Free Nursing Process and Health Assessment MCQs with Answers
50 Nursing Process and Health Assessment MCQs from Fundamentals of Nursing, each with the correct answer and a written explanation of why it is correct. Free and unlimited, with no account needed.
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
Last updated
50 questions · page 2 of 3
- A. Document the reading as the patient's baseline
- B. Apply oxygen without checking the measurement
- C. Warm the hand and repeat the reading
- D. Ask the patient to take rapid deep breaths
Explanation: The nurse should validate an unexpected finding by correcting possible equipment or patient factors and repeating the measurement.
Correct answer: Warm the hand and repeat the reading- A. Previous appendectomy at age 20
- B. Current allergy to penicillin
- C. Mother diagnosed with hypertension
- D. Patient's usual daily exercise pattern
Explanation: Family history records significant illnesses or conditions affecting blood relatives, such as hypertension in the patient's mother.
Correct answer: Mother diagnosed with hypertension23. When assessing a patient's abdomen, which sequence of physical examination techniques is correct?
- A. Inspection, auscultation, percussion, palpation
- B. Palpation, percussion, inspection, auscultation
- C. Auscultation, palpation, inspection, percussion
- D. Percussion, palpation, auscultation, inspection
Explanation: The abdomen is assessed in the order of inspection, auscultation, percussion and palpation.
Correct answer: Inspection, auscultation, percussion, palpation- A. Group related findings into meaningful patterns
- B. Select the first diagnosis in the care plan
- C. Begin all prescribed treatments immediately
- D. Ask the medical officer to name the diagnosis
Explanation: Clustering related assessment cues helps the nurse identify meaningful patterns and supports an accurate nursing diagnosis.
Correct answer: Group related findings into meaningful patterns- A. Wound looks bad and patient is careless
- B. Wound is probably infected and painful
- C. Red, warm area measuring 3 cm surrounds incision
- D. Patient seems unhealthy and does not cooperate
Explanation: The third entry uses observable, measurable and neutral language, making it suitable for the clinical record.
Correct answer: Red, warm area measuring 3 cm surrounds incision- A. A patient requesting help to choose lunch
- B. A patient reporting sudden difficulty speaking
- C. A patient asking for a routine bath
- D. A patient with mild pain before breakfast
Explanation: Sudden difficulty speaking may indicate an acute neurological emergency and requires immediate assessment for safety and possible loss of…
Correct answer: A patient reporting sudden difficulty speaking- A. It describes a problem that is already present
- B. It identifies a possible problem supported by risk factors
- C. It names the disease causing the patient's symptoms
- D. It records the treatment prescribed by the physician
Explanation: A risk nursing diagnosis identifies a patient vulnerability and the factors that increase the chance of a problem developing.
Correct answer: It identifies a possible problem supported by risk factors- A. Use a trained medical interpreter
- B. Ask a young child in the family to interpret
- C. Give the patient a form without further discussion
- D. Proceed using gestures and assumptions
Explanation: A trained medical interpreter promotes accurate communication, privacy and informed participation in assessment.
Correct answer: Use a trained medical interpreter- A. Mark the outcome as achieved because care was provided
- B. Reassess the patient and review the care plan
- C. Discontinue all interventions immediately
- D. Record that the patient failed to cooperate
Explanation: When an outcome is unmet, the nurse reassesses the patient and examines whether the diagnosis, interventions or time frame should be…
Correct answer: Reassess the patient and review the care plan- A. Respiratory rate of 18 per minute with clear speech
- B. Mild thirst after walking to the bathroom
- C. New use of accessory muscles during breathing
- D. Dry skin after spending time in a warm room
Explanation: New use of accessory muscles indicates increased work of breathing and possible respiratory compromise, so breathing assessment is the…
Correct answer: New use of accessory muscles during breathing- A. Assessment, diagnosis, planning, implementation, evaluation
- B. Diagnosis, assessment, planning, evaluation, implementation
- C. Planning, assessment, implementation, diagnosis, evaluation
- D. Assessment, planning, diagnosis, evaluation, implementation
Explanation: The nursing process follows assessment, nursing diagnosis, planning, implementation and evaluation.
Correct answer: Assessment, diagnosis, planning, implementation, evaluation- A. Document the pain as exaggerated
- B. Ask focused questions and reassess the patient
- C. Ignore the report until vital signs change
- D. Record only the objective assessment findings
Explanation: Conflicting data should be validated by asking focused questions and repeating relevant assessments.
Correct answer: Ask focused questions and reassess the patient- A. A comprehensive health history and physical examination
- B. A focused examination of the chief complaint only
- C. A review of the medication list without examination
- D. An emergency assessment limited to airway and breathing
Explanation: A first clinic visit with several concerns requires a comprehensive assessment to establish baseline health information.
Correct answer: A comprehensive health history and physical examination- A. Impaired skin integrity related to immobility as evidenced by a sacral wound
- B. Pneumonia related to fever as evidenced by abnormal breath sounds
- C. Risk for falls related to unsteady gait as evidenced by a previous fall
- D. Acute pain related to appendicitis as evidenced by a surgical incision
Explanation: An actual nursing diagnosis includes the problem, related cause and supporting signs or symptoms.
Correct answer: Impaired skin integrity related to immobility as evidenced by a sacral wound- A. The patient's usual exercise pattern
- B. The tablet name, amount and time taken
- C. The patient's preferred learning method
- D. The patient's usual bowel elimination pattern
Explanation: The substance, approximate amount and time of ingestion guide urgent treatment and monitoring for toxicity.
Correct answer: The tablet name, amount and time taken- A. Grouping related findings before identifying a patient problem
- B. Recording every finding without deciding its meaning
- C. Choosing an intervention before reviewing the assessment
- D. Using the medical diagnosis as the nursing diagnosis
Explanation: Clustering related findings helps the nurse identify patterns and support an accurate nursing diagnosis.
Correct answer: Grouping related findings before identifying a patient problem- A. Give the same printed leaflet used for all patients
- B. Provide verbal teaching with pictures and teach-back
- C. Ask a family member to explain every treatment
- D. Tell the patient to search for instructions online
Explanation: Verbal teaching, pictures and teach-back adapt education to the patient's literacy and comprehension needs.
Correct answer: Provide verbal teaching with pictures and teach-back- A. Continue the same plan without further assessment
- B. Reassess the patient and revise the plan if needed
- C. Mark the outcome as achieved because treatment was given
- D. Remove the nursing diagnosis from the care plan
Explanation: Evaluation compares the patient's actual response with the expected outcome and leads to reassessment and revision when progress is…
Correct answer: Reassess the patient and revise the plan if needed- A. The patient reports feeling tired
- B. The patient states that nausea began today
- C. The nurse observes a three-centimetre skin tear
- D. The patient describes a burning sensation
Explanation: Objective data are observable or measurable findings obtained by the nurse, such as the size and appearance of a skin tear.
Correct answer: The nurse observes a three-centimetre skin tear- A. Inspect and measure the ulcer, then assess circulation and sensation
- B. Apply a dressing before examining the surrounding skin
- C. Ask the patient to walk to determine the wound's severity
- D. Clean the ulcer forcefully until all tissue appears red
Explanation: The initial assessment should document wound features and evaluate circulation and sensation because diabetes increases the risk of…
Correct answer: Inspect and measure the ulcer, then assess circulation and sensation