NR-304 – Health Assessment Methods Covers
systematic health assessment techniques, physical
examination procedures, clinical data collection,
interpretation, and documentation standards.
1. During the general survey, the nurse notes a patient with a flat affect, slow
movements, and soft, monotone speech. This finding is most consistent with:
• A) Anxiety
• B) Parkinsonism or depression
• C) Hyperthyroidism
• D) Mania
Answer: B
Rationale: Parkinsonism and depression present with psychomotor retardation,
flat affect, and hypophonia (soft speech). Anxiety presents with restlessness;
hyperthyroidism with agitation; mania with pressured speech.
2. A patient's blood pressure is 162/94 mm Hg in the right arm. The nurse
should next:
• A) Document the finding as hypertensive urgency
• B) Recheck in the same arm after 5 minutes of rest
• C) Immediately notify the provider
• D) Check the left arm for comparison
Answer: D
Rationale: Compare both arms for a difference >10-15 mm Hg, which may
indicate aortic dissection or subclavian stenosis. Always check both arms at initial
assessment.
,3. The nurse assesses orthostatic blood pressure. Which finding is considered
positive for orthostatic hypotension?
• A) Heart rate increase of 10 bpm with no change in BP
• B) Systolic BP drop of 25 mm Hg with dizziness upon standing
• C) Diastolic BP increase of 5 mm Hg
• D) Systolic BP drop of 10 mm Hg without symptoms
Answer: B
Rationale: Orthostatic hypotension = drop in systolic BP ≥20 mm Hg (or
diastolic ≥10 mm Hg) with symptoms (dizziness, lightheadedness) within 3
minutes of standing.
4. The nurse is measuring body mass index (BMI) for a patient who is 5'4" tall
and weighs 160 lbs. The BMI is approximately:
• A) 22 (normal)
• B) 27 (overweight)
• C) 32 (obese class I)
• D) 18 (underweight)
Answer: B
Rationale: BMI = weight (kg) / height (m²). 5'4" = 1.63 m. 160 lbs ÷ 2.2 = 72.7 kg.
72.7 / (1.63² = 2.66) = 27.3 → overweight category (25-29.9).
5. A patient has a regular radial pulse but the nurse notes occasional pauses.
The nurse should next:
• A) Count the radial pulse for 60 seconds
• B) Auscultate the apical pulse for 60 seconds
• C) Document as "regularly irregular"
• D) Take the patient's blood pressure
,Answer: B
Rationale: Irregular rhythm requires apical auscultation for 60 seconds to detect
heart rate, rhythm, and possible pulse deficits (difference between apical and
radial).
6. The nurse assesses a patient's temperature using the tympanic route. Which
factor can falsely elevate the reading?
• A) Cerumen impaction
• B) Otitis externa (swimmer's ear)
• C) The patient was drinking hot coffee 5 minutes prior
• D) The patient is shivering
Answer: C
Rationale: Recent hot or cold oral intake can affect tympanic temperature if the
thermometer is placed in the ear on the same side as chewing. Cerumen may lower
reading, not elevate.
7. During the general survey, which finding is considered a "red flag"
requiring immediate attention?
• A) Patient wearing mismatched socks
• B) Acrocyanosis in a newborn
• C) Audible stridor at rest
• D) Mild dependent edema
Answer: C
Rationale: Stridor at rest indicates upper airway obstruction (e.g., croup,
epiglottitis, foreign body) – life-threatening. Acrocyanosis in newborn is normal.
Edema requires evaluation but not emergent.
8. A patient's pulse oximetry reads 91% on room air, but the patient is
comfortable and talking normally. The nurse should first:
, • A) Apply oxygen at 2 L/min
• B) Reposition the probe to a different finger
• C) Assess nail polish and capillary refill
• D) Draw an arterial blood gas
Answer: C
Rationale: Troubleshoot the equipment first – poor perfusion, nail polish, cold
fingers, or movement can cause false low reading. Assess patient clinically; if
asymptomatic, likely artifact.
9. The nurse is assessing a patient's respiratory pattern. Which finding is
characteristic of metabolic acidosis (Kussmaul breathing)?
• A) Prolonged expiration with wheezing
• B) Deep, rapid, labored breathing
• C) Irregular breathing with periods of apnea
• D) Shallow, slow breathing
Answer: B
Rationale: Kussmaul breathing – deep, rapid, labored (compensatory
hyperventilation) in metabolic acidosis (DKA, renal failure). Apnea = Cheyne-
Stokes. Wheezing = obstructive.
10. The nurse notes a pulse rate of 52 bpm in an athlete who is asymptomatic.
This finding is:
• A) Bradycardia requiring immediate notification
• B) Sinus bradycardia – normal variant in athletes
• C) First-degree heart block
• D) Junctional rhythm
Answer: B
Rationale: Sinus bradycardia (HR <60) in well-conditioned athletes is a normal
systematic health assessment techniques, physical
examination procedures, clinical data collection,
interpretation, and documentation standards.
1. During the general survey, the nurse notes a patient with a flat affect, slow
movements, and soft, monotone speech. This finding is most consistent with:
• A) Anxiety
• B) Parkinsonism or depression
• C) Hyperthyroidism
• D) Mania
Answer: B
Rationale: Parkinsonism and depression present with psychomotor retardation,
flat affect, and hypophonia (soft speech). Anxiety presents with restlessness;
hyperthyroidism with agitation; mania with pressured speech.
2. A patient's blood pressure is 162/94 mm Hg in the right arm. The nurse
should next:
• A) Document the finding as hypertensive urgency
• B) Recheck in the same arm after 5 minutes of rest
• C) Immediately notify the provider
• D) Check the left arm for comparison
Answer: D
Rationale: Compare both arms for a difference >10-15 mm Hg, which may
indicate aortic dissection or subclavian stenosis. Always check both arms at initial
assessment.
,3. The nurse assesses orthostatic blood pressure. Which finding is considered
positive for orthostatic hypotension?
• A) Heart rate increase of 10 bpm with no change in BP
• B) Systolic BP drop of 25 mm Hg with dizziness upon standing
• C) Diastolic BP increase of 5 mm Hg
• D) Systolic BP drop of 10 mm Hg without symptoms
Answer: B
Rationale: Orthostatic hypotension = drop in systolic BP ≥20 mm Hg (or
diastolic ≥10 mm Hg) with symptoms (dizziness, lightheadedness) within 3
minutes of standing.
4. The nurse is measuring body mass index (BMI) for a patient who is 5'4" tall
and weighs 160 lbs. The BMI is approximately:
• A) 22 (normal)
• B) 27 (overweight)
• C) 32 (obese class I)
• D) 18 (underweight)
Answer: B
Rationale: BMI = weight (kg) / height (m²). 5'4" = 1.63 m. 160 lbs ÷ 2.2 = 72.7 kg.
72.7 / (1.63² = 2.66) = 27.3 → overweight category (25-29.9).
5. A patient has a regular radial pulse but the nurse notes occasional pauses.
The nurse should next:
• A) Count the radial pulse for 60 seconds
• B) Auscultate the apical pulse for 60 seconds
• C) Document as "regularly irregular"
• D) Take the patient's blood pressure
,Answer: B
Rationale: Irregular rhythm requires apical auscultation for 60 seconds to detect
heart rate, rhythm, and possible pulse deficits (difference between apical and
radial).
6. The nurse assesses a patient's temperature using the tympanic route. Which
factor can falsely elevate the reading?
• A) Cerumen impaction
• B) Otitis externa (swimmer's ear)
• C) The patient was drinking hot coffee 5 minutes prior
• D) The patient is shivering
Answer: C
Rationale: Recent hot or cold oral intake can affect tympanic temperature if the
thermometer is placed in the ear on the same side as chewing. Cerumen may lower
reading, not elevate.
7. During the general survey, which finding is considered a "red flag"
requiring immediate attention?
• A) Patient wearing mismatched socks
• B) Acrocyanosis in a newborn
• C) Audible stridor at rest
• D) Mild dependent edema
Answer: C
Rationale: Stridor at rest indicates upper airway obstruction (e.g., croup,
epiglottitis, foreign body) – life-threatening. Acrocyanosis in newborn is normal.
Edema requires evaluation but not emergent.
8. A patient's pulse oximetry reads 91% on room air, but the patient is
comfortable and talking normally. The nurse should first:
, • A) Apply oxygen at 2 L/min
• B) Reposition the probe to a different finger
• C) Assess nail polish and capillary refill
• D) Draw an arterial blood gas
Answer: C
Rationale: Troubleshoot the equipment first – poor perfusion, nail polish, cold
fingers, or movement can cause false low reading. Assess patient clinically; if
asymptomatic, likely artifact.
9. The nurse is assessing a patient's respiratory pattern. Which finding is
characteristic of metabolic acidosis (Kussmaul breathing)?
• A) Prolonged expiration with wheezing
• B) Deep, rapid, labored breathing
• C) Irregular breathing with periods of apnea
• D) Shallow, slow breathing
Answer: B
Rationale: Kussmaul breathing – deep, rapid, labored (compensatory
hyperventilation) in metabolic acidosis (DKA, renal failure). Apnea = Cheyne-
Stokes. Wheezing = obstructive.
10. The nurse notes a pulse rate of 52 bpm in an athlete who is asymptomatic.
This finding is:
• A) Bradycardia requiring immediate notification
• B) Sinus bradycardia – normal variant in athletes
• C) First-degree heart block
• D) Junctional rhythm
Answer: B
Rationale: Sinus bradycardia (HR <60) in well-conditioned athletes is a normal
