Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment — Roles of the Professional Nurse
Question Stem: A nurse is performing a comprehensive
admission assessment on a newly transferred medical patient.
Which statement best describes the nurse’s primary
professional role during this assessment?
A. Diagnose the patient’s medical conditions and prescribe
treatment.
B. Collect and interpret assessment data to inform nursing
diagnoses and care.
C. Perform advanced diagnostic testing to confirm disease
processes.
D. Delegate the entire assessment to ancillary staff to save time.
Correct Answer: B
Rationale (Correct): The professional nurse’s primary role
during an assessment is to gather and interpret data that form
,the basis for nursing diagnoses and individualized nursing care
plans; this aligns with the nurse as provider and manager of
care.
Rationale (A): Incorrect — diagnosing medical conditions and
prescribing is the role of the provider/APRN or physician, not
the registered nurse.
Rationale (C): Incorrect — advanced diagnostic testing is
outside the routine RN assessment scope and is typically
ordered/performed by providers or specialists.
Rationale (D): Incorrect — while delegation is part of
management, the RN retains responsibility for assessment
quality and cannot fully delegate the primary assessment.
Teaching Point: RNs assess and interpret data to guide nursing
care and outcomes.
Citation: Jensen & Smock, Nursing Health Assessment, Ch. 1,
"Roles of the Professional Nurse".
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient requests a comprehensive medication
adjustment discussion. Which provider is most appropriate to
conduct a medication reconciliation that may include
prescribing changes?
A. Staff RN during initial assessment.
B. Advanced Practice Registered Nurse or prescribing provider.
,C. Nursing assistant during medication delivery.
D. Unit clerk who manages patient charts.
Correct Answer: B
Rationale (Correct): APRNs or other licensed prescribers have
the authority and scope to review and change medications; RNs
perform assessment and reconciliation but cannot legally
prescribe or alter regimens.
Rationale (A): Incorrect — RNs perform reconciliation and
identify issues, but prescribing authority is limited by scope of
practice.
Rationale (C): Incorrect — nursing assistants do not have the
training or legal scope to reconcile or alter medications.
Rationale (D): Incorrect — unit clerks handle administrative
tasks and are not clinically authorized to manage medications.
Teaching Point: Prescribing changes require an authorized
prescriber (APRN/physician).
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 nurse identifies an
adult patient with elevated blood pressure and low physical
activity. Which nursing action most appropriately reflects health
promotion?
, A. Provide a written prescription for antihypertensive
medication.
B. Teach and collaboratively set achievable exercise goals with
the patient.
C. Inform the patient that lifestyle changes rarely affect blood
pressure.
D. Schedule immediate hospital admission for monitoring.
Correct Answer: B
Rationale (Correct): Health promotion includes education and
collaborative goal-setting to improve behaviors (e.g., exercise)
that reduce risk and support wellness; this is a primary nursing
intervention.
Rationale (A): Incorrect — prescribing medication is outside RN
scope unless an APRN; RNs support adherence and education.
Rationale (C): Incorrect — false and discouraging; lifestyle
modifications can significantly impact BP and should be
encouraged.
Rationale (D): Incorrect — immediate admission is not
indicated for asymptomatic elevated BP without red flags.
Teaching Point: Teachable behavior change and goal-setting are
core health-promotion nursing actions.
Citation: Jensen & Smock, Ch. 1, "Teaching and Health
Promotion; Wellness and Illness".
4.
Reference: Ch. 1, Section: Social Determinants of Health:
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment — Roles of the Professional Nurse
Question Stem: A nurse is performing a comprehensive
admission assessment on a newly transferred medical patient.
Which statement best describes the nurse’s primary
professional role during this assessment?
A. Diagnose the patient’s medical conditions and prescribe
treatment.
B. Collect and interpret assessment data to inform nursing
diagnoses and care.
C. Perform advanced diagnostic testing to confirm disease
processes.
D. Delegate the entire assessment to ancillary staff to save time.
Correct Answer: B
Rationale (Correct): The professional nurse’s primary role
during an assessment is to gather and interpret data that form
,the basis for nursing diagnoses and individualized nursing care
plans; this aligns with the nurse as provider and manager of
care.
Rationale (A): Incorrect — diagnosing medical conditions and
prescribing is the role of the provider/APRN or physician, not
the registered nurse.
Rationale (C): Incorrect — advanced diagnostic testing is
outside the routine RN assessment scope and is typically
ordered/performed by providers or specialists.
Rationale (D): Incorrect — while delegation is part of
management, the RN retains responsibility for assessment
quality and cannot fully delegate the primary assessment.
Teaching Point: RNs assess and interpret data to guide nursing
care and outcomes.
Citation: Jensen & Smock, Nursing Health Assessment, Ch. 1,
"Roles of the Professional Nurse".
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient requests a comprehensive medication
adjustment discussion. Which provider is most appropriate to
conduct a medication reconciliation that may include
prescribing changes?
A. Staff RN during initial assessment.
B. Advanced Practice Registered Nurse or prescribing provider.
,C. Nursing assistant during medication delivery.
D. Unit clerk who manages patient charts.
Correct Answer: B
Rationale (Correct): APRNs or other licensed prescribers have
the authority and scope to review and change medications; RNs
perform assessment and reconciliation but cannot legally
prescribe or alter regimens.
Rationale (A): Incorrect — RNs perform reconciliation and
identify issues, but prescribing authority is limited by scope of
practice.
Rationale (C): Incorrect — nursing assistants do not have the
training or legal scope to reconcile or alter medications.
Rationale (D): Incorrect — unit clerks handle administrative
tasks and are not clinically authorized to manage medications.
Teaching Point: Prescribing changes require an authorized
prescriber (APRN/physician).
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 nurse identifies an
adult patient with elevated blood pressure and low physical
activity. Which nursing action most appropriately reflects health
promotion?
, A. Provide a written prescription for antihypertensive
medication.
B. Teach and collaboratively set achievable exercise goals with
the patient.
C. Inform the patient that lifestyle changes rarely affect blood
pressure.
D. Schedule immediate hospital admission for monitoring.
Correct Answer: B
Rationale (Correct): Health promotion includes education and
collaborative goal-setting to improve behaviors (e.g., exercise)
that reduce risk and support wellness; this is a primary nursing
intervention.
Rationale (A): Incorrect — prescribing medication is outside RN
scope unless an APRN; RNs support adherence and education.
Rationale (C): Incorrect — false and discouraging; lifestyle
modifications can significantly impact BP and should be
encouraged.
Rationale (D): Incorrect — immediate admission is not
indicated for asymptomatic elevated BP without red flags.
Teaching Point: Teachable behavior change and goal-setting are
core health-promotion nursing actions.
Citation: Jensen & Smock, Ch. 1, "Teaching and Health
Promotion; Wellness and Illness".
4.
Reference: Ch. 1, Section: Social Determinants of Health:
