NR-222 – Health Assessment Comprehensive nursing
course focusing on patient history collection, physical
examination techniques, health screening methods,
documentation, and clinical assessment skills.
1. A nurse is conducting a health history interview. Which client statement
would necessitate the nurse to stop the interview and address the concern
immediately?
A. "I've been feeling tired lately, but I think it's just stress."
B. "Sometimes I hear voices telling me to hurt myself."
C. "My grandmother had breast cancer when she was 60."
D. "I don't really like the food here, it's too salty."
Correct Answer: B
Rationale: Safety is the priority in any assessment. Statements indicating suicidal
or homicidal ideation (command hallucinations to hurt self) require immediate
intervention and safety planning. Options A, C, and D are important but not
immediate safety threats.
2. A nurse documents, “Client is anxious and states, ‘My chest feels tight.’
Respirations 22/min, heart rate 98 bpm.” This is an example of which type of
data?
A. Objective data only
B. Subjective data only
C. Both subjective and objective data
D. Inferential data
Correct Answer: C
Rationale: Subjective data are the client’s words (“My chest feels tight”).
Objective data are what the nurse measures/observes (respirations 22/min, heart
rate 98 bpm, anxious demeanor). Inferential data would be a conclusion (e.g.,
“client is having a heart attack”).
3. Which interview technique is most effective for obtaining a detailed
description of a client’s pain?
A. "Does the pain radiate to your arm?"
B. "Rate your pain on a scale of 0 to 10."
,C. "Tell me about the pain you are experiencing."
D. "Is the pain sharp or dull?"
Correct Answer: C
Rationale: An open-ended question (“Tell me about…”) encourages the client to
elaborate and provide a full narrative. Options A, B, and D are closed-ended or
leading questions that limit the response to specific details.
4. A nurse is assessing a client’s functional health. Which question best
addresses activities of daily living (ADLs)?
A. "Do you have a history of heart disease?"
B. "How do you usually manage your finances?"
C. "Who helps you with bathing and dressing?"
D. "What medications are you currently taking?"
Correct Answer: C
Rationale: ADLs include basic self-care tasks such as bathing, dressing, toileting,
and eating. Managing finances is an instrumental ADL (IADL), not basic ADL.
Medical history and medications are part of the past medical history, not functional
assessment.
5. During a health history, the client reports a rash but denies itching or pain.
The nurse should document this finding as:
A. A symptom
B. A sign
C. A syndrome
D. A risk factor
Correct Answer: B
Rationale: A sign is an objective finding observed or detected by the examiner
(the nurse sees the rash). A symptom is a subjective sensation reported by the
client (pain, itching). Since the client denies sensation but the nurse can see the
rash, it is a sign.
6. A client tells the nurse, “I don’t want to take my blood pressure medicine
because it makes me dizzy.” What is the nurse’s best response?
A. "You must take it or you'll have a stroke."
B. "Tell me more about the dizziness and when it happens."
C. "That's a common side effect, just ignore it."
D. "Let's stop the medication immediately."
Correct Answer: B
,Rationale: The nurse should use therapeutic communication to explore the client’s
concern (non-adherence due to side effects). This allows for problem-solving (e.g.,
timing of dose, consulting provider). Option A is threatening, C dismisses the
client, and D is outside nursing scope without an order.
7. Which part of the health history is best for identifying a client’s potential
genetic risks?
A. Chief complaint
B. History of present illness
C. Past medical history
D. Family history
Correct Answer: D
Rationale: Family history documents health conditions of blood relatives,
revealing patterns of inherited diseases (e.g., breast cancer, hypertension, diabetes).
Past medical history is the client’s own conditions, not genetic risk.
8. A nurse asks, “What happened right before your chest pain started?” This
question is exploring which component of the mnemonic OLD CARTS?
A. Onset
B. Location
C. Duration
D. Timing
Correct Answer: A
Rationale: OLD CARTS stands for Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing, and Severity. Asking “what
happened right before” seeks the Onset – what the client was doing or what
triggered the symptom.
9. A client who speaks limited English is being interviewed. A family member
offers to translate. The nurse should:
A. Proceed with the family member translating as it is efficient.
B. Use a certified medical interpreter per facility policy.
C. Speak loudly and slowly to the client in English.
D. Only use gestures and pictures to communicate.
Correct Answer: B
Rationale: Using a certified medical interpreter ensures accuracy, confidentiality,
and reduces bias. Family members may omit, alter, or filter information, and
, cannot maintain professional boundaries. Speaking loudly does not improve
comprehension.
10. The nurse assesses a client’s spiritual health. Which question is most
appropriate?
A. "What gives your life meaning and purpose?"
B. "Do you go to church every Sunday?"
C. "Are you a Christian or something else?"
D. "You believe in God, don't you?"
Correct Answer: A
Rationale: Spiritual assessment is open-ended and non-judgmental, focusing on
sources of meaning, hope, and connection. Options B, C, and D are leading,
assumptive, or culturally insensitive.
11. A client reports smoking one pack of cigarettes per day for 20 years. The
nurse correctly documents this as:
A. 20 pack-years
B. 1 pack-year
C. 20 pack-months
D. 40 pack-years
Correct Answer: A
Rationale: Pack-years are calculated as (packs per day) × (years smoked). 1
pack/day × 20 years = 20 pack-years.
12. During a review of systems (ROS), the nurse asks, “Do you have any
problems with your heart or blood pressure?” The client says no. Later, the
nurse auscultates an irregular rhythm. This indicates:
A. The client intentionally lied.
B. The ROS should have been more specific.
C. The nurse should ignore the finding.
D. The client has dementia.
Correct Answer: B
Rationale: The ROS uses specific, closed-ended questions to screen for problems
the client may not report spontaneously. Asking “any problems” often yields a
negative answer. A better question: “Have you ever been told you have a heart
murmur or irregular heartbeat?”
13. A nurse notes that a client avoids eye contact during the interview. The
nurse’s best action is to:
course focusing on patient history collection, physical
examination techniques, health screening methods,
documentation, and clinical assessment skills.
1. A nurse is conducting a health history interview. Which client statement
would necessitate the nurse to stop the interview and address the concern
immediately?
A. "I've been feeling tired lately, but I think it's just stress."
B. "Sometimes I hear voices telling me to hurt myself."
C. "My grandmother had breast cancer when she was 60."
D. "I don't really like the food here, it's too salty."
Correct Answer: B
Rationale: Safety is the priority in any assessment. Statements indicating suicidal
or homicidal ideation (command hallucinations to hurt self) require immediate
intervention and safety planning. Options A, C, and D are important but not
immediate safety threats.
2. A nurse documents, “Client is anxious and states, ‘My chest feels tight.’
Respirations 22/min, heart rate 98 bpm.” This is an example of which type of
data?
A. Objective data only
B. Subjective data only
C. Both subjective and objective data
D. Inferential data
Correct Answer: C
Rationale: Subjective data are the client’s words (“My chest feels tight”).
Objective data are what the nurse measures/observes (respirations 22/min, heart
rate 98 bpm, anxious demeanor). Inferential data would be a conclusion (e.g.,
“client is having a heart attack”).
3. Which interview technique is most effective for obtaining a detailed
description of a client’s pain?
A. "Does the pain radiate to your arm?"
B. "Rate your pain on a scale of 0 to 10."
,C. "Tell me about the pain you are experiencing."
D. "Is the pain sharp or dull?"
Correct Answer: C
Rationale: An open-ended question (“Tell me about…”) encourages the client to
elaborate and provide a full narrative. Options A, B, and D are closed-ended or
leading questions that limit the response to specific details.
4. A nurse is assessing a client’s functional health. Which question best
addresses activities of daily living (ADLs)?
A. "Do you have a history of heart disease?"
B. "How do you usually manage your finances?"
C. "Who helps you with bathing and dressing?"
D. "What medications are you currently taking?"
Correct Answer: C
Rationale: ADLs include basic self-care tasks such as bathing, dressing, toileting,
and eating. Managing finances is an instrumental ADL (IADL), not basic ADL.
Medical history and medications are part of the past medical history, not functional
assessment.
5. During a health history, the client reports a rash but denies itching or pain.
The nurse should document this finding as:
A. A symptom
B. A sign
C. A syndrome
D. A risk factor
Correct Answer: B
Rationale: A sign is an objective finding observed or detected by the examiner
(the nurse sees the rash). A symptom is a subjective sensation reported by the
client (pain, itching). Since the client denies sensation but the nurse can see the
rash, it is a sign.
6. A client tells the nurse, “I don’t want to take my blood pressure medicine
because it makes me dizzy.” What is the nurse’s best response?
A. "You must take it or you'll have a stroke."
B. "Tell me more about the dizziness and when it happens."
C. "That's a common side effect, just ignore it."
D. "Let's stop the medication immediately."
Correct Answer: B
,Rationale: The nurse should use therapeutic communication to explore the client’s
concern (non-adherence due to side effects). This allows for problem-solving (e.g.,
timing of dose, consulting provider). Option A is threatening, C dismisses the
client, and D is outside nursing scope without an order.
7. Which part of the health history is best for identifying a client’s potential
genetic risks?
A. Chief complaint
B. History of present illness
C. Past medical history
D. Family history
Correct Answer: D
Rationale: Family history documents health conditions of blood relatives,
revealing patterns of inherited diseases (e.g., breast cancer, hypertension, diabetes).
Past medical history is the client’s own conditions, not genetic risk.
8. A nurse asks, “What happened right before your chest pain started?” This
question is exploring which component of the mnemonic OLD CARTS?
A. Onset
B. Location
C. Duration
D. Timing
Correct Answer: A
Rationale: OLD CARTS stands for Onset, Location, Duration, Character,
Aggravating factors, Relieving factors, Timing, and Severity. Asking “what
happened right before” seeks the Onset – what the client was doing or what
triggered the symptom.
9. A client who speaks limited English is being interviewed. A family member
offers to translate. The nurse should:
A. Proceed with the family member translating as it is efficient.
B. Use a certified medical interpreter per facility policy.
C. Speak loudly and slowly to the client in English.
D. Only use gestures and pictures to communicate.
Correct Answer: B
Rationale: Using a certified medical interpreter ensures accuracy, confidentiality,
and reduces bias. Family members may omit, alter, or filter information, and
, cannot maintain professional boundaries. Speaking loudly does not improve
comprehension.
10. The nurse assesses a client’s spiritual health. Which question is most
appropriate?
A. "What gives your life meaning and purpose?"
B. "Do you go to church every Sunday?"
C. "Are you a Christian or something else?"
D. "You believe in God, don't you?"
Correct Answer: A
Rationale: Spiritual assessment is open-ended and non-judgmental, focusing on
sources of meaning, hope, and connection. Options B, C, and D are leading,
assumptive, or culturally insensitive.
11. A client reports smoking one pack of cigarettes per day for 20 years. The
nurse correctly documents this as:
A. 20 pack-years
B. 1 pack-year
C. 20 pack-months
D. 40 pack-years
Correct Answer: A
Rationale: Pack-years are calculated as (packs per day) × (years smoked). 1
pack/day × 20 years = 20 pack-years.
12. During a review of systems (ROS), the nurse asks, “Do you have any
problems with your heart or blood pressure?” The client says no. Later, the
nurse auscultates an irregular rhythm. This indicates:
A. The client intentionally lied.
B. The ROS should have been more specific.
C. The nurse should ignore the finding.
D. The client has dementia.
Correct Answer: B
Rationale: The ROS uses specific, closed-ended questions to screen for problems
the client may not report spontaneously. Asking “any problems” often yields a
negative answer. A better question: “Have you ever been told you have a heart
murmur or irregular heartbeat?”
13. A nurse notes that a client avoids eye contact during the interview. The
nurse’s best action is to:
