Assessment 1 2025 complete exam set
questions and answers MULTIPLE
CHOICES and RATIONALES
Immediate Attention
a. The person is breathing so quickly they are unable to speak.
b. The individual is unresponsive.
Does not require immediate attention
c. The client is clutching their abdomen.
d. A toddler is clinging to the client's leg.
e. The person reports being in pain. - CORRECT ANSWER- What requires immediate
attention?
What does not require immediate attention?
a. The person is breathing so quickly they are unable to speak.
b. The individual is unresponsive.
c. The client is clutching their abdomen.
d. A toddler is clinging to the client's leg.
e. The person reports being in pain.
b. Return the medical record to the designated storage area.
c. Close the medical record when entering the client's room.
e. Shield identifying information from view by visitors. - CORRECT ANSWER- How do health
professionals protect the client's private information when using a hard copy medical record?
Select all that apply.
a. Allow the client's children to review the medical record.
b. Return the medical record to the designated storage area.
c. Close the medical record when entering the client's room.
d. Lock records in your desk drawer when not in use.
e. Shield identifying information from view by visitors.
b. Assess the UAP. - CORRECT ANSWER- When entering the room to perform a complete
health assessment on a new client, the nurse finds the client and family standing around an
unlicensed assistive personnel (UAP) who is lying on the floor.
What is the priority action for the nurse?
a. Ask what happened.
b. Assess the UAP.
c. Phone for an emergency response.
d. Move the client to another room.
Yes
a. During the complete health assessment.
b. When administering medications.
c. When asking questions from the client's partner.
, a. During the complete health assessment.
b. When administering medications.
c. When asking questions from the client's partner.
d. While reading the nurse practitioner's admission note.
e. As they pass the individual walking in the hallway.
Rapid (Screening) - CORRECT ANSWER- What kind of health assessment is this?
Purpose: Determines the urgency of the client's condition
When used: Each time the client is seen
Includes: Level of consciousness, ease of breathing, and body position
Examples: Urgent: The examiner finds a person in a hospital gown sitting on the floor gasping
for air.Not Urgent: The examiner observes the client speaking complete sentences on the phone
with even respirations.
Complete (Total) Health - CORRECT ANSWER- What kind of health assessment is this?
Purpose: Establishes the medical database for an episode of care
When used: At the first interaction between a person seeking care and the professional
providing care
Includes: A detailed health history and physical examination of all body systems
Examples include the first visit to a new healthcare provider or new admission to a long-term
care facility.
Focused (Problem-Centered) - CORRECT ANSWER- What kind of health assessment is this?
Purpose: To obtain more data about specific concerns or abnormal findings related to a body
system
When used: After abnormal findings are identified during any assessment
Includes: The collection of data related to findings of concern
Example: After noting a client's productive cough and shortness of breath when entering the
room, the examiner begins the assessment by listening to lung sounds, measuring oxygen
saturation (O2 sat), checking for cyanosis, and asking questions related to the noted symptoms
(e.g., How long has the cough been present?).
Follow-Up - CORRECT ANSWER- What kind of health assessment is this?
Purpose: To determine effectiveness during or after treatment
When used: Timing depends on the situation
Includes: A focused assessment used to evaluate how the client is responding to treatment
Examples: Checking on a client 30 minutes after administering pain medication or a follow-up
office visit with a primary care provider to determine the effectiveness of blood pressure
medication
Emergency - CORRECT ANSWER- What kind of health assessment is this?
Purpose: Collection of key data during an urgent or emergent medical situation
When used: When an individual is facing a life-threatening situation
Includes: Assessment of the Airway, Breathing, Circulation, Disabilities, and Exposure (ABCDE)
Examples: The ABCs of CPR specify that if a person is found and appears unresponsive, the
first step is to shake and shout to check level of consciousness, open the airway, check for
breathing, and palpate for a carotid pulse.