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 for a 62-year-old with new heart failure.
Which action best reflects the RN’s role as a provider of care
during the assessment?
A. Performing a focused cardiac exam and teaching the patient
about fluid-restriction.
B. Prescribing diuretic therapy to reduce fluid overload.
C. Delegating the entire admission assessment to a nursing
assistant.
D. Consulting a cardiologist before collecting any subjective
data.
Correct Answer: A
Rationales:
, • A (Correct): Performing a focused cardiac exam and
providing teaching are direct care activities within the RN’s
provider role; this uses assessment data to initiate nursing
interventions. This aligns with the RN’s responsibility to
assess and educate as a provider of care.
• B: Prescribing medications is outside the RN scope unless
they are an APRN with prescriptive authority; RNs
implement and monitor, not prescribe.
• C: Delegating the entire admission assessment to
unlicensed personnel neglects the RN’s accountability for
assessment and is inappropriate.
• D: Consulting a specialist before obtaining basic subjective
data delays timely assessment; initial data collection is the
RN’s responsibility.
Teaching Point: RNs assess, teach, and initiate nursing
interventions within their scope.
Citation: Jensen & Smock, Nursing Health Assessment, 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: An RN admits a patient with complex endocrine
issues and considers whether more advanced testing is needed.
Which choice best describes when an APRN or specialist
,assessment is indicated?
A. When routine subjective data are incomplete.
B. When the problem requires prescriptive authority,
differential diagnosis, or specialty diagnostic reasoning.
C. For every initial history to ensure legal protection.
D. Only when the RN is unavailable to perform the assessment.
Correct Answer: B
Rationales:
• B (Correct): APRNs/specialists are indicated when
diagnostic reasoning extends to prescribing, complex
differential diagnoses, or procedures beyond RN scope.
This differentiates RN assessments from advanced practice
evaluation.
• A: Incomplete subjective data can usually be remedied by
the RN without APRN involvement.
• C: APRN involvement for every history is unnecessary and
inefficient; RNs perform many initial histories.
• D: Availability does not determine scope of practice;
clinical need does.
Teaching Point: Refer to APRN/specialist when assessment
requires advanced diagnostic/prescriptive skills.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
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 assessment, a 45-year-old
patient with obesity states they want to reduce cardiovascular
risk. Which nursing action best fits health promotion?
A. Document the desire and wait for provider orders.
B. Provide tailored counseling on diet, activity, and referral to
resources.
C. Advise the patient to lose 30 pounds in 3 months without
further planning.
D. Focus only on current symptoms and ignore prevention.
Correct Answer: B
Rationales:
• B (Correct): Tailored counseling and referrals are core
health-promotion activities RNs provide during
assessments to support behavior change. This aligns with
teaching and promotion of wellness.
• A: Passive documentation without teaching misses an
opportunity for nursing-led health promotion.
• C: Unrealistic blanket targets without individualized
planning risk discouraging the patient.
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 for a 62-year-old with new heart failure.
Which action best reflects the RN’s role as a provider of care
during the assessment?
A. Performing a focused cardiac exam and teaching the patient
about fluid-restriction.
B. Prescribing diuretic therapy to reduce fluid overload.
C. Delegating the entire admission assessment to a nursing
assistant.
D. Consulting a cardiologist before collecting any subjective
data.
Correct Answer: A
Rationales:
, • A (Correct): Performing a focused cardiac exam and
providing teaching are direct care activities within the RN’s
provider role; this uses assessment data to initiate nursing
interventions. This aligns with the RN’s responsibility to
assess and educate as a provider of care.
• B: Prescribing medications is outside the RN scope unless
they are an APRN with prescriptive authority; RNs
implement and monitor, not prescribe.
• C: Delegating the entire admission assessment to
unlicensed personnel neglects the RN’s accountability for
assessment and is inappropriate.
• D: Consulting a specialist before obtaining basic subjective
data delays timely assessment; initial data collection is the
RN’s responsibility.
Teaching Point: RNs assess, teach, and initiate nursing
interventions within their scope.
Citation: Jensen & Smock, Nursing Health Assessment, 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: An RN admits a patient with complex endocrine
issues and considers whether more advanced testing is needed.
Which choice best describes when an APRN or specialist
,assessment is indicated?
A. When routine subjective data are incomplete.
B. When the problem requires prescriptive authority,
differential diagnosis, or specialty diagnostic reasoning.
C. For every initial history to ensure legal protection.
D. Only when the RN is unavailable to perform the assessment.
Correct Answer: B
Rationales:
• B (Correct): APRNs/specialists are indicated when
diagnostic reasoning extends to prescribing, complex
differential diagnoses, or procedures beyond RN scope.
This differentiates RN assessments from advanced practice
evaluation.
• A: Incomplete subjective data can usually be remedied by
the RN without APRN involvement.
• C: APRN involvement for every history is unnecessary and
inefficient; RNs perform many initial histories.
• D: Availability does not determine scope of practice;
clinical need does.
Teaching Point: Refer to APRN/specialist when assessment
requires advanced diagnostic/prescriptive skills.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
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 assessment, a 45-year-old
patient with obesity states they want to reduce cardiovascular
risk. Which nursing action best fits health promotion?
A. Document the desire and wait for provider orders.
B. Provide tailored counseling on diet, activity, and referral to
resources.
C. Advise the patient to lose 30 pounds in 3 months without
further planning.
D. Focus only on current symptoms and ignore prevention.
Correct Answer: B
Rationales:
• B (Correct): Tailored counseling and referrals are core
health-promotion activities RNs provide during
assessments to support behavior change. This aligns with
teaching and promotion of wellness.
• A: Passive documentation without teaching misses an
opportunity for nursing-led health promotion.
• C: Unrealistic blanket targets without individualized
planning risk discouraging the patient.
