Health Assessment

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Sample questions from Health Assessment

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client arrives in the emergency department with sudden shortness of breath. Respirations are 30/min, pulse is 118/min, blood pressure is 146/88 mm Hg, and oxygen saturation is 86% on room air. The client can speak only two words at a time. Which assessment finding requires the most immediate intervention?

   • A.Bilateral ankle edema rated 2+
   • B.Inability to speak in full sentences
   • C.A productive cough for 3 days
   • D.A history of smoking for 40 years

   Rationale: Inability to speak in full sentences with hypoxemia and tachypnea indicates severe respiratory compromise requiring immediate support. Ankle edema may indicate fluid overload but is less immediately threatening than impaired oxygenation. Cough duration and smoking history help identify the cause but should not delay stabilization. Prioritize current airway and breathing threats over historical or chronic findings.

2. 2.A 74-year-old client in a long-term care facility reports dizziness when standing. After 5 minutes supine, blood pressure is 138/76 mm Hg and pulse is 72/min; after standing for 1 minute, blood pressure is 112/64 mm Hg and pulse is 92/min. What is the nurse's best action?

   • A.Encourage the client to walk while the dizziness resolves
   • B.Repeat the standing measurement after the client walks
   • C.Assist the client to sit or lie down and assess contributing factors
   • D.Document the changes as expected findings of aging

   Rationale: The blood pressure decrease meets criteria for orthostatic hypotension, and dizziness creates an immediate fall risk. Walking or continuing upright assessment while symptomatic increases the risk of injury. Although orthostatic hypotension is more common in older adults, it is not a finding to dismiss as normal aging. Protect the client first, then evaluate medications, hydration, and other causes.

3. 3.A 52-year-old client in an outpatient clinic has an initial blood pressure of 168/94 mm Hg measured immediately after climbing stairs. The client denies headache, chest pain, or dyspnea. Which action best improves the accuracy of the repeat measurement?

   • A.Allow 5 minutes of seated rest and measure with the arm supported at heart level
   • B.Use a smaller cuff to obtain a more distinct reading
   • C.Measure with the client's legs crossed for comfort
   • D.Ask the client to hold the arm unsupported at shoulder height

   Rationale: Seated rest, proper positioning, and an appropriately sized cuff reduce measurement error. A cuff that is too small can falsely elevate the reading. Crossed legs and an unsupported arm can also increase measured blood pressure. Verify technique before interpreting an isolated elevated reading in an asymptomatic client.

4. 4.A 61-year-old client recovering from abdominal surgery rates incisional pain as 8/10 while smiling and talking with visitors. Pulse is 84/min, respirations are 18/min, and blood pressure is 128/76 mm Hg. Which response is most appropriate?

   • A.Record mild pain because the client appears comfortable
   • B.Delay further assessment until the visitors leave
   • C.Use the normal vital signs to explain that severe pain is unlikely
   • D.Accept the report and assess pain characteristics, function, and treatment preferences

   Answer and rationale are in the full material.

5. 5.A 70-year-old client in the emergency department developed right arm weakness and slurred speech 40 minutes ago. Blood pressure is 178/96 mm Hg, pulse is 88/min, and oxygen saturation is 96% on room air. The stroke response team has been activated. Which bedside assessment should the nurse obtain immediately?

   • A.A detailed dietary history
   • B.A capillary blood glucose level
   • C.An orthostatic blood pressure series
   • D.A formal swallowing assessment using water

   Answer and rationale are in the full material.