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 — Roles of the Professional Nurse
Question Stem: A newly hired RN is preparing for a
comprehensive admission assessment on a medical-surgical
unit. Which role best describes the nurse’s primary
responsibility during this assessment?
A. Diagnose the patient’s medical condition and prescribe
treatment.
B. Gather subjective and objective data to inform nursing
diagnoses and plan care.
C. Delegate the entire assessment to nursing assistants to save
time.
D. Provide only focused assessments when the patient appears
stable.
Correct Answer: B
Rationale — Correct: The RN’s primary role in health
assessment is to collect subjective and objective data that
,support nursing diagnoses and plan individualized care. This
aligns with the nurse as a provider of care who uses assessment
findings to guide clinical judgment.
Rationale — A (incorrect): Diagnosing medical conditions and
prescribing treatment are outside the RN’s scope; those are
medical or APRN responsibilities.
Rationale — C (incorrect): While delegation is appropriate for
some tasks, the RN must personally perform or validate the
comprehensive assessment.
Rationale — D (incorrect): Comprehensive admission
assessments are standard even if patients appear stable;
focused assessments are situation-dependent.
Teaching Point: The RN collects assessment data to inform
nursing diagnoses and care planning.
Citation: Ch. 1, The Nurse’s Role in Health Assessment.
2
Reference: Ch. 1, Section: The Registered Nurse Versus
Advanced Practice Registered Nurse
Question Stem: A RN caring for a patient with uncontrolled
hypertension notes new neurologic deficits. Which action
reflects appropriate recognition of role boundaries and
escalation?
A. Immediately adjust the patient’s antihypertensive dosage.
B. Notify the APRN/physician and perform an urgent focused
neurologic assessment.
,C. Document the deficit and wait until the next scheduled
provider round.
D. Discharge the patient home with instructions to follow up
with primary care.
Correct Answer: B
Rationale — Correct: Notifying the APRN/physician while
performing an urgent focused neurologic assessment is within
the RN’s scope and timely for potential acute stroke. This
demonstrates appropriate escalation and assessment within
role boundaries.
Rationale — A (incorrect): Adjusting medication dose is an
advanced practice or prescriber action, not within standard RN
scope.
Rationale — C (incorrect): Waiting delays urgent care and risks
harm when new neurologic deficits appear.
Rationale — D (incorrect): Discharging a patient with new
deficits is unsafe and outside appropriate clinical judgment.
Teaching Point: Escalate urgent changes and complete focused
assessments within RN scope.
Citation: Ch. 1, Registered Nurse Versus Advanced Practice
Assessments.
3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During a wellness visit, a nurse identifies a
, patient’s limited health literacy and multiple chronic conditions.
Which teaching strategy is most appropriate to improve the
patient’s understanding?
A. Provide a 12-page handout detailing pathophysiology and
medication mechanisms.
B. Use teach-back and short, action-oriented instructions
focused on self-management.
C. Refer the patient to online medical journals for more
information.
D. Assume the patient will read materials later and document
education provided.
Correct Answer: B
Rationale — Correct: Teach-back and concise, action-oriented
instructions match health-promotion best practices for patients
with limited health literacy and chronic conditions; they
improve comprehension and adherence.
Rationale — A (incorrect): Long, technical handouts overwhelm
those with limited literacy and are ineffective.
Rationale — C (incorrect): Directing patients to medical
journals is inappropriate for limited health literacy and lacks
tailored instruction.
Rationale — D (incorrect): Assuming later reading without
confirming understanding risks ineffective education and poor
outcomes.
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 — Roles of the Professional Nurse
Question Stem: A newly hired RN is preparing for a
comprehensive admission assessment on a medical-surgical
unit. Which role best describes the nurse’s primary
responsibility during this assessment?
A. Diagnose the patient’s medical condition and prescribe
treatment.
B. Gather subjective and objective data to inform nursing
diagnoses and plan care.
C. Delegate the entire assessment to nursing assistants to save
time.
D. Provide only focused assessments when the patient appears
stable.
Correct Answer: B
Rationale — Correct: The RN’s primary role in health
assessment is to collect subjective and objective data that
,support nursing diagnoses and plan individualized care. This
aligns with the nurse as a provider of care who uses assessment
findings to guide clinical judgment.
Rationale — A (incorrect): Diagnosing medical conditions and
prescribing treatment are outside the RN’s scope; those are
medical or APRN responsibilities.
Rationale — C (incorrect): While delegation is appropriate for
some tasks, the RN must personally perform or validate the
comprehensive assessment.
Rationale — D (incorrect): Comprehensive admission
assessments are standard even if patients appear stable;
focused assessments are situation-dependent.
Teaching Point: The RN collects assessment data to inform
nursing diagnoses and care planning.
Citation: Ch. 1, The Nurse’s Role in Health Assessment.
2
Reference: Ch. 1, Section: The Registered Nurse Versus
Advanced Practice Registered Nurse
Question Stem: A RN caring for a patient with uncontrolled
hypertension notes new neurologic deficits. Which action
reflects appropriate recognition of role boundaries and
escalation?
A. Immediately adjust the patient’s antihypertensive dosage.
B. Notify the APRN/physician and perform an urgent focused
neurologic assessment.
,C. Document the deficit and wait until the next scheduled
provider round.
D. Discharge the patient home with instructions to follow up
with primary care.
Correct Answer: B
Rationale — Correct: Notifying the APRN/physician while
performing an urgent focused neurologic assessment is within
the RN’s scope and timely for potential acute stroke. This
demonstrates appropriate escalation and assessment within
role boundaries.
Rationale — A (incorrect): Adjusting medication dose is an
advanced practice or prescriber action, not within standard RN
scope.
Rationale — C (incorrect): Waiting delays urgent care and risks
harm when new neurologic deficits appear.
Rationale — D (incorrect): Discharging a patient with new
deficits is unsafe and outside appropriate clinical judgment.
Teaching Point: Escalate urgent changes and complete focused
assessments within RN scope.
Citation: Ch. 1, Registered Nurse Versus Advanced Practice
Assessments.
3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During a wellness visit, a nurse identifies a
, patient’s limited health literacy and multiple chronic conditions.
Which teaching strategy is most appropriate to improve the
patient’s understanding?
A. Provide a 12-page handout detailing pathophysiology and
medication mechanisms.
B. Use teach-back and short, action-oriented instructions
focused on self-management.
C. Refer the patient to online medical journals for more
information.
D. Assume the patient will read materials later and document
education provided.
Correct Answer: B
Rationale — Correct: Teach-back and concise, action-oriented
instructions match health-promotion best practices for patients
with limited health literacy and chronic conditions; they
improve comprehension and adherence.
Rationale — A (incorrect): Long, technical handouts overwhelm
those with limited literacy and are ineffective.
Rationale — C (incorrect): Directing patients to medical
journals is inappropriate for limited health literacy and lacks
tailored instruction.
Rationale — D (incorrect): Assuming later reading without
confirming understanding risks ineffective education and poor
outcomes.
