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 licensed RN is preparing to perform an
admission assessment on a 68-year-old patient. Which
statement best reflects the RN role in health assessment?
A. The RN performs only data collection and defers all
interpretation to the provider.
B. The RN collects, synthesizes data, and uses clinical judgment
to contribute to the plan of care.
C. The RN should focus exclusively on physical findings;
psychosocial needs are assessed later.
D. The RN replaces the provider’s diagnostic role by making
medical diagnoses.
Correct Answer: B
Rationales:
, • Correct (B): The RN’s role includes data collection,
synthesis, and applying clinical judgment to inform nursing
diagnoses and plan of care, consistent with professional
nursing responsibilities.
• A: Incorrect — RNs interpret and synthesize assessment
data, not merely collect it.
• C: Incorrect — Comprehensive nursing assessment
integrates physical, psychosocial, and functional domains
concurrently.
• D: Incorrect — RNs formulate nursing diagnoses and care
plans but do not make independent medical diagnoses
reserved for providers.
Teaching Point: RNs assess, interpret, and use clinical judgment
to guide nursing care.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment.
2
Reference: Ch. 1, Section: The Registered Nurse Versus
Specialty or Advanced Practice Assessments
Question Stem: A clinic nurse receives an order for a
preoperative history and physical on a routine case. When
should the nurse consult an APRN or provider to expand the
assessment?
,A. Only if the patient is scheduled for major surgery.
B. When assessment reveals unexpected abnormal findings or
complex comorbidities.
C. Never — the RN completes all preoperative assessments
independently.
D. Only if the patient expressly requests to speak with an APRN.
Correct Answer: B
Rationales:
• Correct (B): RNs escalate to APRN/provider when findings
are complex or outside routine scope — ensuring
appropriate specialty assessment and decision-making.
• A: Incorrect — complexity, not just the label “major,”
dictates consultation.
• C: Incorrect — RNs recognize limits and consult when
findings require advanced assessment.
• D: Incorrect — Patient request alone is not the primary
trigger; clinical findings and scope of practice determine
escalation.
Teaching Point: Escalate when assessment uncovers complex or
unexpected problems.
Citation: Jensen & Smock, Ch. 1, Registered Nurse Versus
Specialty or Advanced Practice Assessments.
3
, Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 45-year-old with prehypertension asks how
to reduce cardiovascular risk. As part of health promotion,
which teaching priority should the nurse emphasize first?
A. Discussing surgical options to prevent heart disease.
B. Implementing lifestyle changes: diet, physical activity, and
weight control.
C. Starting multiple prescription medications immediately.
D. Recommending annual screening only.
Correct Answer: B
Rationales:
• Correct (B): Primary prevention emphasizes modifiable
lifestyle factors (diet, exercise, weight) as first-line
interventions for prehypertension.
• A: Incorrect — Surgery is not a first-line preventive strategy
for prehypertension.
• C: Incorrect — Pharmacotherapy may be appropriate later;
lifestyle change is first priority for prehypertension.
• D: Incorrect — Screening is important but not sufficient;
active behavioral change is needed now.
Teaching Point: Prioritize lifestyle modification for primary
prevention of cardiovascular risk.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion.
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 licensed RN is preparing to perform an
admission assessment on a 68-year-old patient. Which
statement best reflects the RN role in health assessment?
A. The RN performs only data collection and defers all
interpretation to the provider.
B. The RN collects, synthesizes data, and uses clinical judgment
to contribute to the plan of care.
C. The RN should focus exclusively on physical findings;
psychosocial needs are assessed later.
D. The RN replaces the provider’s diagnostic role by making
medical diagnoses.
Correct Answer: B
Rationales:
, • Correct (B): The RN’s role includes data collection,
synthesis, and applying clinical judgment to inform nursing
diagnoses and plan of care, consistent with professional
nursing responsibilities.
• A: Incorrect — RNs interpret and synthesize assessment
data, not merely collect it.
• C: Incorrect — Comprehensive nursing assessment
integrates physical, psychosocial, and functional domains
concurrently.
• D: Incorrect — RNs formulate nursing diagnoses and care
plans but do not make independent medical diagnoses
reserved for providers.
Teaching Point: RNs assess, interpret, and use clinical judgment
to guide nursing care.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment.
2
Reference: Ch. 1, Section: The Registered Nurse Versus
Specialty or Advanced Practice Assessments
Question Stem: A clinic nurse receives an order for a
preoperative history and physical on a routine case. When
should the nurse consult an APRN or provider to expand the
assessment?
,A. Only if the patient is scheduled for major surgery.
B. When assessment reveals unexpected abnormal findings or
complex comorbidities.
C. Never — the RN completes all preoperative assessments
independently.
D. Only if the patient expressly requests to speak with an APRN.
Correct Answer: B
Rationales:
• Correct (B): RNs escalate to APRN/provider when findings
are complex or outside routine scope — ensuring
appropriate specialty assessment and decision-making.
• A: Incorrect — complexity, not just the label “major,”
dictates consultation.
• C: Incorrect — RNs recognize limits and consult when
findings require advanced assessment.
• D: Incorrect — Patient request alone is not the primary
trigger; clinical findings and scope of practice determine
escalation.
Teaching Point: Escalate when assessment uncovers complex or
unexpected problems.
Citation: Jensen & Smock, Ch. 1, Registered Nurse Versus
Specialty or Advanced Practice Assessments.
3
, Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 45-year-old with prehypertension asks how
to reduce cardiovascular risk. As part of health promotion,
which teaching priority should the nurse emphasize first?
A. Discussing surgical options to prevent heart disease.
B. Implementing lifestyle changes: diet, physical activity, and
weight control.
C. Starting multiple prescription medications immediately.
D. Recommending annual screening only.
Correct Answer: B
Rationales:
• Correct (B): Primary prevention emphasizes modifiable
lifestyle factors (diet, exercise, weight) as first-line
interventions for prehypertension.
• A: Incorrect — Surgery is not a first-line preventive strategy
for prehypertension.
• C: Incorrect — Pharmacotherapy may be appropriate later;
lifestyle change is first priority for prehypertension.
• D: Incorrect — Screening is important but not sufficient;
active behavioral change is needed now.
Teaching Point: Prioritize lifestyle modification for primary
prevention of cardiovascular risk.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion.
