Nursing Health Assessment
APEA Exam 2 Test Bank Q&A
(Exam Prep) 2026 A+ Study
Guide
The nurse is preparing to assess the remote memory of a
client who has a diagnosis of early stage Alzheimer's
disease. Which question would be most appropriate for
the nurse to use?
A) Can you tell me what you have eaten in the last 24
hours?
B) When did you get your first job?
C) What did you do last evening?
D) How are an apple and orange the same?
Correct Answer: B) When did you get your first job?
When assessing the mental status of a 67-year-old
woman, the nurse detects some difficulty with free-flow of
thought and the woman's ability to follow directions. Which
of the following would the nurse do first?
A) Use a geriatric depression scale
B) Refer for further medical evaluation
C) Assess the client's vision and hearing
D) Refer the client to social services for home assistance
Correct Answer: C) Assess the client's vision and hearing
The nurse utilizes the Depression Questionnaire on a
client who has recently moved to a long-term care facility.
The total score is 22. Which of the following would be
most appropriate for the nurse to do next?
A) Refer for further evaluation
B) Evaluate benefits vs risks of a mental health label
C) Assess further for dementia
1
,D) Document this as a normal score
Correct Answer: A) Refer for further evaluation
The nurse notes that an older adult client is wearing
multiple layers of clothing on a warm fall day. Which of the
following would be the nurse's priority assessment at this
time?
A) Asking whether the client often feels cold
B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene
Correct Answer: A) Asking whether the client often feels
cold
A nurse is working in a clinic in a low-income
neighborhood and assesses as female adult client who
states that she has a urinary tract infection. The nurse
notes that the client is unkempt, wearing stained clothing,
and has a strong body odor. The client mentions that she
was evicted from her apartment two weeks ago. Which
nursing diagnosis would the nurse most likely identify for
this client?
A) Caregiver role stain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficit fluid volume related to possible urinary tract
infection
D) Self-care deficit related to possible homelessness
Correct Answer: D) Self-care deficit related to possible
homelessness
When preparing to obtain information about a client's
mental and psychosocial status, which of the following
would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and
behaviors
B) Perform a neurologic examination to determine any
deficits
2
,C) Check the client's level of consciousness for changes
D) Explain the purpose of the exam and types of
questions
Correct Answer: D) Explain the purpose of the exam and
types of questions
A nursing student has been assigned to the care of a
client whose history suggests the need for mental status
assessment. This client most likely has a history of health
problems affecting what body system?
A) Respiratory
B) Neurologic
C) Cardiovascular
D) Renal
Correct Answer: B) Neurologic
The nurse begins the physical examination of newly
admitted client by assessing the client's mental status.
What is the nurse's best rationale for performing the
mental status exam early in the assessment?
A) The client will be less anxious early, providing the
nurse with more accurate and reliable data
B) The exam can provide clues about the validity of the
client's responses now and throughout
C) The exam provides data about mental health problems
that the client may be afraid to report
D) The client's fears about having a serious illness may be
alleviated by the results of the exam
Correct Answer: B) The exam can provide clues about the
validity of the client's responses now and throughout
A client's recent episode of becoming lost near his home
has prompted the nurse to use the Saint Louis University
Mental Status (SLUMS) Assessment Tool. The nurse
should begin this assessment by asking what question?
A) How would you respond if someone said that you might
have dementia?
3
, B)Can I ask you some questions about your memory?
C) Do you generally consider yourself to be an intelligent
person?
D) I want to ask you some questions to see if you have
Alzheimer's
Correct Answer: B) Can I ask you some questions about
your memory?
Assessment of a client who has suffered a recent stroke
reveals that he is unresponsive to all stimuli and his eyes
remain closed. The nurse documents the clients level of
consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy
Correct Answer: C) Coma
An emergency department nurse has utilized the
Confusion Assessment Method (CAM) in the assessment
of a 79 year old client with a new onset of urinary
incontinence. This assessment tool will allow the nurse to
confirm the presence of what health problem?
A) Delirium
B) Vascular dementia
C) Schizophrenia
D) Psychosis
Correct Answer: A) Delirium
The nurse is assessing a client using the Glasgow Coma
Scale following an acute hypoglycemic episode and
obtains a score of 14. The nurse interprets this as
indicating which of the following?
A) Deep coma
B) Coma
C) Obtunded
D) Alert and oriented
4
APEA Exam 2 Test Bank Q&A
(Exam Prep) 2026 A+ Study
Guide
The nurse is preparing to assess the remote memory of a
client who has a diagnosis of early stage Alzheimer's
disease. Which question would be most appropriate for
the nurse to use?
A) Can you tell me what you have eaten in the last 24
hours?
B) When did you get your first job?
C) What did you do last evening?
D) How are an apple and orange the same?
Correct Answer: B) When did you get your first job?
When assessing the mental status of a 67-year-old
woman, the nurse detects some difficulty with free-flow of
thought and the woman's ability to follow directions. Which
of the following would the nurse do first?
A) Use a geriatric depression scale
B) Refer for further medical evaluation
C) Assess the client's vision and hearing
D) Refer the client to social services for home assistance
Correct Answer: C) Assess the client's vision and hearing
The nurse utilizes the Depression Questionnaire on a
client who has recently moved to a long-term care facility.
The total score is 22. Which of the following would be
most appropriate for the nurse to do next?
A) Refer for further evaluation
B) Evaluate benefits vs risks of a mental health label
C) Assess further for dementia
1
,D) Document this as a normal score
Correct Answer: A) Refer for further evaluation
The nurse notes that an older adult client is wearing
multiple layers of clothing on a warm fall day. Which of the
following would be the nurse's priority assessment at this
time?
A) Asking whether the client often feels cold
B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene
Correct Answer: A) Asking whether the client often feels
cold
A nurse is working in a clinic in a low-income
neighborhood and assesses as female adult client who
states that she has a urinary tract infection. The nurse
notes that the client is unkempt, wearing stained clothing,
and has a strong body odor. The client mentions that she
was evicted from her apartment two weeks ago. Which
nursing diagnosis would the nurse most likely identify for
this client?
A) Caregiver role stain related to fatigue
B) Impaired skin integrity related to neurologic deficits
C) Deficit fluid volume related to possible urinary tract
infection
D) Self-care deficit related to possible homelessness
Correct Answer: D) Self-care deficit related to possible
homelessness
When preparing to obtain information about a client's
mental and psychosocial status, which of the following
would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and
behaviors
B) Perform a neurologic examination to determine any
deficits
2
,C) Check the client's level of consciousness for changes
D) Explain the purpose of the exam and types of
questions
Correct Answer: D) Explain the purpose of the exam and
types of questions
A nursing student has been assigned to the care of a
client whose history suggests the need for mental status
assessment. This client most likely has a history of health
problems affecting what body system?
A) Respiratory
B) Neurologic
C) Cardiovascular
D) Renal
Correct Answer: B) Neurologic
The nurse begins the physical examination of newly
admitted client by assessing the client's mental status.
What is the nurse's best rationale for performing the
mental status exam early in the assessment?
A) The client will be less anxious early, providing the
nurse with more accurate and reliable data
B) The exam can provide clues about the validity of the
client's responses now and throughout
C) The exam provides data about mental health problems
that the client may be afraid to report
D) The client's fears about having a serious illness may be
alleviated by the results of the exam
Correct Answer: B) The exam can provide clues about the
validity of the client's responses now and throughout
A client's recent episode of becoming lost near his home
has prompted the nurse to use the Saint Louis University
Mental Status (SLUMS) Assessment Tool. The nurse
should begin this assessment by asking what question?
A) How would you respond if someone said that you might
have dementia?
3
, B)Can I ask you some questions about your memory?
C) Do you generally consider yourself to be an intelligent
person?
D) I want to ask you some questions to see if you have
Alzheimer's
Correct Answer: B) Can I ask you some questions about
your memory?
Assessment of a client who has suffered a recent stroke
reveals that he is unresponsive to all stimuli and his eyes
remain closed. The nurse documents the clients level of
consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy
Correct Answer: C) Coma
An emergency department nurse has utilized the
Confusion Assessment Method (CAM) in the assessment
of a 79 year old client with a new onset of urinary
incontinence. This assessment tool will allow the nurse to
confirm the presence of what health problem?
A) Delirium
B) Vascular dementia
C) Schizophrenia
D) Psychosis
Correct Answer: A) Delirium
The nurse is assessing a client using the Glasgow Coma
Scale following an acute hypoglycemic episode and
obtains a score of 14. The nurse interprets this as
indicating which of the following?
A) Deep coma
B) Coma
C) Obtunded
D) Alert and oriented
4
