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
Question Stem: A 68-year-old patient is admitted after a fall at
home. The RN completes a focused neurological assessment
and refers the patient for imaging because of focal weakness.
Which statement best describes the RN’s role in this situation?
Options:
A. The RN is practicing beyond scope because ordering imaging
is reserved for APRNs and physicians.
B. The RN is functioning as a provider of care by conducting
assessment, recognizing abnormal findings, and initiating
referral.
C. The RN acted only as a manager of care because delegation
to imaging was the main action.
D. The RN should perform the imaging prior to referral to
,confirm the diagnosis.
Correct Answer: B
Rationales:
Correct: B — The RN’s role includes performing assessments,
recognizing abnormal findings, and initiating appropriate
referrals or escalations, demonstrating provider-of-care
responsibilities (Jensen & Smock).
A: Incorrect — While RNs do not independently order most
tests, identifying abnormal findings and initiating referral is
within scope and appropriate.
C: Incorrect — Manager of care focuses on coordination; the
primary action here is clinical assessment and referral, not only
delegation.
D: Incorrect — RNs do not perform diagnostic imaging; imaging
is performed by trained radiology staff after referral/ordering.
Teaching Point: RNs assess, detect abnormalities, and initiate
referrals—core provider responsibilities.
Citation: Jensen & Smock, Nursing Health Assessment: A Clinical
Judgment Approach, 4th Ed., Ch. 1, Section: Roles of the
Professional Nurse.
2
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A new graduate RN is asked to perform a
,focused cardiac assessment on a client complaining of chest
discomfort. Which action reflects appropriate scope and
differentiation between RN and APRN responsibilities?
Options:
A. The RN prescribes an ECG and nitroglycerin.
B. The RN conducts inspection, auscultation, documents
findings, and notifies the provider for further orders.
C. The RN interprets the ECG and adjusts cardiac medications.
D. The RN performs invasive hemodynamic monitoring to
diagnose the cause.
Correct Answer: B
Rationales:
Correct: B — RNs perform focused assessments, document
objective findings, and escalate to providers; prescribing and
independent diagnostic interpretation are APRN/physician
functions.
A: Incorrect — Prescribing tests and medications is outside RN
scope and requires provider orders.
C: Incorrect — ECG interpretation and medication adjustments
typically fall to providers/APRNs unless after specific
institutional delegation and training.
D: Incorrect — Invasive hemodynamic monitoring is a
specialty/advanced procedure, not routine RN assessment.
Teaching Point: RNs assess, document, and escalate; ordering
and prescribing are provider/APRN tasks.
, Citation: Jensen & Smock, Ch. 1, Section: 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, an RN assesses a
middle-aged patient’s readiness to quit smoking. Which
assessment question best supports teaching and health
promotion?
Options:
A. “Do you think smoking causes any health problems?”
B. “On a scale of 1–10, how ready are you to make a plan to quit
in the next 30 days?”
C. “You should quit now because smoking is dangerous.”
D. “How many times have you tried to quit in the past?”
Correct Answer: B
Rationales:
Correct: B — Asking readiness using a scale measures
motivation and helps tailor teaching and behavior change
interventions (health promotion strategy).
A: Incorrect — This elicits knowledge but not readiness or
motivation for behavior change.
C: Incorrect — Directive advice alone is less effective than
assessing readiness and collaborating on a plan.
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
Question Stem: A 68-year-old patient is admitted after a fall at
home. The RN completes a focused neurological assessment
and refers the patient for imaging because of focal weakness.
Which statement best describes the RN’s role in this situation?
Options:
A. The RN is practicing beyond scope because ordering imaging
is reserved for APRNs and physicians.
B. The RN is functioning as a provider of care by conducting
assessment, recognizing abnormal findings, and initiating
referral.
C. The RN acted only as a manager of care because delegation
to imaging was the main action.
D. The RN should perform the imaging prior to referral to
,confirm the diagnosis.
Correct Answer: B
Rationales:
Correct: B — The RN’s role includes performing assessments,
recognizing abnormal findings, and initiating appropriate
referrals or escalations, demonstrating provider-of-care
responsibilities (Jensen & Smock).
A: Incorrect — While RNs do not independently order most
tests, identifying abnormal findings and initiating referral is
within scope and appropriate.
C: Incorrect — Manager of care focuses on coordination; the
primary action here is clinical assessment and referral, not only
delegation.
D: Incorrect — RNs do not perform diagnostic imaging; imaging
is performed by trained radiology staff after referral/ordering.
Teaching Point: RNs assess, detect abnormalities, and initiate
referrals—core provider responsibilities.
Citation: Jensen & Smock, Nursing Health Assessment: A Clinical
Judgment Approach, 4th Ed., Ch. 1, Section: Roles of the
Professional Nurse.
2
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A new graduate RN is asked to perform a
,focused cardiac assessment on a client complaining of chest
discomfort. Which action reflects appropriate scope and
differentiation between RN and APRN responsibilities?
Options:
A. The RN prescribes an ECG and nitroglycerin.
B. The RN conducts inspection, auscultation, documents
findings, and notifies the provider for further orders.
C. The RN interprets the ECG and adjusts cardiac medications.
D. The RN performs invasive hemodynamic monitoring to
diagnose the cause.
Correct Answer: B
Rationales:
Correct: B — RNs perform focused assessments, document
objective findings, and escalate to providers; prescribing and
independent diagnostic interpretation are APRN/physician
functions.
A: Incorrect — Prescribing tests and medications is outside RN
scope and requires provider orders.
C: Incorrect — ECG interpretation and medication adjustments
typically fall to providers/APRNs unless after specific
institutional delegation and training.
D: Incorrect — Invasive hemodynamic monitoring is a
specialty/advanced procedure, not routine RN assessment.
Teaching Point: RNs assess, document, and escalate; ordering
and prescribing are provider/APRN tasks.
, Citation: Jensen & Smock, Ch. 1, Section: 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, an RN assesses a
middle-aged patient’s readiness to quit smoking. Which
assessment question best supports teaching and health
promotion?
Options:
A. “Do you think smoking causes any health problems?”
B. “On a scale of 1–10, how ready are you to make a plan to quit
in the next 30 days?”
C. “You should quit now because smoking is dangerous.”
D. “How many times have you tried to quit in the past?”
Correct Answer: B
Rationales:
Correct: B — Asking readiness using a scale measures
motivation and helps tailor teaching and behavior change
interventions (health promotion strategy).
A: Incorrect — This elicits knowledge but not readiness or
motivation for behavior change.
C: Incorrect — Directive advice alone is less effective than
assessing readiness and collaborating on a plan.
