Health Assessment MCQs

Questions and Answers

1. The nurse is assessing a client's smoking behaviour. During the interview, the nurse learns
that the client wants to stop smoking but needs help with this behaviour change. Which
nursing theory would best support the care this client needs?
A. Health promotion model
B. Ecologic model
C. Clinical model
D. Eudemonistic model

Correct Answer
A. Health promotion model
Explanation
The Health Promotion Model would best support the care this client needs because it focuses
on empowering individuals to take control of their own health behaviours and make positive
changes. This model emphasizes the importance of self-efficacy, or the belief in one's ability
to successfully change behaviour, which aligns with the client's desire to quit smoking but
needing help to do so. By using this model, the nurse can provide the client with resources,
support, and strategies to assist in their smoking cessation journey.
2. After completing the health history, the nurse begins to ask more detailed questions to
clarify points and follow up on concerns expressed by the client during the interview. This
portion of the health assessment is:
A. Informal teaching
B. Objective data
C. Focused interview
D. Interpretation of findings
Correct Answer
C. Focused interview
A focused interview is the portion of the health assessment where the nurse asks more
detailed questions to clarify points and follow up on concerns expressed by the client during
the interview. This allows the nurse to gather more specific information and gain a deeper
understanding of the client's health history and concerns. It helps the nurse to focus on
specific areas of the client's health and gather objective data to further assess and interpret the
findings.
3. During the health assessment, the nurse reviews the client's laboratory data. This is an
example of:
A. Constant data
B. A primary source of information
C. Subjective data
D. A secondary source of information
Correct Answer
D. A secondary source of information
Laboratory data is considered a secondary source of information. Other secondary sources
include charts, reports from diagnostic testing, and information from family and other
members of the health team.
Constant data is information that does not change over time, such as race, gender, or blood
type.
The primary source of information is the client.
Subjective data is information obtained from the client during the health history.
4. After conducting the health interview, the nurse begins to measure the client's vital signs.
The nurse is collecting:
A. Subjective data
B. Objective data
C. Secondary data
D. Constant data
Correct Answer
B. Objective data
Explanation
In this scenario, the nurse is measuring the client's vital signs, which are measurable and
observable data such as blood pressure, heart rate, temperature, and respiratory rate. These
vital signs can be collected through direct observation or by using medical instruments.
Therefore, the nurse is collecting objective data, which refers to factual and measurable
information that does not depend on personal opinions or interpretations.

5. The nurse is documenting the findings from a health assessment. Which of the following
demonstrates the documentation of subjective information?
A. "It hurts when I put weight on my leg."
B. Abdomen soft and nontender to palpation
C. Blood pressure 110/68
D. "Pulses present in lower extremities"
Correct Answer
A. "It hurts when I put weight on my leg."
The correct answer demonstrates the documentation of subjective information because it is a
statement made by the patient about their own experience or perception of pain. Subjective
information is based on personal feelings, beliefs, and opinions, and cannot be measured or
observed by others. In contrast, the other options in the question are objective findings that
can be measured, observed, or assessed by the nurse.
6. The nurse begins to document approximately three hours after completing the health, and
physical assessment of a client admitted with acute right lower quadrant abdominal pain.
Which of the following might be true about this documentation?

A. It will be highly accurate because the nurse has had more time to interact with the
client.
B. It may not be as detailed due to the time that has elapsed since the assessment.
C. It will be focused and concise.
D. It will be thorough and complete.
Correct Answer
B. It may not be as detailed due to the time that has elapsed since the assessment.
Documentation of data collected in a health assessment should be completed as soon as
possible. With the delay of three hours, there is a chance that the information will not be
highly accurate, focused, concise, thorough, or complete. Ideally, the nurse should document
sooner than three hours after the assessment.
7. After completing a health assessment, the nurse documents the findings on a flow sheet
with checkmarks and short notations. The type of documentation this nurse is using is most
likely:
A. Narrative
B. SOAP
C. APIE
D. Charting by exception
Correct Answer
D. Charting by exception
The nurse is most likely using charting by exception as a type of documentation. This method
involves only documenting significant findings or exceptions to the normal assessment, rather
than documenting every detail. It is often represented by checkmarks and short notations on a
flow sheet. This approach allows for more efficient and streamlined documentation, as it
focuses on deviations from the expected rather than repetitive normal findings.
8. During the health interview, the client mentioned that she is "very stressed about her home
situation." The nurse sees this information as impacting the client's level of pain control.
Which approach is the nurse using during the health interview?
A. Cultural
B. Holistic
 C. Developmental
D. Communication
Correct Answer
B. Holistic
The nurse is considering more than the physiologic health status of the client. Holism
includes all factors that impact the client's physical and emotional well-being.
There is no information in the question that links the client's culture and home situation with
pain.
The developmental level has an impact on health assessment. However, there is no
information in the question that links the client's developmental level and home situation with
pain.
Communication refers to the exchange of information.
9. During a health interview, the client states that she becomes increasingly short of breath
when sitting in city traffic. The nurse views this information as:
A. A cultural factor
B. An internal environmental factor
C. An external environmental factor
D. An emotional factor
Correct Answer
C. An external environmental factor
The client's statement about becoming short of breath when sitting in city traffic indicates
that the external environment, specifically the air quality in the city, is affecting her
breathing. This is supported by the fact that she experiences this symptom only when sitting
in city traffic, suggesting that it is not related to her cultural background, internal body
functions, or emotions.

10. The nurse is looking at the information collected during the health interview in an effort
to cluster or group the data together. The nurse is demonstrating which phase of the nursing
process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer
B. Diagnosis
The nurse is demonstrating the diagnosis phase of the nursing process. This phase involves
analyzing and clustering the data collected during the health interview to identify patterns,
problems, and potential nursing diagnoses. By grouping the data together, the nurse can
identify commonalities and make connections to formulate a diagnosis and develop a plan of
care.
11. The nurse is phoning the physical therapy department to alter a client's scheduled therapy
appointment. Afterward, the nurse coordinates the time for the same client's morning care and
afternoon radiology appointment. This nurse is functioning as:
A. A teacher
B. A caregiver
C. A client advocate
D. A manager
Correct Answer
D. A manager
The nurse in this scenario is functioning as a manager. They are responsible for coordinating
the client's therapy appointment, morning care, and radiology appointment. This involves
organizing and scheduling these different aspects of the client's care, which is a managerial
role.
12. The staff on a rehabilitation unit is attending an educational session to review the newest
treatment options for clients with knee injuries. This program is most likely being presented
by:
A. A nurse researcher
B. A clinical nurse specialist
C. A nurse practitioner
D. A nurse administrator
Correct Answer
B. A clinical nurse specialist
Clinical nurse specialists have advanced education and degrees in a specific aspect of
practice. They provide direct client care, direct and teach other team members providing care,
and conduct nursing research within the area of specialization.
The nurse researcher identifies problems regarding client care, designs plans of study,
develops tools, analyses findings, and disseminates knowledge.
Nurse practitioners provide client care independently in a variety of settings.
Nurse administrators have a variety of responsibilities, including staffing, budgets, client
care, and consulting.
13. During the interview with Ms. Wong, she complains of nausea, vomiting, diarrhea, and
fever. Which of Ms. Wong’s symptoms needs to be assessed first?
 A. Vomiting
B. Nausea
C. Diarrhoea
D. Fever
Correct Answer
B. Nausea
Nausea should be assessed first because it is often an early symptom of various medical
conditions and can indicate a more serious underlying problem. It is important to determine
the cause of the nausea in order to provide appropriate treatment and prevent further
complications. Additionally, addressing the nausea may help alleviate the other symptoms
such as vomiting, diarrhea, and fever.
14. Based on the interview and physical examination of Ms. Wong, which of the following
NANDAs would be the priority NANDA for this client?
A. Abdominal discomfort related to constipation
B. Fluid volume, the deficient risk for related to vomiting and diarrhoea
C. Pain, chronic
D. Activity intolerance
Correct Answer
B. Fluid volume, the deficient risk for related to vomiting and diarrhea
The Nursing Diagnosis (NANDA) is the basis for planning and implementing nursing care.
The pain that Ms. Wong is experiencing is not related to activity intolerance.
15. During the interview process and physical assessment of Ms. Wong, which of the
following would alert the nurse of a possible fluid volume deficit?
A. Skin warm
B. Lips and mucous membranes dry
C. Abdominal tenderness
D. Nausea
Correct Answer
B. Lips and mucous membranes dry
NANDA diagnoses are formulated by the nurse according to the PES (P – Problem, E –
Etiology, and S – Symptoms) system. When the nurse collects the data, Ms. Wong’s lips’
being cracked and dry alerts the nurse to a potential problem with fluid volume.