, auscultation, inspection, palpation
Correct Answer: B
Rationale: The standard sequence is inspection first, followed by palpation, percussion,
and auscultation, minimizing technique-induced changes before observation. The
abdomen is the exception, where auscultation precedes palpation and percussion.
Q10: While taking the health history, a patient's eyes fill with tears when discussing her
recent cancer diagnosis. What is the nurse's best response?
, A. Continue with the next question about family history
B. Hand the patient a tissue and leave the room
C. Pause, sit quietly with the patient, and say, "This seems very difficult for you."
[CORRECT]
D. Tell the patient that crying will not help the situation
Correct Answer: C
Rationale: Therapeutic use of silence with an empathic, acknowledging statement
supports the patient's expression of feelings. Ignoring the emotion, leaving, or
dismissing the tears obstructs the nurse–patient relationship and data collection.
Section B: General Survey, Vital Signs & Pain Assessment (Q11–Q20)
Q11: Which components are included in the general survey performed when first
encountering a patient?
A. Heart sounds, bowel sounds, and breath sounds
B. Deep tendon reflexes, muscle strength, and sensation
C. Pupil response, visual acuity, and hearing
D. Appearance, body structure, behavior, and measurements [CORRECT]
Correct Answer: D
Rationale: The general survey is the first observational impression, encompassing
appearance, body structure, behavior, and measurements such as height, weight, and
vital signs. The other options are specific system examinations, not the general survey.
Q12: A patient reports dizziness when standing. Which procedure should the nurse use
to assess for orthostatic hypotension?
A. Compare blood pressure in both arms in the sitting position
B. Measure blood pressure and pulse with the patient lying, then sitting, then standing,
noting a drop of 20 mm Hg systolic or 10 mm Hg diastolic [CORRECT]
C. Take a single blood pressure in each lower extremity
D. Measure blood pressure only after the patient walks the hallway
Correct Answer: B
Rationale: Orthostatic vital signs are taken in sequential lying, sitting, and standing
positions, with a drop of ≥20 systolic or ≥10 diastolic indicating orthostatic hypotension.
Single-arm comparison, leg pressures, and post-ambulation readings do not test
postural change.
