NR-302 Health Assessment I - Set 1 - Part 3

Correct Answer: Coarse crackles are heard at the base

Crackles are heard by the nurse through a stethoscope, so another examiner listening to the same chest would perceive them too. A finding detected by the examiner's senses or an instrument is objective data. Option a is incorrect because a reported cough is the client's own account of a symptom. Coughing that the nurse actually hears during the interview would be objective, but the report of it stays subjective. Option c is incorrect because feeling feverish is a sensation only this client can perceive. The measured temperature would supply the objective counterpart, and the two entries belong side by side in the chart. Option d is incorrect because chills overnight reached the nurse only through the client's description of the night before. Nothing was observed or measured, which places the entry squarely in the subjective half of the database.

Correct Answer: Critical thinking applied to the information

Critical thinking is the disciplined habit of questioning assumptions, weighing the quality of information, noticing when something does not add up, and considering alternatives. It underlies every stage of nursing work. Option a is incorrect because judgment is identified by a conclusion reached or an action carried out for the client. This nurse is still examining information and has decided nothing. Option b is incorrect because intuition arrives fast and without visible effort, resting on stored experience rather than deliberate scrutiny. The behavior described is slow, effortful and openly questioning. Option d is incorrect because deduction starts from a general rule and predicts what a particular client should show. No rule is being applied here; an assumption is being examined for soundness.

Correct Answer: Use short direct questions about onset and duration

Closed questions are the right tool when a specific fact is needed fast, as in an emergency history that runs alongside treatment. They yield a time, a number or a single word, which is all this moment allows. Option a is incorrect because a broad narrative invitation is the standard opener for a complete history, not for a client in crushing pain. Time and the client's tolerance both run out during the story. Option b is incorrect because reflection is used selectively at an emotionally loaded or ambiguous word. Echoing every answer during a cardiac emergency doubles the length of the history and adds no new facts. Option c is incorrect because explanation gives factual information and does reduce anxiety, but a lecture on anatomy delays the few facts the team needs. A short statement about the next step would serve better.

Correct Answer: Face him, cut the noise, and rephrase

Shouting distorts speech and lifts pitch into the range presbycusis has already taken. Facing the client in good light, reducing background noise, and rephrasing a missed sentence preserve both lip reading and meaning. Option a is incorrect because volume is not the barrier when the loss sits in the high frequencies. Louder speech distorts consonants further and stretches the mouth in ways that make lip reading harder. Option b is incorrect because relaying questions through a relative filters the history and strips privacy from a conversation the client is entitled to hold directly. He can hear with the right conditions. Option d is incorrect because writing everything out is slow and assumes a reading level the nurse has not checked. Written notes work as a supplement once speaking conditions have been corrected first.

Correct Answer: As a drug intolerance rather than allergy

Nausea and vomiting without skin, airway, or circulatory involvement describe an intolerance, an unpleasant side effect rather than an immune reaction. Recording it accurately keeps a useful drug available when the client genuinely needs it. Option a is incorrect because anaphylaxis involves airway swelling, wheeze, hypotension, and collapse within minutes of exposure. Nothing in her account describes those features, and labelling it that way strips future prescribers of a safe option. Option c is incorrect because one drug causing an upset stomach says nothing about the whole opioid class. Blocking every opioid on that basis would leave the client without effective pain relief after surgery or injury. Option d is incorrect because the description is already clear enough to classify at the bedside. Gastrointestinal upset with intact skin and breathing is a recognised intolerance, so no allergy testing is needed before charting it.

Correct Answer: Anchoring on the handoff impression

Anchoring fixes the nurse on the first piece of information received and blocks adjustment as new data arrives. The handoff label became the diagnosis, and the reported breathlessness was never assessed. Option b is incorrect because search satisficing means halting the survey once one abnormality turns up, so a second problem elsewhere goes unfound. This nurse never began searching in the first place. Option c is incorrect because availability bias inflates the likelihood of whatever comes easily to mind, usually a recent or dramatic case. Nothing suggests a run of similar clients shaped this judgment. Option d is incorrect because diagnosis momentum describes a label hardening as it is passed unverified from one clinician to the next. Only a single handoff has occurred, and no diagnosis was attached.

Correct Answer: The conclusion that she appears anxious

Cues are the raw findings the nurse can see and hear. Calling the client anxious is an interpretation laid over those findings, and interpretations belong to the diagnosis step rather than to data collection. Option a is incorrect because wringing hands is something the nurse watched happen. A second nurse walking in would see the same movement, which is the mark of a cue rather than a judgment. Option b is incorrect because rapid speech is heard directly. It carries no explanation with it, and the nurse could record the observation without deciding anything at all about the client's emotional state. Option c is incorrect because pacing describes movement across the room and nothing more. Behavior recorded this way stays at the level of what was witnessed, so the next nurse can picture the scene exactly.

Correct Answer: "I will ask myself what would prove my explanation wrong."

Deliberately hunting for the finding that would disprove the current explanation is the direct antidote to confirmation bias, and it forces the student to check data that has been quietly ignored. Option a is incorrect because clinging to a first impression is the definition of anchoring, the very habit the teaching targets. A first impression should be treated as one hypothesis among several. Option b is incorrect because taking over another clinician's label unchecked is how diagnosis momentum builds. Each nurse should ask what evidence supports the label before carrying it into a new shift. Option d is incorrect because choosing whichever cause appears most often in memory is availability bias in plain form. Base rates and treatment related causes deserve consideration alongside whatever the student remembers vividly.

Correct Answer: State her own name and nursing role

The opening begins with the nurse introducing herself by name and stating her role, so the client knows who is asking and why. Purpose, duration, preferred name and confidentiality follow. Option a is incorrect because the broad opening question belongs after the introduction, the stated purpose and the confidentiality statement. Asking it first leaves the client answering personal questions for a stranger. Option c is incorrect because chart review happens before the nurse walks in, not during the opening. Reading records at the bedside wastes the client's time and delays the introduction she is waiting for. Option d is incorrect because summarizing belongs to the closing, once data has been gathered. Nothing has been learned yet, so there is no set of problems or agreed plan to restate.

Correct Answer: "Tell me what brings you in today."

An open ended invitation cannot be answered yes or no and lets the client name what matters most to her. Every interview and every new topic within it starts this way. Option b is incorrect because a yes or no question about pain collects one narrow fact. Closed questions belong later, when the narrative is finished and specific gaps in the account need filling. Option c is incorrect because naming the rash and asking for agreement leads the client toward the answer the nurse already has in mind. Whatever else brought her in never gets mentioned. Option d is incorrect because asking about a prior episode narrows the encounter to one problem before the client has described any. It also yields a single word where a story was needed.