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 man arrives for a postoperative
check. Which action best exemplifies the registered nurse’s role
as provider of care during the health assessment?
A. Developing unit staffing assignments for the day
B. Performing a focused respiratory assessment and initiating
oxygen per protocol
C. Writing policies for postoperative pain management for the
hospital
D. Referring the patient to a specialty clinic for follow up care
Correct Answer: B
Rationale (correct): Performing the focused respiratory
assessment and initiating oxygen per protocol is direct, hands-
on care the RN provides at the bedside and aligns with the RN’s
,provider role. This is the most immediate, patient-centered
action. (Ch. 1). LWW Official Store
Rationale (A): Staffing assignments describe a manager role,
not direct patient care.
Rationale (C): Policy writing is typically a managerial or
organizational role rather than immediate clinical assessment.
Rationale (D): Referrals are part of coordinating care but are
not the RN’s immediate provider actions during assessment.
Teaching Point: Provider of care = direct, hands-on assessment
and interventions.
Citation: Jensen & Smock, Ch. 1: The Nurse’s Role in Health
Assessment. LWW Official Store
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
Question Stem: An Advanced Practice Registered Nurse (APRN)
is assessing a patient who reports new chest pain. Which action
demonstrates the APRN’s expanded scope relative to a staff RN?
A. Documenting pain using a 0–10 scale
B. Ordering a stat ECG and initiating a guideline-based
antianginal medication
C. Providing patient education about activity restrictions
D. Reporting vital sign changes to the charge nurse
Correct Answer: B
,Rationale (correct): Ordering diagnostic testing and initiating
prescription medication fall within the APRN’s advanced
practice scope and responsibilities for diagnostic/therapeutic
decision-making. (Ch. 1). LWW Official Store
Rationale (A): Pain documentation is appropriate for all RNs but
does not reflect expanded scope.
Rationale (C): Patient education is part of RN care but not
uniquely APRN.
Rationale (D): Reporting is routine RN communication, not
advanced practice decision-making.
Teaching Point: APRNs can diagnose and initiate treatments per
scope of practice.
Citation: Jensen & Smock, Ch. 1. LWW Official Store
3
Reference: Ch. 2, Section: Health History and Interview
Question Stem: A 24-year-old woman reports intermittent
palpitations. Which question best follows interview principles to
elicit subjective data about her palpitations?
A. “Show me exactly where your ECG leads were placed.”
B. “When did the palpitations first start, and what were you
doing?”
C. “Your heart rate is 110—do you feel short of breath?”
D. “I will auscultate your heart now to check for murmurs.”
Correct Answer: B
, Rationale (correct): Asking about onset and context collects
subjective history directly from the patient and follows
interviewing principles for symptom characterization. (Ch. 2).
LWW Official Store
Rationale (A): Lead placement is an objective/technical detail,
not subjective history.
Rationale (C): Stating a measured heart rate mixes objective
data with a closed question.
Rationale (D): Auscultation is an objective assessment step, not
an interview question.
Teaching Point: Use open, contextual questions to gather
subjective symptom history.
Citation: Jensen & Smock, Ch. 2. LWW Official Store
4
Reference: Ch. 3, Section: Assessment Techniques, Safety, and
Infection Control
Question Stem: While preparing to perform a head-to-toe
assessment, which action best demonstrates adherence to
standard infection-control techniques?
A. Wearing sterile gloves for auscultation of the lungs
B. Hand hygiene before touching the patient and after removing
gloves
C. Skipping hand hygiene if wearing gloves throughout the exam
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 man arrives for a postoperative
check. Which action best exemplifies the registered nurse’s role
as provider of care during the health assessment?
A. Developing unit staffing assignments for the day
B. Performing a focused respiratory assessment and initiating
oxygen per protocol
C. Writing policies for postoperative pain management for the
hospital
D. Referring the patient to a specialty clinic for follow up care
Correct Answer: B
Rationale (correct): Performing the focused respiratory
assessment and initiating oxygen per protocol is direct, hands-
on care the RN provides at the bedside and aligns with the RN’s
,provider role. This is the most immediate, patient-centered
action. (Ch. 1). LWW Official Store
Rationale (A): Staffing assignments describe a manager role,
not direct patient care.
Rationale (C): Policy writing is typically a managerial or
organizational role rather than immediate clinical assessment.
Rationale (D): Referrals are part of coordinating care but are
not the RN’s immediate provider actions during assessment.
Teaching Point: Provider of care = direct, hands-on assessment
and interventions.
Citation: Jensen & Smock, Ch. 1: The Nurse’s Role in Health
Assessment. LWW Official Store
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
Question Stem: An Advanced Practice Registered Nurse (APRN)
is assessing a patient who reports new chest pain. Which action
demonstrates the APRN’s expanded scope relative to a staff RN?
A. Documenting pain using a 0–10 scale
B. Ordering a stat ECG and initiating a guideline-based
antianginal medication
C. Providing patient education about activity restrictions
D. Reporting vital sign changes to the charge nurse
Correct Answer: B
,Rationale (correct): Ordering diagnostic testing and initiating
prescription medication fall within the APRN’s advanced
practice scope and responsibilities for diagnostic/therapeutic
decision-making. (Ch. 1). LWW Official Store
Rationale (A): Pain documentation is appropriate for all RNs but
does not reflect expanded scope.
Rationale (C): Patient education is part of RN care but not
uniquely APRN.
Rationale (D): Reporting is routine RN communication, not
advanced practice decision-making.
Teaching Point: APRNs can diagnose and initiate treatments per
scope of practice.
Citation: Jensen & Smock, Ch. 1. LWW Official Store
3
Reference: Ch. 2, Section: Health History and Interview
Question Stem: A 24-year-old woman reports intermittent
palpitations. Which question best follows interview principles to
elicit subjective data about her palpitations?
A. “Show me exactly where your ECG leads were placed.”
B. “When did the palpitations first start, and what were you
doing?”
C. “Your heart rate is 110—do you feel short of breath?”
D. “I will auscultate your heart now to check for murmurs.”
Correct Answer: B
, Rationale (correct): Asking about onset and context collects
subjective history directly from the patient and follows
interviewing principles for symptom characterization. (Ch. 2).
LWW Official Store
Rationale (A): Lead placement is an objective/technical detail,
not subjective history.
Rationale (C): Stating a measured heart rate mixes objective
data with a closed question.
Rationale (D): Auscultation is an objective assessment step, not
an interview question.
Teaching Point: Use open, contextual questions to gather
subjective symptom history.
Citation: Jensen & Smock, Ch. 2. LWW Official Store
4
Reference: Ch. 3, Section: Assessment Techniques, Safety, and
Infection Control
Question Stem: While preparing to perform a head-to-toe
assessment, which action best demonstrates adherence to
standard infection-control techniques?
A. Wearing sterile gloves for auscultation of the lungs
B. Hand hygiene before touching the patient and after removing
gloves
C. Skipping hand hygiene if wearing gloves throughout the exam
