, CHAPTER LIST
Chapter 17: Heart and Neck Vessels
Chapter 1: The Nurse’s Role in Health
Assessment
Assessment
Chapter 18: Peripheral Vascular with
Chapter 2: Health History and Interview
Lymphatics Assessment
Chapter 3: Assessment Techniques,
Chapter 19: Breast and Axillae
Safety, and Infection Control
Assessment
Chapter 4: Documentation and
Chapter 20: Abdominal Assessment
Interprofessional Communication
Chapter 21: Musculoskeletal Assessment
Chapter 5: Vital Signs and General
Survey
Chapter 22: Neurological and Mental
Status Assessment
Chapter 6: Pain Assessment
Chapter 23: Male Genitalia and Rectum
Chapter 7: Nutrition Assessment
Assessment
Chapter 8: Assessment of Developmental
Chapter 24: Female Genitalia and
Stages
Rectum Assessment
Chapter 9: Mental Health, Violence, and
Chapter 25: Pregnancy
Substance Use Disorder
Chapter 26: Newborns and Infants
Chapter 10: Cultural Assessment
Chapter 27: Children and Adolescents
Chapter 11: Skin, Hair, and Nails
Assessment
Chapter 28: Older Adults
Chapter 12: Head and Neck, with Vision
Chapter 29: Assessment of the
and Hearing Basics
Hospitalized Adult
Chapter 13: Eye Assessment for
Chapter 30: Head-to-Toe Assessment of
Advanced and Specialty Practice
Adult
Chapter 14: Ear Assessment for
Advanced and Specialty Practice
Chapter 15: Nose, Sinuses, Mouth, and
Throat Assessment
Chapter 16: Thorax and Lungs
Assessment
,Chapter 1: The Nurse’s Role in Health Assessment.
1. A nurse is conducting an initial assessment on a patient admitted with
chest pain. According to the NCSBN Clinical Judgment Measurement
Model (NCJMM), which action represents the "Recognize Cues" stage?
o A) Determining if the pain is cardiac or muscular in origin.
o B) Identifying that the patient is diaphoretic and clutching their
chest.
o C) Deciding to administer sublingual nitroglycerin immediately.
o D) Predicting that the patient may be experiencing a myocardial
infarction.
Answer: B
Rationale: Recognizing cues involves identifying relevant
information from the patient's presentation, such as physical signs
and symptoms. This is the first step in the clinical judgment process,
providing the data needed for subsequent analysis.
Key words: NCJMM, Recognize Cues, Assessment.
2. The nurse understands that health assessment is a continuous process
rather than a one-time task. Which clinical situation best illustrates this
principle?
o A) Completing a comprehensive head-to-toe assessment upon
admission.
o B) Documenting a patient's medical history in the electronic health
record.
o C) Reassessing a patient’s lung sounds after administering a
nebulizer treatment.
, o D) Screening a patient for falls risk using a standardized scale.
Answer: C
Rationale: Continuous assessment involves ongoing evaluation of
the patient's status to monitor changes and the effectiveness of
interventions. Reassessing after an intervention demonstrates the
dynamic nature of nursing care.
Key words: Continuous Assessment, Reassessment, Evaluation.
3. When applying the NCJMM to a patient with a high fever and
productive cough, the nurse "Prioritizes Hypotheses." Which action
does this describe?
o A) Gathering data on the color and consistency of the sputum.
o B) Determining that the risk for impaired gas exchange is more
urgent than the risk for dehydration.
o C) Developing a plan to increase oral fluid intake to 2 liters per day.
o D) Administering the first dose of a prescribed antibiotic.
Answer: B
Rationale: Prioritizing hypotheses involves ranking potential issues
or nursing diagnoses based on urgency, risk, and patient needs.
Identifying which problem requires the most immediate attention is
central to clinical judgment.
Key words: NCJMM, Prioritize Hypotheses, Clinical Judgment.
4. A nurse is caring for a patient who underwent abdominal surgery four
hours ago. Which finding represents a "clinical cue" that requires
immediate analysis?
o A) The patient reports pain at a level 4 on a scale of 0 to 10.
o B) The surgical dressing is dry and intact with no drainage.
, o C) The patient’s heart rate has increased from 78 to 112 beats per
minute.
o D) The patient asks for a sip of water due to a dry mouth.
Answer: C
Rationale: A significant change in vital signs, such as tachycardia, is a critical cue
that suggests a potential complication like hemorrhage or pain. Nurses must
recognize and analyze these cues to ensure patient safety and early intervention.
Key words: Clinical Cue, Tachycardia, Safety.
5. Which statement best describes the role of evidence-based practice
(EBP) in health assessment?
o A) Using assessment techniques passed down through clinical
tradition.
o B) Relying solely on the nurse’s intuition when evaluating a
patient’s condition.
o C) Integrating the best research evidence with clinical expertise and
patient values.
o D) Following hospital protocols regardless of individual patient
presentation.
Answer: C
Rationale: EBP ensures that assessment methods and clinical
decisions are grounded in proven research, combined with the
nurse's professional experience and the patient's unique
preferences. This approach improves patient outcomes and care
quality.
Key words: Evidence-Based Practice, Decision-Making, Clinical
Expertise.
,6. In the NCJMM, the step "Generate Solutions" is most closely
associated with which phase of the traditional nursing process?
o A) Assessment
o B) Diagnosis
o C) Planning
o D) Evaluation
Answer: C
Rationale: Generating solutions involves identifying goals and
interventions to address the prioritized hypotheses, which aligns
with the planning phase of the nursing process. It focuses on what
the nurse can do to help the patient.
Key words: NCJMM, Generate Solutions, Planning.
7. A nurse performs a focused assessment on a patient complaining of
sudden shortness of breath. What is the primary goal of this
assessment type?
o A) To collect a complete database of the patient's health history.
o B) To evaluate the patient's overall wellness and health promotion
needs.
o C) To identify and address a specific, immediate problem or change
in status.
o D) To document baseline data for comparison during future hospital
visits.
Answer: C
Rationale: A focused assessment is targeted toward a specific
concern or body system to rapidly identify issues in urgent
situations. It prioritizes immediate needs over a comprehensive
review.
, Key words: Focused Assessment, Shortness of Breath, Urgency.
8. How does the nurse’s role in health assessment contribute to patient
safety?
o A) By delegating all physical assessment tasks to unlicensed assistive
personnel.
o B) By identifying early signs of clinical deterioration through regular
monitoring.
o C) By focusing only on the chief complaint to save time during the
shift.
o D) By ensuring that the medical record is filled out completely for
billing.
Answer: B
Rationale: Ongoing assessment allows nurses to detect subtle
changes in a patient's condition before they become life-
threatening. This "failure to rescue" prevention is a cornerstone of
nursing's contribution to safety.
Key words: Patient Safety, Clinical Deterioration, Monitoring.
9. During an assessment, a nurse notices a patient is unusually quiet and
avoids eye contact. The nurse "Analyzes Cues" by:
o A) Documenting "patient is uncooperative" in the progress notes.
o B) Asking the patient directly if they are feeling anxious or upset.
o C) Considering if this behavior is related to cultural factors or
emotional distress.
o D) Asking a family member why the patient is acting differently.
Answer: C
Rationale: Analyzing cues involves interpreting the data gathered to
understand what it might mean in the context of the patient's
Chapter 17: Heart and Neck Vessels
Chapter 1: The Nurse’s Role in Health
Assessment
Assessment
Chapter 18: Peripheral Vascular with
Chapter 2: Health History and Interview
Lymphatics Assessment
Chapter 3: Assessment Techniques,
Chapter 19: Breast and Axillae
Safety, and Infection Control
Assessment
Chapter 4: Documentation and
Chapter 20: Abdominal Assessment
Interprofessional Communication
Chapter 21: Musculoskeletal Assessment
Chapter 5: Vital Signs and General
Survey
Chapter 22: Neurological and Mental
Status Assessment
Chapter 6: Pain Assessment
Chapter 23: Male Genitalia and Rectum
Chapter 7: Nutrition Assessment
Assessment
Chapter 8: Assessment of Developmental
Chapter 24: Female Genitalia and
Stages
Rectum Assessment
Chapter 9: Mental Health, Violence, and
Chapter 25: Pregnancy
Substance Use Disorder
Chapter 26: Newborns and Infants
Chapter 10: Cultural Assessment
Chapter 27: Children and Adolescents
Chapter 11: Skin, Hair, and Nails
Assessment
Chapter 28: Older Adults
Chapter 12: Head and Neck, with Vision
Chapter 29: Assessment of the
and Hearing Basics
Hospitalized Adult
Chapter 13: Eye Assessment for
Chapter 30: Head-to-Toe Assessment of
Advanced and Specialty Practice
Adult
Chapter 14: Ear Assessment for
Advanced and Specialty Practice
Chapter 15: Nose, Sinuses, Mouth, and
Throat Assessment
Chapter 16: Thorax and Lungs
Assessment
,Chapter 1: The Nurse’s Role in Health Assessment.
1. A nurse is conducting an initial assessment on a patient admitted with
chest pain. According to the NCSBN Clinical Judgment Measurement
Model (NCJMM), which action represents the "Recognize Cues" stage?
o A) Determining if the pain is cardiac or muscular in origin.
o B) Identifying that the patient is diaphoretic and clutching their
chest.
o C) Deciding to administer sublingual nitroglycerin immediately.
o D) Predicting that the patient may be experiencing a myocardial
infarction.
Answer: B
Rationale: Recognizing cues involves identifying relevant
information from the patient's presentation, such as physical signs
and symptoms. This is the first step in the clinical judgment process,
providing the data needed for subsequent analysis.
Key words: NCJMM, Recognize Cues, Assessment.
2. The nurse understands that health assessment is a continuous process
rather than a one-time task. Which clinical situation best illustrates this
principle?
o A) Completing a comprehensive head-to-toe assessment upon
admission.
o B) Documenting a patient's medical history in the electronic health
record.
o C) Reassessing a patient’s lung sounds after administering a
nebulizer treatment.
, o D) Screening a patient for falls risk using a standardized scale.
Answer: C
Rationale: Continuous assessment involves ongoing evaluation of
the patient's status to monitor changes and the effectiveness of
interventions. Reassessing after an intervention demonstrates the
dynamic nature of nursing care.
Key words: Continuous Assessment, Reassessment, Evaluation.
3. When applying the NCJMM to a patient with a high fever and
productive cough, the nurse "Prioritizes Hypotheses." Which action
does this describe?
o A) Gathering data on the color and consistency of the sputum.
o B) Determining that the risk for impaired gas exchange is more
urgent than the risk for dehydration.
o C) Developing a plan to increase oral fluid intake to 2 liters per day.
o D) Administering the first dose of a prescribed antibiotic.
Answer: B
Rationale: Prioritizing hypotheses involves ranking potential issues
or nursing diagnoses based on urgency, risk, and patient needs.
Identifying which problem requires the most immediate attention is
central to clinical judgment.
Key words: NCJMM, Prioritize Hypotheses, Clinical Judgment.
4. A nurse is caring for a patient who underwent abdominal surgery four
hours ago. Which finding represents a "clinical cue" that requires
immediate analysis?
o A) The patient reports pain at a level 4 on a scale of 0 to 10.
o B) The surgical dressing is dry and intact with no drainage.
, o C) The patient’s heart rate has increased from 78 to 112 beats per
minute.
o D) The patient asks for a sip of water due to a dry mouth.
Answer: C
Rationale: A significant change in vital signs, such as tachycardia, is a critical cue
that suggests a potential complication like hemorrhage or pain. Nurses must
recognize and analyze these cues to ensure patient safety and early intervention.
Key words: Clinical Cue, Tachycardia, Safety.
5. Which statement best describes the role of evidence-based practice
(EBP) in health assessment?
o A) Using assessment techniques passed down through clinical
tradition.
o B) Relying solely on the nurse’s intuition when evaluating a
patient’s condition.
o C) Integrating the best research evidence with clinical expertise and
patient values.
o D) Following hospital protocols regardless of individual patient
presentation.
Answer: C
Rationale: EBP ensures that assessment methods and clinical
decisions are grounded in proven research, combined with the
nurse's professional experience and the patient's unique
preferences. This approach improves patient outcomes and care
quality.
Key words: Evidence-Based Practice, Decision-Making, Clinical
Expertise.
,6. In the NCJMM, the step "Generate Solutions" is most closely
associated with which phase of the traditional nursing process?
o A) Assessment
o B) Diagnosis
o C) Planning
o D) Evaluation
Answer: C
Rationale: Generating solutions involves identifying goals and
interventions to address the prioritized hypotheses, which aligns
with the planning phase of the nursing process. It focuses on what
the nurse can do to help the patient.
Key words: NCJMM, Generate Solutions, Planning.
7. A nurse performs a focused assessment on a patient complaining of
sudden shortness of breath. What is the primary goal of this
assessment type?
o A) To collect a complete database of the patient's health history.
o B) To evaluate the patient's overall wellness and health promotion
needs.
o C) To identify and address a specific, immediate problem or change
in status.
o D) To document baseline data for comparison during future hospital
visits.
Answer: C
Rationale: A focused assessment is targeted toward a specific
concern or body system to rapidly identify issues in urgent
situations. It prioritizes immediate needs over a comprehensive
review.
, Key words: Focused Assessment, Shortness of Breath, Urgency.
8. How does the nurse’s role in health assessment contribute to patient
safety?
o A) By delegating all physical assessment tasks to unlicensed assistive
personnel.
o B) By identifying early signs of clinical deterioration through regular
monitoring.
o C) By focusing only on the chief complaint to save time during the
shift.
o D) By ensuring that the medical record is filled out completely for
billing.
Answer: B
Rationale: Ongoing assessment allows nurses to detect subtle
changes in a patient's condition before they become life-
threatening. This "failure to rescue" prevention is a cornerstone of
nursing's contribution to safety.
Key words: Patient Safety, Clinical Deterioration, Monitoring.
9. During an assessment, a nurse notices a patient is unusually quiet and
avoids eye contact. The nurse "Analyzes Cues" by:
o A) Documenting "patient is uncooperative" in the progress notes.
o B) Asking the patient directly if they are feeling anxious or upset.
o C) Considering if this behavior is related to cultural factors or
emotional distress.
o D) Asking a family member why the patient is acting differently.
Answer: C
Rationale: Analyzing cues involves interpreting the data gathered to
understand what it might mean in the context of the patient's
