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 hospitalized patient asks why the registered
nurse (RN) is performing a comprehensive admission
assessment when an advanced practice nurse (APRN) is
available. Which explanation best reflects the RN’s role?
A. The RN performs assessments only to collect data for the
APRN to interpret.
B. The RN is responsible for conducting holistic assessments and
initiating nursing care.
C. The RN’s assessment is limited to vital signs and hygiene
needs.
D. The RN only documents what the APRN asks for during
rounds.
Correct Answer: B
Rationales:
, • Correct (B): RNs perform holistic nursing assessments,
synthesize subjective and objective data, and initiate
nursing interventions and referrals — a central RN role.
This aligns with the textbook’s description of the RN as
provider of care and assessor.
• Incorrect (A): Incorrect because the RN’s role is
autonomous in assessment and not merely data collector
for APRNs.
• Incorrect (C): Incorrect because RN assessments extend
beyond vital signs to a comprehensive holistic appraisal.
• Incorrect (D): Incorrect since RNs document independently
and respond to findings, not only to APRN requests.
Teaching Point: RNs independently assess and initiate
nursing care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient with chronic heart failure requests
education about self-management. Which provider is best
matched to perform an expanded differential assessment and
adjust medications?
A. Registered Nurse (RN) during routine care
,B. Nursing assistant during teaching rounds
C. Advanced Practice Registered Nurse (APRN) in a clinic visit
D. Unit secretary coordinating appointments
Correct Answer: C
Rationales:
• Correct (C): APRNs have advanced assessment and
prescriptive authority to perform expanded differential
assessments and adjust pharmacologic therapy as
appropriate.
• Incorrect (A): RNs perform comprehensive assessments
and education but generally do not independently adjust
medications.
• Incorrect (B): Nursing assistants do not perform advanced
assessments or medication management.
• Incorrect (D): Unit secretaries do not provide clinical
assessment or medication management.
Teaching Point: APRNs conduct advanced assessments and
may alter treatment plans.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During discharge teaching, a nurse discovers
the patient reads only in the patient’s native language and has
, limited literacy. What is the best immediate action?
A. Provide standard printed discharge instructions in English.
B. Use teach-back with culturally and linguistically appropriate
materials.
C. Assume the family will translate and skip teach-back.
D. Give only verbal instructions to save time.
Correct Answer: B
Rationales:
• Correct (B): Using teach-back with culturally and
linguistically appropriate materials ensures comprehension
and aligns with teaching and health promotion principles.
• Incorrect (A): Providing English materials only likely results
in misunderstanding and nonadherence.
• Incorrect (C): Assuming family will translate risks
inaccuracies and violates patient-centered teaching
principles.
• Incorrect (D): Verbal instructions alone without verification
(teach-back) risk poor retention, especially with limited
literacy.
Teaching Point: Use teach-back and culturally appropriate
materials to confirm understanding.
Citation: Jensen & Smock, Ch. 1, Section: Teaching and
Health Promotion
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 hospitalized patient asks why the registered
nurse (RN) is performing a comprehensive admission
assessment when an advanced practice nurse (APRN) is
available. Which explanation best reflects the RN’s role?
A. The RN performs assessments only to collect data for the
APRN to interpret.
B. The RN is responsible for conducting holistic assessments and
initiating nursing care.
C. The RN’s assessment is limited to vital signs and hygiene
needs.
D. The RN only documents what the APRN asks for during
rounds.
Correct Answer: B
Rationales:
, • Correct (B): RNs perform holistic nursing assessments,
synthesize subjective and objective data, and initiate
nursing interventions and referrals — a central RN role.
This aligns with the textbook’s description of the RN as
provider of care and assessor.
• Incorrect (A): Incorrect because the RN’s role is
autonomous in assessment and not merely data collector
for APRNs.
• Incorrect (C): Incorrect because RN assessments extend
beyond vital signs to a comprehensive holistic appraisal.
• Incorrect (D): Incorrect since RNs document independently
and respond to findings, not only to APRN requests.
Teaching Point: RNs independently assess and initiate
nursing care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A patient with chronic heart failure requests
education about self-management. Which provider is best
matched to perform an expanded differential assessment and
adjust medications?
A. Registered Nurse (RN) during routine care
,B. Nursing assistant during teaching rounds
C. Advanced Practice Registered Nurse (APRN) in a clinic visit
D. Unit secretary coordinating appointments
Correct Answer: C
Rationales:
• Correct (C): APRNs have advanced assessment and
prescriptive authority to perform expanded differential
assessments and adjust pharmacologic therapy as
appropriate.
• Incorrect (A): RNs perform comprehensive assessments
and education but generally do not independently adjust
medications.
• Incorrect (B): Nursing assistants do not perform advanced
assessments or medication management.
• Incorrect (D): Unit secretaries do not provide clinical
assessment or medication management.
Teaching Point: APRNs conduct advanced assessments and
may alter treatment plans.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During discharge teaching, a nurse discovers
the patient reads only in the patient’s native language and has
, limited literacy. What is the best immediate action?
A. Provide standard printed discharge instructions in English.
B. Use teach-back with culturally and linguistically appropriate
materials.
C. Assume the family will translate and skip teach-back.
D. Give only verbal instructions to save time.
Correct Answer: B
Rationales:
• Correct (B): Using teach-back with culturally and
linguistically appropriate materials ensures comprehension
and aligns with teaching and health promotion principles.
• Incorrect (A): Providing English materials only likely results
in misunderstanding and nonadherence.
• Incorrect (C): Assuming family will translate risks
inaccuracies and violates patient-centered teaching
principles.
• Incorrect (D): Verbal instructions alone without verification
(teach-back) risk poor retention, especially with limited
literacy.
Teaching Point: Use teach-back and culturally appropriate
materials to confirm understanding.
Citation: Jensen & Smock, Ch. 1, Section: Teaching and
Health Promotion
