NUR 2092/NUR2092 Exam 1 V1 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. Which phase of the nursing process involves the systematic collection of data about a
patient?
A. Planning
B. Evaluation
C. Implementation
D. Assessment
Answer: D
Rationale: Assessment is the first step of the nursing process and focuses on data
collection. It includes gathering subjective information from the patient and objective
information through physical examination. This step provides the foundation for
identifying nursing diagnoses and developing a plan of care.
2. During an interview, the nurse asks, ‘You mentioned you have been feeling tired. Tell me
more about that.’ This is an example of which communication technique?
A. Reflection
B. Clarification
C. Interpretation
,D. Facilitation
Answer: D
Rationale: Facilitation encourages the patient to say more and shows that the nurse is
interested. It helps provide a roadmap for the patient to expand on their feelings or
symptoms. Effective use of facilitation ensures a more comprehensive health history is
obtained.
3. Which of the following is considered objective data?
A. Patient reporting a headache
B. Patient stating they feel nauseous
C. A blood pressure reading of 140/90 mmHg
D. Patient complaining of back pain
Answer: C
Rationale: Objective data is what the health professional observes by inspecting, palpating,
percussing, and auscultating during the physical examination. It includes measurable data
such as vital signs, laboratory results, and physical findings. In contrast, subjective data is
what the person says about himself or herself during history taking.
4. When performing a physical assessment, what is the standard order of techniques for most
body systems?
A. Inspection, Palpation, Percussion, Auscultation
, B. Palpation, Inspection, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Rationale: The standard sequence for a physical assessment is inspection, palpation,
percussion, and then auscultation. Inspection always comes first to gather visual data
before touching the patient. The sequence only changes for the abdominal assessment to
avoid altering bowel sounds.
5. The nurse is assessing a patient’s radial pulse and notes it is irregular. What is the next
appropriate action?
A. Count the pulse for 15 seconds and multiply by four.
B. Count the pulse for a full 60 seconds.
C. Count the pulse for 30 seconds and multiply by two.
D. Document it as normal if the rate is between 60-100.
Answer: B
Rationale: If a pulse is irregular, the nurse must count for a full minute to ensure accuracy.
This allows for a better assessment of the rhythm and rate despite the irregularity.
Comparing the radial pulse to the apical pulse may also be necessary if a deficit is
suspected.
Assessment Q&A with Rationale |
Rasmussen University
1. Which phase of the nursing process involves the systematic collection of data about a
patient?
A. Planning
B. Evaluation
C. Implementation
D. Assessment
Answer: D
Rationale: Assessment is the first step of the nursing process and focuses on data
collection. It includes gathering subjective information from the patient and objective
information through physical examination. This step provides the foundation for
identifying nursing diagnoses and developing a plan of care.
2. During an interview, the nurse asks, ‘You mentioned you have been feeling tired. Tell me
more about that.’ This is an example of which communication technique?
A. Reflection
B. Clarification
C. Interpretation
,D. Facilitation
Answer: D
Rationale: Facilitation encourages the patient to say more and shows that the nurse is
interested. It helps provide a roadmap for the patient to expand on their feelings or
symptoms. Effective use of facilitation ensures a more comprehensive health history is
obtained.
3. Which of the following is considered objective data?
A. Patient reporting a headache
B. Patient stating they feel nauseous
C. A blood pressure reading of 140/90 mmHg
D. Patient complaining of back pain
Answer: C
Rationale: Objective data is what the health professional observes by inspecting, palpating,
percussing, and auscultating during the physical examination. It includes measurable data
such as vital signs, laboratory results, and physical findings. In contrast, subjective data is
what the person says about himself or herself during history taking.
4. When performing a physical assessment, what is the standard order of techniques for most
body systems?
A. Inspection, Palpation, Percussion, Auscultation
, B. Palpation, Inspection, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Answer: A
Rationale: The standard sequence for a physical assessment is inspection, palpation,
percussion, and then auscultation. Inspection always comes first to gather visual data
before touching the patient. The sequence only changes for the abdominal assessment to
avoid altering bowel sounds.
5. The nurse is assessing a patient’s radial pulse and notes it is irregular. What is the next
appropriate action?
A. Count the pulse for 15 seconds and multiply by four.
B. Count the pulse for a full 60 seconds.
C. Count the pulse for 30 seconds and multiply by two.
D. Document it as normal if the rate is between 60-100.
Answer: B
Rationale: If a pulse is irregular, the nurse must count for a full minute to ensure accuracy.
This allows for a better assessment of the rhythm and rate despite the irregularity.
Comparing the radial pulse to the apical pulse may also be necessary if a deficit is
suspected.
