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
Question Stem: A 68-year-old male with COPD arrives
complaining of increased dyspnea. Which role is the RN
primarily demonstrating when performing a focused respiratory
assessment and initiating oxygen per protocol?
A. Member of a Profession
B. Provider of Care
C. Manager of Care
D. Advanced Practice Registered Nurse (APRN)
Correct Answer: B
Rationale (correct): As provider of care, the RN directly
assesses the patient’s respiratory status and implements
evidence-based interventions within the nursing scope, such as
oxygen per protocol. This role emphasizes hands-on
assessment, immediate nursing interventions, and monitoring.
(Aligns with RN responsibilities in assessment and care
,provision.)
Rationale (A): Being a member of a profession refers to ethical
standards and advocacy, not the immediate clinical assessment
and intervention.
Rationale (C): Manager of care focuses on coordination and
resource allocation rather than direct bedside assessment and
immediate intervention.
Rationale (D): APRN implies advanced scope (prescribing,
diagnosis); the described actions fall within RN provider scope
under protocol.
Teaching Point: Provider of care = direct assessment and
immediate nursing interventions.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role in
Health Assessment.
2
Reference: Ch. 1, Section: Provider of Care / APRN vs RN
Assessments
Question Stem: A nurse is asked to perform a preoperative
assessment for an elective surgery. Which assessment type best
fits a comprehensive preoperative evaluation?
A. Focused assessment
B. Comprehensive assessment
C. Emergency assessment
D. Rapid primary survey
Correct Answer: B
,Rationale (correct): A comprehensive assessment
systematically collects a full health history and head-to-toe
physical exam appropriate for preoperative risk identification
and baseline data. It is the standard for planned, nonurgent
encounters to guide perioperative planning.
Rationale (A): Focused assessments address specific problems;
preoperative evaluation requires broader data.
Rationale (C): Emergency assessments prioritize life-threatening
issues and are not appropriate for elective preoperative
evaluation.
Rationale (D): Rapid primary survey (ABCs) is used in
immediate trauma/critically ill patients, not routine
preoperative workups.
Teaching Point: Use comprehensive assessments for planned,
baseline evaluations.
Citation: Jensen & Smock, Ch. 1, Section: Types of Nursing
Assessments.
3
Reference: Ch. 2, Section: Subjective and Objective Cues (Unit 1
Components)
Question Stem: During admission, a patient reports “I feel off
balance.” The nurse documents this statement as:
A. Objective cue — vestibular dysfunction noted
B. Subjective cue — patient reports dizziness
C. Objective cue — abnormal gait observed
, D. Subjective cue — nurse notes vertigo on exam
Correct Answer: B
Rationale (correct): A patient’s verbal report is a subjective cue
and should be documented as such (e.g., patient states “I feel
off balance” or “dizzy”). Subjective data come from the
patient’s perspective and require further objective assessment.
Rationale (A): “Vestibular dysfunction” is a diagnostic inference,
not an objective cue.
Rationale (C): Objective cues are observed findings (e.g.,
abnormal gait), which are distinct from what the patient
reports.
Rationale (D): The nurse cannot convert patient report into an
objective finding without observation; “notes vertigo” would be
inaccurate documentation.
Teaching Point: Patient statements = subjective data; observe
to collect objective findings.
Citation: Jensen & Smock, Ch. 2, Section: Subjective and
Objective Cues.
4
Reference: Ch. 3, Section: Documentation and Communication
— SBAR & Progress Note
Question Stem: A nurse preparing an SBAR to communicate a
rapid change writes: “S: Shortness of breath worsened; B: RR
30, SpO₂ 88% on room air; A: Possible COPD exacerbation; R:
Please assess and consider oxygen.” Which SBAR component is
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
Question Stem: A 68-year-old male with COPD arrives
complaining of increased dyspnea. Which role is the RN
primarily demonstrating when performing a focused respiratory
assessment and initiating oxygen per protocol?
A. Member of a Profession
B. Provider of Care
C. Manager of Care
D. Advanced Practice Registered Nurse (APRN)
Correct Answer: B
Rationale (correct): As provider of care, the RN directly
assesses the patient’s respiratory status and implements
evidence-based interventions within the nursing scope, such as
oxygen per protocol. This role emphasizes hands-on
assessment, immediate nursing interventions, and monitoring.
(Aligns with RN responsibilities in assessment and care
,provision.)
Rationale (A): Being a member of a profession refers to ethical
standards and advocacy, not the immediate clinical assessment
and intervention.
Rationale (C): Manager of care focuses on coordination and
resource allocation rather than direct bedside assessment and
immediate intervention.
Rationale (D): APRN implies advanced scope (prescribing,
diagnosis); the described actions fall within RN provider scope
under protocol.
Teaching Point: Provider of care = direct assessment and
immediate nursing interventions.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role in
Health Assessment.
2
Reference: Ch. 1, Section: Provider of Care / APRN vs RN
Assessments
Question Stem: A nurse is asked to perform a preoperative
assessment for an elective surgery. Which assessment type best
fits a comprehensive preoperative evaluation?
A. Focused assessment
B. Comprehensive assessment
C. Emergency assessment
D. Rapid primary survey
Correct Answer: B
,Rationale (correct): A comprehensive assessment
systematically collects a full health history and head-to-toe
physical exam appropriate for preoperative risk identification
and baseline data. It is the standard for planned, nonurgent
encounters to guide perioperative planning.
Rationale (A): Focused assessments address specific problems;
preoperative evaluation requires broader data.
Rationale (C): Emergency assessments prioritize life-threatening
issues and are not appropriate for elective preoperative
evaluation.
Rationale (D): Rapid primary survey (ABCs) is used in
immediate trauma/critically ill patients, not routine
preoperative workups.
Teaching Point: Use comprehensive assessments for planned,
baseline evaluations.
Citation: Jensen & Smock, Ch. 1, Section: Types of Nursing
Assessments.
3
Reference: Ch. 2, Section: Subjective and Objective Cues (Unit 1
Components)
Question Stem: During admission, a patient reports “I feel off
balance.” The nurse documents this statement as:
A. Objective cue — vestibular dysfunction noted
B. Subjective cue — patient reports dizziness
C. Objective cue — abnormal gait observed
, D. Subjective cue — nurse notes vertigo on exam
Correct Answer: B
Rationale (correct): A patient’s verbal report is a subjective cue
and should be documented as such (e.g., patient states “I feel
off balance” or “dizzy”). Subjective data come from the
patient’s perspective and require further objective assessment.
Rationale (A): “Vestibular dysfunction” is a diagnostic inference,
not an objective cue.
Rationale (C): Objective cues are observed findings (e.g.,
abnormal gait), which are distinct from what the patient
reports.
Rationale (D): The nurse cannot convert patient report into an
objective finding without observation; “notes vertigo” would be
inaccurate documentation.
Teaching Point: Patient statements = subjective data; observe
to collect objective findings.
Citation: Jensen & Smock, Ch. 2, Section: Subjective and
Objective Cues.
4
Reference: Ch. 3, Section: Documentation and Communication
— SBAR & Progress Note
Question Stem: A nurse preparing an SBAR to communicate a
rapid change writes: “S: Shortness of breath worsened; B: RR
30, SpO₂ 88% on room air; A: Possible COPD exacerbation; R:
Please assess and consider oxygen.” Which SBAR component is
