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 newly hired RN is preparing to perform a
complete health assessment on an adult admitted for
uncontrolled diabetes. Which role best describes the RN’s
responsibility during this assessment?
A. Diagnose the specific endocrine disorder and prescribe
insulin adjustments.
B. Collect comprehensive subjective and objective data to
inform nursing diagnoses.
C. Provide advanced diagnostic testing such as ordering an
HbA1c.
D. Function solely as a bedside technician following physician
orders.
Correct Answer: B
Rationales:
Correct (B): The RN’s core role in assessment is to gather
,subjective and objective patient data to identify nursing
problems and guide care planning. This aligns with the RN as
provider of care and assessor.
A: Diagnosing a specific medical endocrine disorder and
prescribing is outside the RN’s scope; that is a provider/APRN
responsibility.
C: Ordering diagnostic lab tests (e.g., HbA1c) is typically a
provider/APRN function, not a routine RN assessment action.
D: The RN’s role is autonomous and professional, not limited to
technician tasks; critical thinking and assessment are central.
Teaching Point: RN collects and synthesizes assessment data to
identify nursing needs.
Citation: Ch. 1, Section: The Nurse’s Role in Health Assessment.
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
(APRN) vs RN Assessments
Question Stem: An APRN is performing a focused
cardiovascular assessment in a clinic. Which action distinguishes
an APRN assessment from a typical RN assessment?
A. Measuring blood pressure and auscultating heart sounds.
B. Identifying nursing diagnoses related to activity intolerance.
C. Ordering and interpreting an ECG and initiating treatment for
arrhythmia.
D. Documenting findings using a standardized head-to-toe
,template.
Correct Answer: C
Rationales:
Correct (C): APRNs have advanced diagnostic and prescriptive
authority in many settings; ordering/interpreting ECGs and
initiating treatment reflects advanced practice.
A: Measuring BP and auscultation are essential assessment
tasks done by both RNs and APRNs.
B: Identifying nursing diagnoses is a core RN competency and
not unique to APRNs.
D: Using standardized documentation is common to all nursing
roles; it does not distinguish APRN scope.
Teaching Point: APRNs may perform advanced diagnostic and
prescriptive functions.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 55-year-old patient with hypertension asks
the nurse about lifestyle changes to reduce cardiovascular risk.
Which teaching point most directly aligns with primary
prevention?
A. Begin taking antihypertensive medication immediately.
B. Reduce dietary sodium and increase physical activity.
C. Schedule a stress test to detect existing coronary disease.
, D. Plan for cardiac catheterization if chest pain occurs.
Correct Answer: B
Rationales:
Correct (B): Primary prevention focuses on health promotion
and risk reduction—dietary sodium reduction and increased
activity lower cardiovascular risk.
A: Medication treats an existing condition (secondary/tertiary
prevention), not primary prevention.
C: Stress testing is a diagnostic measure to detect disease, not a
primary prevention strategy.
D: Cardiac catheterization is an invasive diagnostic/therapeutic
intervention for established disease.
Teaching Point: Primary prevention emphasizes lifestyle
changes to reduce disease risk.
Citation: Ch. 1, Section: Teaching and Health Promotion.
4
Reference: Ch. 1, Section: Social Determinants of Health:
Healthy People 2030
Question Stem: A community health nurse notes that several
local residents lack access to fresh produce. Which social
determinant of health does this finding represent and why is it
important?
A. Education level — it directly predicts produce consumption.
B. Health care access — produce is provided by clinics.
C. Neighborhood and built environment — affects access to
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 newly hired RN is preparing to perform a
complete health assessment on an adult admitted for
uncontrolled diabetes. Which role best describes the RN’s
responsibility during this assessment?
A. Diagnose the specific endocrine disorder and prescribe
insulin adjustments.
B. Collect comprehensive subjective and objective data to
inform nursing diagnoses.
C. Provide advanced diagnostic testing such as ordering an
HbA1c.
D. Function solely as a bedside technician following physician
orders.
Correct Answer: B
Rationales:
Correct (B): The RN’s core role in assessment is to gather
,subjective and objective patient data to identify nursing
problems and guide care planning. This aligns with the RN as
provider of care and assessor.
A: Diagnosing a specific medical endocrine disorder and
prescribing is outside the RN’s scope; that is a provider/APRN
responsibility.
C: Ordering diagnostic lab tests (e.g., HbA1c) is typically a
provider/APRN function, not a routine RN assessment action.
D: The RN’s role is autonomous and professional, not limited to
technician tasks; critical thinking and assessment are central.
Teaching Point: RN collects and synthesizes assessment data to
identify nursing needs.
Citation: Ch. 1, Section: The Nurse’s Role in Health Assessment.
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
(APRN) vs RN Assessments
Question Stem: An APRN is performing a focused
cardiovascular assessment in a clinic. Which action distinguishes
an APRN assessment from a typical RN assessment?
A. Measuring blood pressure and auscultating heart sounds.
B. Identifying nursing diagnoses related to activity intolerance.
C. Ordering and interpreting an ECG and initiating treatment for
arrhythmia.
D. Documenting findings using a standardized head-to-toe
,template.
Correct Answer: C
Rationales:
Correct (C): APRNs have advanced diagnostic and prescriptive
authority in many settings; ordering/interpreting ECGs and
initiating treatment reflects advanced practice.
A: Measuring BP and auscultation are essential assessment
tasks done by both RNs and APRNs.
B: Identifying nursing diagnoses is a core RN competency and
not unique to APRNs.
D: Using standardized documentation is common to all nursing
roles; it does not distinguish APRN scope.
Teaching Point: APRNs may perform advanced diagnostic and
prescriptive functions.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 55-year-old patient with hypertension asks
the nurse about lifestyle changes to reduce cardiovascular risk.
Which teaching point most directly aligns with primary
prevention?
A. Begin taking antihypertensive medication immediately.
B. Reduce dietary sodium and increase physical activity.
C. Schedule a stress test to detect existing coronary disease.
, D. Plan for cardiac catheterization if chest pain occurs.
Correct Answer: B
Rationales:
Correct (B): Primary prevention focuses on health promotion
and risk reduction—dietary sodium reduction and increased
activity lower cardiovascular risk.
A: Medication treats an existing condition (secondary/tertiary
prevention), not primary prevention.
C: Stress testing is a diagnostic measure to detect disease, not a
primary prevention strategy.
D: Cardiac catheterization is an invasive diagnostic/therapeutic
intervention for established disease.
Teaching Point: Primary prevention emphasizes lifestyle
changes to reduce disease risk.
Citation: Ch. 1, Section: Teaching and Health Promotion.
4
Reference: Ch. 1, Section: Social Determinants of Health:
Healthy People 2030
Question Stem: A community health nurse notes that several
local residents lack access to fresh produce. Which social
determinant of health does this finding represent and why is it
important?
A. Education level — it directly predicts produce consumption.
B. Health care access — produce is provided by clinics.
C. Neighborhood and built environment — affects access to
