NSG3160 Assessment 1 (Health Assessment) Review
Latest Update
Priority Setting & Critical Thinking
Q1: A patient admitted with asthma has the following problems: A. Ineffective self-health
management B. Impaired gas exchange C. Readiness for enhanced spiritual well-being
D. Risk for infection
Answer: B. Impaired gas exchange
Rationale: First-level priority problems are those that threaten life (airway, breathing,
circulation). Impaired gas exchange directly affects oxygenation, making it the most
urgent concern.
Types of Databases
Q2: Which type of database is most appropriate for a patient admitted to long-term
care? A. Emergency database B. Complete database C. Focused/problem-centered
database D. Follow-up database
Answer: B. Complete database
Rationale: A complete database provides a full health history and physical exam,
essential for baseline care in long-term settings.
Subjective vs Objective Data
Q3: Which of the following is subjective data? A. Alert and oriented x3 B. Pain rated
7/10 C. Skin warm to touch D. Respiratory rate 22
Answer: B. Pain rated 7/10
Rationale: Subjective data comes from the patient’s perspective (symptoms, feelings).
Objective data is observable and measurable (vital signs, exam findings).
Palpation Techniques
Q4: Which part of the hand is best used to assess vibration? A. Fingertips B. Dorsum of
hand C. Base of fingers D. Palm
Answer: C. Base of fingers
, Rationale: The base of fingers (metacarpophalangeal joints) is most sensitive to
vibrations, while fingertips detect fine texture and dorsum detects temperature.
Family Medical History
Q5: Why is collecting family medical history important in health assessments? A. It
identifies communicable diseases only B. It highlights genetic and lifestyle risks C. It
reduces interview time D. It is optional unless patient requests
Answer: B. It highlights genetic and lifestyle risks
Rationale: Family history reveals predispositions to conditions like hypertension,
diabetes, cancer, and cardiovascular disease, guiding preventive care and early
screening.
Communication & Interpreters
Q6: What is the benefit of using trained medical interpreters in healthcare? A. Faster
interviews B. Lower admission rates and improved outcomes C. Reduced need for
documentation D. Avoids cultural sensitivity issues
Answer: B. Lower admission rates and improved outcomes
Rationale: Trained interpreters ensure accurate communication, leading to better
preventive care, improved satisfaction, and reduced errors compared to untrained
interpreters.
Abuse Assessment
Q7: Which finding may indicate elder abuse? A. Multiple bruises in various healing
stages B. Patient reports occasional dizziness C. Mild forgetfulness D. Controlled
hypertension
Answer: A. Multiple bruises in various healing stages
Rationale: Bruises at different stages of healing are a red flag for physical abuse.
Nurses must assess for safety and report suspected abuse.
Physical Assessment Techniques
Q8: Which assessment technique is always performed first in a physical exam? A.
Palpation B. Inspection C. Percussion D. Auscultation
Answer: B. Inspection
,Rationale: Inspection begins every exam because it requires no physical contact and
provides baseline observations before other techniques alter findings.
Developmental Considerations
Q9: When assessing an older adult, which change is expected? A. Increased skin
elasticity B. Decreased lung expansion C. Increased muscle strength D. Faster reflexes
Answer: B. Decreased lung expansion
Rationale: Aging reduces chest wall compliance and respiratory muscle strength,
leading to decreased expansion.
Vital Signs
Q10: Which vital sign change is most concerning in a patient with sepsis? A.
Temperature 100.4°F B. Heart rate 110 bpm C. Respiratory rate 28/min D. Blood
pressure 88/50 mmHg
Answer: D. Blood pressure 88/50 mmHg
Rationale: Hypotension indicates septic shock and poor perfusion, requiring immediate
intervention.
Interview Techniques
Q11: Which statement demonstrates the use of an open-ended question? A. “Are you
having pain?” B. “Does your pain feel sharp?” C. “Tell me how your pain feels.” D. “Is
your pain worse at night?”
Answer: C. “Tell me how your pain feels.”
Rationale: Open-ended questions encourage detailed responses, while closed-ended
questions limit answers to yes/no.
Cultural Competence
Q12: A nurse caring for a patient from a different culture should: A. Assume the
patient’s beliefs are similar to others from that culture B. Avoid discussing cultural
practices C. Ask the patient to describe their health beliefs and practices D. Rely on
family members for interpretation
Answer: C. Ask the patient to describe their health beliefs and practices
Rationale: Individual variation exists within cultures; direct communication ensures
respectful, patient-centered care.
, Pain Assessment
Q13: Which tool is most appropriate for assessing pain in a nonverbal patient with
dementia? A. Numeric rating scale B. Visual analog scale C. FLACC scale D. Verbal
descriptor scale
Answer: C. FLACC scale
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for
nonverbal populations, including dementia patients.
General Survey
Q14: During the general survey, the nurse primarily assesses: A. Detailed cardiac
function B. Overall physical appearance and behavior C. Neurological reflexes D. Skin
turgor
Answer: B. Overall physical appearance and behavior
Rationale: The general survey provides a first impression of health status, including
posture, mobility, hygiene, and affect.
Growth & Development
Q15: Which developmental stage is characterized by identity vs. role confusion?
• A. Infancy
• B. Adolescence
• C. Middle adulthood
• D. Late adulthood
Answer: B. Adolescence
Rationale: Erikson’s psychosocial theory identifies adolescence as the stage where
individuals form identity or struggle with role confusion.
Respiratory Assessment
Q16: Which finding is abnormal during lung auscultation?
• A. Vesicular sounds over peripheral lung fields
• B. Bronchial sounds over trachea
• C. Crackles at lung bases
• D. Bronchovesicular sounds near sternum
Answer: C. Crackles at lung bases
Latest Update
Priority Setting & Critical Thinking
Q1: A patient admitted with asthma has the following problems: A. Ineffective self-health
management B. Impaired gas exchange C. Readiness for enhanced spiritual well-being
D. Risk for infection
Answer: B. Impaired gas exchange
Rationale: First-level priority problems are those that threaten life (airway, breathing,
circulation). Impaired gas exchange directly affects oxygenation, making it the most
urgent concern.
Types of Databases
Q2: Which type of database is most appropriate for a patient admitted to long-term
care? A. Emergency database B. Complete database C. Focused/problem-centered
database D. Follow-up database
Answer: B. Complete database
Rationale: A complete database provides a full health history and physical exam,
essential for baseline care in long-term settings.
Subjective vs Objective Data
Q3: Which of the following is subjective data? A. Alert and oriented x3 B. Pain rated
7/10 C. Skin warm to touch D. Respiratory rate 22
Answer: B. Pain rated 7/10
Rationale: Subjective data comes from the patient’s perspective (symptoms, feelings).
Objective data is observable and measurable (vital signs, exam findings).
Palpation Techniques
Q4: Which part of the hand is best used to assess vibration? A. Fingertips B. Dorsum of
hand C. Base of fingers D. Palm
Answer: C. Base of fingers
, Rationale: The base of fingers (metacarpophalangeal joints) is most sensitive to
vibrations, while fingertips detect fine texture and dorsum detects temperature.
Family Medical History
Q5: Why is collecting family medical history important in health assessments? A. It
identifies communicable diseases only B. It highlights genetic and lifestyle risks C. It
reduces interview time D. It is optional unless patient requests
Answer: B. It highlights genetic and lifestyle risks
Rationale: Family history reveals predispositions to conditions like hypertension,
diabetes, cancer, and cardiovascular disease, guiding preventive care and early
screening.
Communication & Interpreters
Q6: What is the benefit of using trained medical interpreters in healthcare? A. Faster
interviews B. Lower admission rates and improved outcomes C. Reduced need for
documentation D. Avoids cultural sensitivity issues
Answer: B. Lower admission rates and improved outcomes
Rationale: Trained interpreters ensure accurate communication, leading to better
preventive care, improved satisfaction, and reduced errors compared to untrained
interpreters.
Abuse Assessment
Q7: Which finding may indicate elder abuse? A. Multiple bruises in various healing
stages B. Patient reports occasional dizziness C. Mild forgetfulness D. Controlled
hypertension
Answer: A. Multiple bruises in various healing stages
Rationale: Bruises at different stages of healing are a red flag for physical abuse.
Nurses must assess for safety and report suspected abuse.
Physical Assessment Techniques
Q8: Which assessment technique is always performed first in a physical exam? A.
Palpation B. Inspection C. Percussion D. Auscultation
Answer: B. Inspection
,Rationale: Inspection begins every exam because it requires no physical contact and
provides baseline observations before other techniques alter findings.
Developmental Considerations
Q9: When assessing an older adult, which change is expected? A. Increased skin
elasticity B. Decreased lung expansion C. Increased muscle strength D. Faster reflexes
Answer: B. Decreased lung expansion
Rationale: Aging reduces chest wall compliance and respiratory muscle strength,
leading to decreased expansion.
Vital Signs
Q10: Which vital sign change is most concerning in a patient with sepsis? A.
Temperature 100.4°F B. Heart rate 110 bpm C. Respiratory rate 28/min D. Blood
pressure 88/50 mmHg
Answer: D. Blood pressure 88/50 mmHg
Rationale: Hypotension indicates septic shock and poor perfusion, requiring immediate
intervention.
Interview Techniques
Q11: Which statement demonstrates the use of an open-ended question? A. “Are you
having pain?” B. “Does your pain feel sharp?” C. “Tell me how your pain feels.” D. “Is
your pain worse at night?”
Answer: C. “Tell me how your pain feels.”
Rationale: Open-ended questions encourage detailed responses, while closed-ended
questions limit answers to yes/no.
Cultural Competence
Q12: A nurse caring for a patient from a different culture should: A. Assume the
patient’s beliefs are similar to others from that culture B. Avoid discussing cultural
practices C. Ask the patient to describe their health beliefs and practices D. Rely on
family members for interpretation
Answer: C. Ask the patient to describe their health beliefs and practices
Rationale: Individual variation exists within cultures; direct communication ensures
respectful, patient-centered care.
, Pain Assessment
Q13: Which tool is most appropriate for assessing pain in a nonverbal patient with
dementia? A. Numeric rating scale B. Visual analog scale C. FLACC scale D. Verbal
descriptor scale
Answer: C. FLACC scale
Rationale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is validated for
nonverbal populations, including dementia patients.
General Survey
Q14: During the general survey, the nurse primarily assesses: A. Detailed cardiac
function B. Overall physical appearance and behavior C. Neurological reflexes D. Skin
turgor
Answer: B. Overall physical appearance and behavior
Rationale: The general survey provides a first impression of health status, including
posture, mobility, hygiene, and affect.
Growth & Development
Q15: Which developmental stage is characterized by identity vs. role confusion?
• A. Infancy
• B. Adolescence
• C. Middle adulthood
• D. Late adulthood
Answer: B. Adolescence
Rationale: Erikson’s psychosocial theory identifies adolescence as the stage where
individuals form identity or struggle with role confusion.
Respiratory Assessment
Q16: Which finding is abnormal during lung auscultation?
• A. Vesicular sounds over peripheral lung fields
• B. Bronchial sounds over trachea
• C. Crackles at lung bases
• D. Bronchovesicular sounds near sternum
Answer: C. Crackles at lung bases
