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 graduated RN is preparing to perform a
comprehensive health assessment on a 72-year-old patient
admitted for new-onset confusion. Which action best
demonstrates the RN’s role as a provider of care during this
assessment?
A. Delegating initial vital signs and documentation to nursing
assistive personnel.
B. Performing a focused neurologic assessment and
synthesizing findings for the care plan.
C. Scheduling the patient’s medication reconciliation with the
unit pharmacist.
D. Teaching the patient’s family about community resources
after discharge.
Correct Answer: B
Rationales:
, • Correct (B): Performing and interpreting a focused
neurologic assessment and using those findings to guide
the plan exemplifies the RN’s direct provision of clinical
care and assessment responsibilities. (Aligns with provider
role in assessment.)
• A: Delegation of routine tasks is appropriate but does not
demonstrate the RN’s direct provider role in assessment or
clinical judgment.
• C: Medication reconciliation is an important safety activity
often done collaboratively, but scheduling it demonstrates
coordination rather than direct assessment.
• D: Teaching families is part of the nurse’s role but is more
aligned with health promotion and discharge planning
than immediate clinical assessment.
Teaching Point: RNs directly assess and synthesize findings to
guide immediate care.
Citation: Jensen & Smock, Ch. 1, “Roles of the Professional
Nurse.”
2)
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: An RN is caring for a patient with complex
endocrine disease who requests a medication change. Which
action best reflects appropriate role boundaries between the
,RN and an APRN?
A. The RN independently adjusts the dose based on lab trends.
B. The RN documents the patient’s request and alerts the APRN
for evaluation.
C. The RN prescribes a short course of the alternative
medication.
D. The RN orders additional diagnostic testing to confirm the
need for change.
Correct Answer: B
Rationales:
• Correct (B): Documenting the request and notifying the
APRN follows scope-of-practice boundaries while ensuring
the advanced provider evaluates and prescribes.
• A: Independently adjusting medication dose exceeds RN
scope and risks unsafe practice.
• C: Prescribing is outside typical RN scope unless advanced
practice prescriptive authority exists.
• D: Ordering diagnostic testing is typically within provider
or APRN authority; the RN should recommend or
collaborate rather than independently order.
Teaching Point: RNs gather and communicate assessment data;
prescriptive decisions are for advanced providers.
Citation: Jensen & Smock, Ch. 1, “Registered Nurse Versus
Specialty or Advanced Practice Assessments.”
, 3)
Reference: Ch. 1, Section: Teaching and Health Promotion —
Wellness and Illness
Question Stem: During a wellness visit, a 45-year-old patient
expresses readiness to change diet but is unsure where to start.
Which nurse action best applies health promotion principles?
A. Provide a generic handout on low-fat diets and discharge the
patient.
B. Ask about the patient’s typical meals and co-create one
small, achievable change.
C. Refer immediately to a dietitian and postpone any
counseling.
D. Advise the patient to eliminate all carbohydrates to speed
weight loss.
Correct Answer: B
Rationales:
• Correct (B): Assessing current habits and collaboratively
setting a realistic, patient-centered goal is core to health
promotion and behavior change.
• A: Generic materials without tailoring are less effective for
sustained behavior change.
• C: Referral may be appropriate but delaying initial
counseling misses an opportunity for immediate, nurse-led
intervention.
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 graduated RN is preparing to perform a
comprehensive health assessment on a 72-year-old patient
admitted for new-onset confusion. Which action best
demonstrates the RN’s role as a provider of care during this
assessment?
A. Delegating initial vital signs and documentation to nursing
assistive personnel.
B. Performing a focused neurologic assessment and
synthesizing findings for the care plan.
C. Scheduling the patient’s medication reconciliation with the
unit pharmacist.
D. Teaching the patient’s family about community resources
after discharge.
Correct Answer: B
Rationales:
, • Correct (B): Performing and interpreting a focused
neurologic assessment and using those findings to guide
the plan exemplifies the RN’s direct provision of clinical
care and assessment responsibilities. (Aligns with provider
role in assessment.)
• A: Delegation of routine tasks is appropriate but does not
demonstrate the RN’s direct provider role in assessment or
clinical judgment.
• C: Medication reconciliation is an important safety activity
often done collaboratively, but scheduling it demonstrates
coordination rather than direct assessment.
• D: Teaching families is part of the nurse’s role but is more
aligned with health promotion and discharge planning
than immediate clinical assessment.
Teaching Point: RNs directly assess and synthesize findings to
guide immediate care.
Citation: Jensen & Smock, Ch. 1, “Roles of the Professional
Nurse.”
2)
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: An RN is caring for a patient with complex
endocrine disease who requests a medication change. Which
action best reflects appropriate role boundaries between the
,RN and an APRN?
A. The RN independently adjusts the dose based on lab trends.
B. The RN documents the patient’s request and alerts the APRN
for evaluation.
C. The RN prescribes a short course of the alternative
medication.
D. The RN orders additional diagnostic testing to confirm the
need for change.
Correct Answer: B
Rationales:
• Correct (B): Documenting the request and notifying the
APRN follows scope-of-practice boundaries while ensuring
the advanced provider evaluates and prescribes.
• A: Independently adjusting medication dose exceeds RN
scope and risks unsafe practice.
• C: Prescribing is outside typical RN scope unless advanced
practice prescriptive authority exists.
• D: Ordering diagnostic testing is typically within provider
or APRN authority; the RN should recommend or
collaborate rather than independently order.
Teaching Point: RNs gather and communicate assessment data;
prescriptive decisions are for advanced providers.
Citation: Jensen & Smock, Ch. 1, “Registered Nurse Versus
Specialty or Advanced Practice Assessments.”
, 3)
Reference: Ch. 1, Section: Teaching and Health Promotion —
Wellness and Illness
Question Stem: During a wellness visit, a 45-year-old patient
expresses readiness to change diet but is unsure where to start.
Which nurse action best applies health promotion principles?
A. Provide a generic handout on low-fat diets and discharge the
patient.
B. Ask about the patient’s typical meals and co-create one
small, achievable change.
C. Refer immediately to a dietitian and postpone any
counseling.
D. Advise the patient to eliminate all carbohydrates to speed
weight loss.
Correct Answer: B
Rationales:
• Correct (B): Assessing current habits and collaboratively
setting a realistic, patient-centered goal is core to health
promotion and behavior change.
• A: Generic materials without tailoring are less effective for
sustained behavior change.
• C: Referral may be appropriate but delaying initial
counseling misses an opportunity for immediate, nurse-led
intervention.
