Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A 68-year-old man arrives for a preoperative
assessment. The nurse identifies teaching needs, documents
baseline vitals, and notifies the surgeon of a new irregular
pulse. Which statement best reflects the nurse’s primary role in
this situation?
A. Treat the irregular pulse with IV medications immediately.
B. Function as provider of care by assessing, communicating
findings, and initiating appropriate referrals.
C. Defer all assessment findings to the surgeon and record them
in the chart only.
D. Restrict assessment to the chief complaint to conserve time.
Correct Answer: B
Rationales:
Correct option: The professional nurse’s role includes providing
direct care (assessment), communicating abnormal findings,
,and initiating referrals or escalation as needed; this is aligned
with the provider-of-care role. (Ch. 1).
A: Incorrect — Initiating IV medication is beyond immediate
scope unless protocols/orders exist; the nurse should report
and act per facility policy.
C: Incorrect — Deferring entirely neglects the nurse’s
responsibility for assessment and communication.
D: Incorrect — Limiting assessment to the chief complaint risks
missing urgent findings; comprehensive judgment is needed.
Teaching Point: Nurses assess, communicate, and escalate—
don’t simply defer abnormal findings.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. LWW Official Store
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient in clinic requests medication
management for chronic pain. Which action demonstrates
appropriate role awareness by a registered nurse (RN)?
A. Prescribe a new analgesic after assessment.
B. Perform a focused pain assessment and arrange APRN/MD
follow-up for medication decisions.
C. Discharge the patient without documentation because
prescribing is not RN work.
D. Independently alter the patient’s current prescription dose.
,Correct Answer: B
Rationales:
Correct option: RNs perform assessments and coordinate care;
prescribing and medication adjustments are responsibilities of
APRNs/physicians unless authorized by protocols.
A: Incorrect — Prescribing requires APRN/physician authority.
C: Incorrect — Failing to document or arrange follow-up violates
professional duties.
D: Incorrect — Changing prescriptions is outside RN scope
unless an authorized protocol exists.
Teaching Point: RNs assess and coordinate; medication orders
require appropriate prescriptive authority.
Citation: Jensen & Smock, Ch. 1, RN vs Specialty/Advanced
Practice Assessments. LWW Official Store
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse provides discharge teaching to a patient
with newly diagnosed hypertension. Which statement best
reflects evidence-based teaching practice?
A. Give the whole lecture at once and hand a pamphlet.
B. Assess the patient’s readiness to learn, prioritize key self-
management skills, and use teach-back.
C. Assume the patient understands because they nod during
teaching.
D. Delay teaching until the patient is discharged home.
, Correct Answer: B
Rationales:
Correct option: Effective teaching includes assessing readiness,
prioritizing essential skills, and using teach-back to confirm
understanding.
A: Incorrect — Overloading information reduces retention;
chunking is better.
C: Incorrect — Nodding is not reliable; teach-back validates
comprehension.
D: Incorrect — Delaying education may miss an opportunity to
ensure safe self-care at discharge.
Teaching Point: Use readiness assessment and teach-back to
confirm learning.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion. LWW Official Store
4.
Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: During a community screening the nurse notes
a patient lacks reliable transportation to medical appointments.
Which action best addresses this social determinant of health?
A. Ignore it; transportation is outside nursing responsibility.
B. Document the barrier and connect the patient with
community resources and follow-up.
C. Tell the patient they must find their own transportation.
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A 68-year-old man arrives for a preoperative
assessment. The nurse identifies teaching needs, documents
baseline vitals, and notifies the surgeon of a new irregular
pulse. Which statement best reflects the nurse’s primary role in
this situation?
A. Treat the irregular pulse with IV medications immediately.
B. Function as provider of care by assessing, communicating
findings, and initiating appropriate referrals.
C. Defer all assessment findings to the surgeon and record them
in the chart only.
D. Restrict assessment to the chief complaint to conserve time.
Correct Answer: B
Rationales:
Correct option: The professional nurse’s role includes providing
direct care (assessment), communicating abnormal findings,
,and initiating referrals or escalation as needed; this is aligned
with the provider-of-care role. (Ch. 1).
A: Incorrect — Initiating IV medication is beyond immediate
scope unless protocols/orders exist; the nurse should report
and act per facility policy.
C: Incorrect — Deferring entirely neglects the nurse’s
responsibility for assessment and communication.
D: Incorrect — Limiting assessment to the chief complaint risks
missing urgent findings; comprehensive judgment is needed.
Teaching Point: Nurses assess, communicate, and escalate—
don’t simply defer abnormal findings.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. LWW Official Store
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient in clinic requests medication
management for chronic pain. Which action demonstrates
appropriate role awareness by a registered nurse (RN)?
A. Prescribe a new analgesic after assessment.
B. Perform a focused pain assessment and arrange APRN/MD
follow-up for medication decisions.
C. Discharge the patient without documentation because
prescribing is not RN work.
D. Independently alter the patient’s current prescription dose.
,Correct Answer: B
Rationales:
Correct option: RNs perform assessments and coordinate care;
prescribing and medication adjustments are responsibilities of
APRNs/physicians unless authorized by protocols.
A: Incorrect — Prescribing requires APRN/physician authority.
C: Incorrect — Failing to document or arrange follow-up violates
professional duties.
D: Incorrect — Changing prescriptions is outside RN scope
unless an authorized protocol exists.
Teaching Point: RNs assess and coordinate; medication orders
require appropriate prescriptive authority.
Citation: Jensen & Smock, Ch. 1, RN vs Specialty/Advanced
Practice Assessments. LWW Official Store
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse provides discharge teaching to a patient
with newly diagnosed hypertension. Which statement best
reflects evidence-based teaching practice?
A. Give the whole lecture at once and hand a pamphlet.
B. Assess the patient’s readiness to learn, prioritize key self-
management skills, and use teach-back.
C. Assume the patient understands because they nod during
teaching.
D. Delay teaching until the patient is discharged home.
, Correct Answer: B
Rationales:
Correct option: Effective teaching includes assessing readiness,
prioritizing essential skills, and using teach-back to confirm
understanding.
A: Incorrect — Overloading information reduces retention;
chunking is better.
C: Incorrect — Nodding is not reliable; teach-back validates
comprehension.
D: Incorrect — Delaying education may miss an opportunity to
ensure safe self-care at discharge.
Teaching Point: Use readiness assessment and teach-back to
confirm learning.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion. LWW Official Store
4.
Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: During a community screening the nurse notes
a patient lacks reliable transportation to medical appointments.
Which action best addresses this social determinant of health?
A. Ignore it; transportation is outside nursing responsibility.
B. Document the barrier and connect the patient with
community resources and follow-up.
C. Tell the patient they must find their own transportation.
