,Chapter 1: Nurse's Role in Health Assessment
Section A: Multiple Choice Questions (1–50)
1. The nurse is performing a comprehensive health assessment on a newly admitted patient. Which
statement best describes the primary purpose of this assessment?
A) To identify the patient's medical diagnosis
B) To collect data to establish a baseline and identify patient needs
C) To determine the patient's insurance coverage
D) To evaluate the effectiveness of prescribed treatments
Correct Answer: B
Rationale: The purpose of health assessment is to collect subjective and objective data to establish a
baseline, identify patient needs, and inform nursing interventions. Medical diagnosis (A) is the provider's
role. Insurance coverage (C) is administrative. Evaluating treatment effectiveness (D) occurs later in the
process.
2. During an initial interview, a patient reports feeling dizzy. The nurse observes an unsteady gait and a
small abrasion on the patient's arm. Which statement correctly identifies the subjective and objective
data?
A) Both dizziness and unsteady gait are subjective
B) Dizziness is subjective; unsteady gait and abrasion are objective
C) The abrasion is subjective because the patient reported pain
D) The unsteady gait is subjective because it is an interpretation
Correct Answer: B
Rationale: Subjective data is what the patient reports (dizziness). Objective data is what the nurse
observes or measures (unsteady gait, abrasion). This combination supports fall-risk interventions .
3. A patient who had surgery two days ago now reports new shortness of breath. Which type of
assessment should the nurse prioritize?
A) Comprehensive head-to-toe assessment
B) Focused cardiopulmonary assessment
C) Routine medication reconciliation
D) Discharge planning assessment
Correct Answer: B
,Rationale: New respiratory symptoms after surgery warrant a focused cardiopulmonary assessment to
identify urgent problems such as atelectasis or pulmonary embolism .
4. The nurse is interviewing a 22-year-old patient who hesitates when asked about substance use. Which
approach best facilitates disclosure?
A) Skip the question to avoid discomfort
B) State confidentiality limits, use open-ended questions, and normalize the topic before asking again
C) Demand an immediate answer
D) Document "patient refuses to answer" and move on
Correct Answer: B
Rationale: Stating confidentiality limits, using open-ended questions, and normalizing the topic
encourage disclosure while respecting comfort. This is a core therapeutic interviewing technique .
5. Which activity is within the scope of practice for the registered nurse performing a health
assessment?
A) Prescribing medications based on assessment findings
B) Collecting subjective and objective data and documenting findings
C) Ordering diagnostic tests
D) Making a medical diagnosis
Correct Answer: B
Rationale: Registered nurses collect and document assessment data. Prescribing (A), ordering tests (C),
and medical diagnosis (D) are outside nursing scope of practice.
6. A nurse is assessing an 85-year-old patient who reports difficulty rising from a chair and has fallen
once at home. Which assessment should the nurse prioritize?
A) Functional assessment of activities of daily living
B) Nutritional assessment
C) Spiritual assessment D) Cultural assessment
Correct Answer: A
Rationale: Difficulty rising from a chair and a fall at home indicate a need for functional assessment and
fall-risk evaluation .
, 7. The nurse notices another clinician has entered a medication allergy incorrectly in the electronic
health record. What is the nurse's priority action?
A) Ignore it because it was another clinician's entry
B) Document the correct allergy in the notes section
C) Report the error according to facility policy and ensure the record is corrected
D) Discuss it with the patient only
Correct Answer: C
Rationale: Patient safety requires correcting documentation errors according to facility policy. This
addresses data integrity and legal considerations .
8. Which technique is most appropriate for building rapport during an initial health interview?
A) Using closed-ended questions exclusively
B) Open-ended questions and reflective listening
C) Interrupting to clarify details frequently
D) Focusing only on physical symptoms
Correct Answer: B
Rationale: Open-ended questions and reflective listening build rapport and reduce anxiety, improving
the accuracy of sensitive disclosures .
9. The nurse is preparing to conduct a health assessment for a patient from a different cultural
background. Which action demonstrates cultural competence?
A) Applying the nurse's own cultural norms to the assessment
B) Avoiding questions about cultural practices
C) Respecting the patient's cultural beliefs and adapting the assessment approach
D) Assuming the patient speaks English fluently
Correct Answer: C
Rationale: Cultural competence involves respecting the patient's beliefs and adapting the assessment to
meet cultural needs .
10. Which finding is an example of objective data?
A) Patient states, "I have a headache"
Section A: Multiple Choice Questions (1–50)
1. The nurse is performing a comprehensive health assessment on a newly admitted patient. Which
statement best describes the primary purpose of this assessment?
A) To identify the patient's medical diagnosis
B) To collect data to establish a baseline and identify patient needs
C) To determine the patient's insurance coverage
D) To evaluate the effectiveness of prescribed treatments
Correct Answer: B
Rationale: The purpose of health assessment is to collect subjective and objective data to establish a
baseline, identify patient needs, and inform nursing interventions. Medical diagnosis (A) is the provider's
role. Insurance coverage (C) is administrative. Evaluating treatment effectiveness (D) occurs later in the
process.
2. During an initial interview, a patient reports feeling dizzy. The nurse observes an unsteady gait and a
small abrasion on the patient's arm. Which statement correctly identifies the subjective and objective
data?
A) Both dizziness and unsteady gait are subjective
B) Dizziness is subjective; unsteady gait and abrasion are objective
C) The abrasion is subjective because the patient reported pain
D) The unsteady gait is subjective because it is an interpretation
Correct Answer: B
Rationale: Subjective data is what the patient reports (dizziness). Objective data is what the nurse
observes or measures (unsteady gait, abrasion). This combination supports fall-risk interventions .
3. A patient who had surgery two days ago now reports new shortness of breath. Which type of
assessment should the nurse prioritize?
A) Comprehensive head-to-toe assessment
B) Focused cardiopulmonary assessment
C) Routine medication reconciliation
D) Discharge planning assessment
Correct Answer: B
,Rationale: New respiratory symptoms after surgery warrant a focused cardiopulmonary assessment to
identify urgent problems such as atelectasis or pulmonary embolism .
4. The nurse is interviewing a 22-year-old patient who hesitates when asked about substance use. Which
approach best facilitates disclosure?
A) Skip the question to avoid discomfort
B) State confidentiality limits, use open-ended questions, and normalize the topic before asking again
C) Demand an immediate answer
D) Document "patient refuses to answer" and move on
Correct Answer: B
Rationale: Stating confidentiality limits, using open-ended questions, and normalizing the topic
encourage disclosure while respecting comfort. This is a core therapeutic interviewing technique .
5. Which activity is within the scope of practice for the registered nurse performing a health
assessment?
A) Prescribing medications based on assessment findings
B) Collecting subjective and objective data and documenting findings
C) Ordering diagnostic tests
D) Making a medical diagnosis
Correct Answer: B
Rationale: Registered nurses collect and document assessment data. Prescribing (A), ordering tests (C),
and medical diagnosis (D) are outside nursing scope of practice.
6. A nurse is assessing an 85-year-old patient who reports difficulty rising from a chair and has fallen
once at home. Which assessment should the nurse prioritize?
A) Functional assessment of activities of daily living
B) Nutritional assessment
C) Spiritual assessment D) Cultural assessment
Correct Answer: A
Rationale: Difficulty rising from a chair and a fall at home indicate a need for functional assessment and
fall-risk evaluation .
, 7. The nurse notices another clinician has entered a medication allergy incorrectly in the electronic
health record. What is the nurse's priority action?
A) Ignore it because it was another clinician's entry
B) Document the correct allergy in the notes section
C) Report the error according to facility policy and ensure the record is corrected
D) Discuss it with the patient only
Correct Answer: C
Rationale: Patient safety requires correcting documentation errors according to facility policy. This
addresses data integrity and legal considerations .
8. Which technique is most appropriate for building rapport during an initial health interview?
A) Using closed-ended questions exclusively
B) Open-ended questions and reflective listening
C) Interrupting to clarify details frequently
D) Focusing only on physical symptoms
Correct Answer: B
Rationale: Open-ended questions and reflective listening build rapport and reduce anxiety, improving
the accuracy of sensitive disclosures .
9. The nurse is preparing to conduct a health assessment for a patient from a different cultural
background. Which action demonstrates cultural competence?
A) Applying the nurse's own cultural norms to the assessment
B) Avoiding questions about cultural practices
C) Respecting the patient's cultural beliefs and adapting the assessment approach
D) Assuming the patient speaks English fluently
Correct Answer: C
Rationale: Cultural competence involves respecting the patient's beliefs and adapting the assessment to
meet cultural needs .
10. Which finding is an example of objective data?
A) Patient states, "I have a headache"
