NR-302 Health Assessment I - Set 1 - Part 1

Correct Answer: "I will summarize and ask what else she wants me to know."

The closing summarizes what was learned and offers an open final question, which is where a client raises the thing she has been holding back. Positive health behaviors get named too. Option a is incorrect because standing up ends the encounter abruptly and physically rather than easing into it. The client who was working up to a hard question now has nowhere to put it. Option b is incorrect because deferring new concerns discards the most valuable minute of the interview. What a client raises at the door is frequently the reason she came in at all. Option d is incorrect because a problem list alone leaves out the agreed plan, the client's own strengths and the invitation to add anything. Naming a positive health behavior is part of every closing.

Correct Answer: Signal the colleague to handle it and continue

Refusing interruptions is one of the two external controls the nurse owns, and this disclosure is exactly the moment that cannot be broken. Attention stays with the client, and the colleague absorbs the call. Option b is incorrect because leaving mid sentence tells the client her story ranks below whatever is outside. If a departure truly cannot be avoided, the nurse excuses herself and bridges back on return. Option c is incorrect because answering the desk phone during a disclosure about a marriage guarantees the subject never comes back. Clients rarely restart a hard topic once the thread has been dropped. Option d is incorrect because stopping the interview abandons an account that is only half told. Documentation of a fragment is worth far less than the rest of what the client was about to say.

Correct Answer: Facilitating the account with brief encouragers

The working phase is where the data is gathered, so the nurse keeps the narrative moving with facilitation, silence, reflection and targeted closed questions. Purpose and thanks belong at the two ends. Option a is incorrect because purpose and duration are announced in the opening, before any data is collected. Repeating them once the client is mid narrative interrupts the very account the nurse asked for. Option b is incorrect because telling the client who comes next and when results arrive is part of the closing sequence. That information means little until the nurse knows what the problems actually are. Option d is incorrect because thanks close an encounter and signal that it is over. Offering it while the client is still describing symptoms would read as a polite instruction to stop talking.

Correct Answer: Explore the difference between his words and behavior

A gap between what the client says and what the nurse sees is itself a finding. Naming the discrepancy gently and inviting him to say more usually uncovers the real reason he is declining relief. Option b is incorrect because simply accepting the words ignores half the data. Guarding, shallow breathing and tachycardia point the other way, and a nurse who walks out leaves an unresolved conflict in the record. Option c is incorrect because medicating a competent adult who has declined is a consent violation. Objective signs justify a conversation, never an override, and forcing the issue destroys the trust the interview depends on. Option d is incorrect because a four hour wait hands the client four more hours of unrelieved pain. Fear of addiction or of bothering staff often sits behind a refusal, and it surfaces only when someone asks.

Correct Answer: The nonverbal message is the more reliable one

Nonverbal behavior is largely unconscious and therefore reflects true feeling more accurately than chosen words. When the two channels conflict, believe the body, then name what is seen and invite the client to talk. Option a is incorrect because words are consciously selected and easily shaped to what a client thinks the nurse wants to hear. That is precisely why the spoken reassurance carries less weight than the clenched jaw. Option b is incorrect because deliberate concealment assumes an intent no evidence supports. Most clients who say they are fine while their body says otherwise are managing fear, not hiding facts from the nurse. Option c is incorrect because a gap between content and affect is data in its own right. Incongruence tells the nurse where to look next, and ignoring it wastes the clearest signal in the exchange.

Correct Answer: Severity and its effect on function

Severity is the one characteristic no part of the note captures. The nurse still needs to know how intense the cough is and what it costs the client in sleep, work, or daily activity. Option a is incorrect because the word dry is exactly what character asks for, describing the sound and feel of the cough. That element is already on the page and needs no repeating. Option b is incorrect because three weeks gives duration and the nightly worsening gives pattern, so timing is documented. Both halves of that characteristic appear in the student's entry without any gap. Option d is incorrect because the scratchy throat is a companion symptom, and recording it satisfies the associated manifestations element. Naming it as the gap would send the student back for information already collected.

Correct Answer: Using impersonal grammar to create distance

Saying 'the left breast' rather than 'your left breast' is distancing, the impersonal grammar a nurse reaches for when the subject is frightening. Clients hear evasion and can lose track of whose body is meant. Option b is incorrect because avoidance language swaps a plain word for a gentler one, as when a family is told their mother slipped away rather than died. The words chosen here were direct enough. Option c is incorrect because professional jargon describes technical vocabulary a client will not question, such as excision or benign. Every word in this sentence sits within ordinary English. Option d is incorrect because using authority sounds like telling the client the team already knows what is best. This sentence gives information about the operation and never invokes anyone's rank.

Correct Answer: Assess airway and breathing while treatment begins

An emergency database is rapid and runs at the same time as life saving care. The nurse assesses airway, breathing and circulation while opening the airway and delivering oxygen rather than finishing one before starting the other. Option a is incorrect because a head to toe sweep costs minutes this client cannot spare. Soot around the mouth with noisy breathing points to an airway that may close, and that finding outranks everything else. Option b is incorrect because history taking is compressed to essentials during a resuscitation. Allergies, medications and the events leading up can be collected from the crew after the airway is secured, not before. Option c is incorrect because waiting for the provider surrenders the minutes that decide this outcome. Nurses are expected to assess and act on a failing airway themselves, and an order is not required to open one.

Correct Answer: Complete the full health history and examination

Once the emergency has passed the nurse returns for the fuller picture. The complete database supplies past history, medications, allergies, functional status and psychosocial data that the rapid survey deliberately skipped while life was at risk. Option b is incorrect because the rapid survey has already done its work. Airway, breathing and circulation were addressed downstairs, and repeating only those elements would leave the admission database as thin as it was in the trauma bay. Option c is incorrect because narrowing to one limb hides everything else a crash can injure. Trauma clients need a systematic look at every system, since a ruptured spleen or a rib fracture announces itself late. Option d is incorrect because a competent adult supplies his own history. Family may add detail later, but delaying assessment for their arrival leaves the unit caring for a trauma client with no baseline at all.

Correct Answer: A focused assessment of the affected leg

A new complaint calls for a mini database built around that problem. The nurse examines the calf for swelling, warmth, color change and tenderness, then compares it with the opposite leg before reporting. Option a is incorrect because repeating the entire history and examination wastes time the client does not have. The admission database is only hours old, and nothing in the new complaint suggests it is unreliable. Option b is incorrect because an emergency survey belongs to clients who are losing an airway or bleeding out. Calf pain deserves prompt attention, yet this client is talking, breathing and perfusing normally right now. Option d is incorrect because tracking the pneumonia would answer a different question entirely. Follow up data measures whether a known problem is improving, while the calf pain is a fresh finding with no prior record.

Correct Answer: What relieves or palliates the symptom

The P stands for provocative and palliative together, so the nurse asks both what brings the symptom on and what makes it better. Students lose credit by capturing only the provoking half of that letter. Option b is incorrect because radiation sits with region, the letter that maps where the symptom starts and where it spreads. Placing radiation under provocation scrambles two separate letters of the mnemonic. Option c is incorrect because episode length belongs to timing, which gathers onset, duration, and frequency. Duration answers how long an attack runs, a question entirely separate from what eases the symptom. Option d is incorrect because the client's own explanation of the problem is the understanding element, the final letter of the mnemonic. That belief shapes whether care is sought, but it is not part of provocation.

Correct Answer: Use the words physical therapy and nothing by mouth

Jargon is invisible to the person using it, and clients rarely admit they did not follow a term. Plain words first, with the technical term second if it is needed at all. Option a is incorrect because volume has no effect on vocabulary. The client heard every syllable clearly and still had no idea what either abbreviation meant, so louder delivery changes nothing at all. Option b is incorrect because asking whether someone understood produces a yes from almost everyone. Admitting confusion feels shaming, which is precisely why nodding is such an unreliable sign of comprehension. Option c is incorrect because handing the puzzle to a relative leaves the client dependent on someone else's guess. The abbreviations remain unexplained, and the person who must follow the plan still does not know it.

Correct Answer: The onset timing and the calf findings

A clot typically announces itself with abrupt onset and may bring unilateral calf swelling or tenderness, while collapsed tissue develops gradually with bilateral basilar findings. Onset and calf assessment discriminate between them. Option a is incorrect because sleep routine belongs to the functional history and predicts nothing about either explanation. A discriminating question is one where the two possibilities predict different answers. Option b is incorrect because a previous operation raises the risk of clotting yet fits both explanations equally, since surgery also drives shallow breathing. Shared risk factors cannot tell the two apart. Option d is incorrect because a medication route preference guides comfort planning and has no power to confirm or eliminate either cause of the breathlessness. It answers a question nobody asked here.

Correct Answer: Auscultation findings are objective examination data

The review of systems holds only what the client reports, symptom by symptom. Clear breath sounds are something the nurse heard, so that finding belongs in the physical examination record rather than the subjective history. Option a is incorrect because moving the entry to another body system heading keeps objective data inside a subjective section. The problem is the kind of data, not the heading it was filed under. Option c is incorrect because clear to auscultation is a precise, standard description of breath sounds. Vagueness is not the flaw here, since the phrase would be perfectly acceptable inside the physical examination note. Option d is incorrect because listening to breath sounds falls within independent nursing practice and needs no order. Documentation placement, not authorisation, is what the instructor flagged in the student's written history.

Correct Answer: Interview him alone after explaining confidentiality limits

Adolescents disclose when they are seen alone and told exactly where privacy ends. Normalising the private portion and naming the limits up front protects both honesty and the nurse's duty to report danger. Option a is incorrect because routing sensitive questions through the mother removes the client from his own history. A teenager will not correct or contradict a parent's account of his sexual activity or substance use. Option b is incorrect because blanket secrecy is a promise no nurse can keep. Harm to himself or others and mandated reporting both override privacy, and a broken promise ends disclosure permanently. Option c is incorrect because deferring the psychosocial history assumes a second visit that many adolescents never make. Risk behaviours carry immediate consequences, so the sports physical is the opportunity available right now.

Correct Answer: Document the change and screen for causes

The functional assessment is read as a trajectory, and loss between visits is the finding. Recording the decline and hunting for vision, cardiac, cognitive, mood, or medication causes turns an observation into a plan. Option a is incorrect because reassurance closes a conversation that has just opened. Giving up driving within half a year is not an ordinary age change, and new weakness should never be blamed on age. Option b is incorrect because a placement referral leaps past assessment to a decision nobody has justified. The cause of her decline is unknown, and several likely causes are correctable in the clinic. Option d is incorrect because a full symptom sweep across every body system is a slow answer to a focused concern. The nurse needs targeted questions about driving, walking, and vision rather than the whole questionnaire.

Correct Answer: Clinical judgment as the observable outcome

Clinical judgment is the outcome of reasoning, the conclusion the nurse reaches and the action that follows. Raising the bed and calling the provider are the observable products of the thinking. Option a is incorrect because critical thinking is the general, disciplined habit of questioning assumptions and testing the quality of information. It runs underneath the whole process and is not itself the decision. Option c is incorrect because diagnostic reasoning names the analysis that moves from health data toward a conclusion. That work happened while the nurse weighed explanations, before any bed was raised or call placed. Option d is incorrect because induction builds a general conclusion out of specific observations, a direction of thinking rather than a result. Naming the direction leaves the nurse's decision and action unaccounted for.

Correct Answer: Rechecking the capillary glucose and comparing values

Evaluation asks whether the outcome happened, and answering it takes new data. Rechecking the glucose and setting the new number beside the old one tells the nurse whether the treatment worked. Option b is incorrect because recording what was given documents the intervention itself. Charting is part of implementation, and it says nothing about whether the client's glucose actually rose after the carbohydrate. Option c is incorrect because choosing a snack is another act of treatment. Offering food may well be appropriate, yet the nurse is still delivering care rather than judging the result of care already delivered. Option d is incorrect because generating explanations for a finding is diagnostic work. Sorting through insulin timing, missed meals or activity happens when the nurse interprets data, which sits earlier in the cycle.

Correct Answer: Analyzing cues as expected or unexpected

Analyzing cues is the operation that sorts findings into expected and unexpected for this client and links them to the condition. Separating chronic changes from acute ones is exactly that work. Option a is incorrect because taking action covers the implementation of interventions in the safest order for the current priority. The nurse in this scenario has done no more than interpret findings. Option b is incorrect because generating solutions identifies expected outcomes and the interventions that could reach them, including what to avoid. Sorting findings by whether they surprise the nurse precedes any such planning. Option c is incorrect because evaluating outcomes compares the client's actual response with the result the nurse predicted. No intervention has yet been delivered, leaving nothing to weigh against a predicted response.

Correct Answer: The specific reaction the drug produced

An allergy entry is unusable without the reaction itself. Hives, wheeze, or swelling identify a true allergy, while nausea points to intolerance, and that difference shapes prescribing for the rest of the client's life. Option b is incorrect because the dose taken when the reaction occurred does not change how the team treats the allergy. Even a small exposure can trigger anaphylaxis, so dose adds little to safe prescribing. Option c is incorrect because brand names vary by manufacturer while the allergen stays the same drug class. Recording a trade name without the reaction still leaves the team unable to judge how dangerous re-exposure would be. Option d is incorrect because drug allergies are individual responses and are not inherited in a way that guides this client's care. A relative's reaction would not appear in his own allergy record.