NURSING HEALTH ASSESSMENT: A
CLINICAL JUDGMENT APPROACH;4th
Edition | Jensen &
Smock:COMPREHENSIVE TEST BANK
Multiple-Choice Questions with
Answers and Rationales Covering
Foundations of Health Assessment,
The Nurse's Role, Clinical Judgment,
and Priority Setting
A 68-year-old patient is admitted with shortness of breath and new pedal
edema. As the provider of care, which action by the registered nurse best
reflects an initial assessment priority?
A. Complete a comprehensive head-to-toe assessment immediately.
B. Perform a focused assessment of airway, breathing, and circulation and
obtain vital signs.
C. Schedule teaching on heart failure self-management for discharge.
D. Document family history of cardiac disease in the electronic record.
Correct Answer: B
,Rationale: The RN's priority as provider of care is to address immediate
physiological concerns. A focused ABC assessment identifies life-
threatening issues first. Comprehensive assessments are important but not
the initial priority in acute situations. Teaching and documentation, while
essential, occur after stabilization and data collection .
A newly licensed RN is preparing to perform a comprehensive admission
assessment on a stable adult. Which action best reflects the RN's role as
provider of care during this assessment?
A. Delegating the entire admission history to a nursing assistant.
B. Completing a focused exam only on the system the patient complains
about.
C. Performing a full head-to-toe physical exam and documenting findings.
D. Referring the patient immediately to an advanced practice provider for
diagnosis.
Correct Answer: C
Rationale: Performing a full head-to-toe exam and documenting findings
is central to the RN's provider role, collecting data to plan care. Delegating
the entire history to a nursing assistant abandons professional
responsibility. A focused exam may be appropriate in some situations, but a
comprehensive admission requires head-to-toe assessment for baseline
data .
A community health nurse is implementing a program that teaches proper
hand hygiene techniques to elementary school children. Which of the four
broad goals of professional nursing is the nurse primarily fulfilling?
A. Treating human responses to health or illness.
B. Preventing illness.
,C. Promoting health.
D. Advocating for individuals, families, communities, and populations.
Correct Answer: C
Rationale: Promoting health involves optimizing well-being and
functioning through activities like health education. Teaching hand hygiene
directly promotes health by instilling behaviors that maintain optimal
functioning. While hand hygiene does prevent illness, the primary focus is
actively promoting healthy behaviors rather than preventing specific
diseases .
A nonnursing colleague asks about the purpose of the nursing code of
ethics. Which response best defines its purpose?
A. Improves self-health care.
B. Protects the patient's confidentiality.
C. Ensures identical care to all patients.
D. Defines the principles of right and wrong to provide patient care.
Correct Answer: D
Rationale: The code of ethics provides philosophical ideals of right and
wrong that define principles used to provide care for patients. When giving
care, it is essential to provide specified services according to standards of
practice and follow a code of ethics .
The nurse obtains vital signs, auscultates lung sounds, listens to heart
sounds, determines level of comfort, and collects blood and sputum
samples for analysis. Which standard of practice is being performed?
A. Diagnosis.
B. Evaluation.
, C. Assessment.
D. Implementation.
Correct Answer: C
Rationale: Assessment is the collection of comprehensive data pertinent to
the patient's health and/or situation. The actions described—obtaining vital
signs, auscultating, and collecting samples—all represent data collection
activities central to the assessment phase .
A patient wants to go home on oxygen and be comfortable. The family
wants the patient to have a new surgical procedure. The nurse explains the
risks and benefits of surgery to the family and discusses the patient's wishes
with them. Which nursing role is the nurse demonstrating?
A. Educator.
B. Advocate.
C. Caregiver.
D. Case manager.
Correct Answer: B
Rationale: An advocate protects the patient's human and legal right to
make choices about care. The nurse provides information to help the
patient decide whether to accept treatment and communicates the
patient's wishes to family members .
Which statement best reflects evidence-based practice?
A. Nursing care based on tradition.
B. Scholarly inquiry of nursing and biomedical research literature only.
C. A problem-solving approach that integrates best current evidence with
clinical practice.
CLINICAL JUDGMENT APPROACH;4th
Edition | Jensen &
Smock:COMPREHENSIVE TEST BANK
Multiple-Choice Questions with
Answers and Rationales Covering
Foundations of Health Assessment,
The Nurse's Role, Clinical Judgment,
and Priority Setting
A 68-year-old patient is admitted with shortness of breath and new pedal
edema. As the provider of care, which action by the registered nurse best
reflects an initial assessment priority?
A. Complete a comprehensive head-to-toe assessment immediately.
B. Perform a focused assessment of airway, breathing, and circulation and
obtain vital signs.
C. Schedule teaching on heart failure self-management for discharge.
D. Document family history of cardiac disease in the electronic record.
Correct Answer: B
,Rationale: The RN's priority as provider of care is to address immediate
physiological concerns. A focused ABC assessment identifies life-
threatening issues first. Comprehensive assessments are important but not
the initial priority in acute situations. Teaching and documentation, while
essential, occur after stabilization and data collection .
A newly licensed RN is preparing to perform a comprehensive admission
assessment on a stable adult. Which action best reflects the RN's role as
provider of care during this assessment?
A. Delegating the entire admission history to a nursing assistant.
B. Completing a focused exam only on the system the patient complains
about.
C. Performing a full head-to-toe physical exam and documenting findings.
D. Referring the patient immediately to an advanced practice provider for
diagnosis.
Correct Answer: C
Rationale: Performing a full head-to-toe exam and documenting findings
is central to the RN's provider role, collecting data to plan care. Delegating
the entire history to a nursing assistant abandons professional
responsibility. A focused exam may be appropriate in some situations, but a
comprehensive admission requires head-to-toe assessment for baseline
data .
A community health nurse is implementing a program that teaches proper
hand hygiene techniques to elementary school children. Which of the four
broad goals of professional nursing is the nurse primarily fulfilling?
A. Treating human responses to health or illness.
B. Preventing illness.
,C. Promoting health.
D. Advocating for individuals, families, communities, and populations.
Correct Answer: C
Rationale: Promoting health involves optimizing well-being and
functioning through activities like health education. Teaching hand hygiene
directly promotes health by instilling behaviors that maintain optimal
functioning. While hand hygiene does prevent illness, the primary focus is
actively promoting healthy behaviors rather than preventing specific
diseases .
A nonnursing colleague asks about the purpose of the nursing code of
ethics. Which response best defines its purpose?
A. Improves self-health care.
B. Protects the patient's confidentiality.
C. Ensures identical care to all patients.
D. Defines the principles of right and wrong to provide patient care.
Correct Answer: D
Rationale: The code of ethics provides philosophical ideals of right and
wrong that define principles used to provide care for patients. When giving
care, it is essential to provide specified services according to standards of
practice and follow a code of ethics .
The nurse obtains vital signs, auscultates lung sounds, listens to heart
sounds, determines level of comfort, and collects blood and sputum
samples for analysis. Which standard of practice is being performed?
A. Diagnosis.
B. Evaluation.
, C. Assessment.
D. Implementation.
Correct Answer: C
Rationale: Assessment is the collection of comprehensive data pertinent to
the patient's health and/or situation. The actions described—obtaining vital
signs, auscultating, and collecting samples—all represent data collection
activities central to the assessment phase .
A patient wants to go home on oxygen and be comfortable. The family
wants the patient to have a new surgical procedure. The nurse explains the
risks and benefits of surgery to the family and discusses the patient's wishes
with them. Which nursing role is the nurse demonstrating?
A. Educator.
B. Advocate.
C. Caregiver.
D. Case manager.
Correct Answer: B
Rationale: An advocate protects the patient's human and legal right to
make choices about care. The nurse provides information to help the
patient decide whether to accept treatment and communicates the
patient's wishes to family members .
Which statement best reflects evidence-based practice?
A. Nursing care based on tradition.
B. Scholarly inquiry of nursing and biomedical research literature only.
C. A problem-solving approach that integrates best current evidence with
clinical practice.
