ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
CONTENT
Unit 1: Foundations of Health Assessment
Chapter 1 — The Nurse’s Role in Health Assessment
Chapter 2 — Health History and Interview
Chapter 3 — Assessment Techniques, Safety, and Infection Control
Chapter 4 — Documentation and Interprofessional Communication
Unit 2: General Examinations
Chapter 5 — Vital Signs and General Survey
Chapter 6 — Pain Assessment
Chapter 7 — Nutrition Assessment
Chapter 8 — Assessment of Developmental Stages
Chapter 9 — Mental Health, Violence, and Substance Use Disorder
Chapter 10 — Cultural Assessment
Unit 3: Regional Examinations
Chapter 11 — Skin, Hair, and Nails
Chapter 12 — Head and Neck, with Vision and Hearing Basics
Chapter 13 — Eye Assessment for Advanced and Specialty Practice
Chapter 14 — Ear Assessment for Advanced and Specialty Practice
Chapter 15 — Nose, Sinuses, Mouth, and Throat
Chapter 16 — Thorax and Lungs
Chapter 17 — Heart and Neck Vessels
Chapter 18 — Peripheral Vascular with Lymphatics
Chapter 19 — Breast and Axillae Assessment
Chapter 20 — Abdominal Assessment
Chapter 21 — Musculoskeletal Assessment
Chapter 22 — Neurological and Mental Status
Chapter 23 — Male Genitalia and Rectum
Chapter 24 — Female Genitalia and Rectum
Unit 4: Special Populations and Foci
Chapter 25 — Pregnancy
Chapter 26 — Newborns and Infants
Chapter 27 — Children and Adolescents
Chapter 28 — Older Adults
Unit 5: Putting It All Together
Chapter 29 — Assessment of the Hospitalized Adult
Chapter 30 — Head-to-Toe Assessment of Adult
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Chapter 1 – The Nurse’s Role in Health Assessment
Theme: Nurse’s responsibility in collecting accurate health data, clinical judgment, patient-
centered care, ethics, scope of practice, legal considerations.
1.
A 32-year-old patient with a history of hypertension arrives for a routine check-up. The nurse
reviews the patient’s records and prepares to perform a health assessment.
Which action demonstrates the nurse’s use of clinical judgment in this context?
A. Immediately performing all assessment steps in a fixed sequence without considering the
patient’s history.
B. Using the patient’s history and current symptoms to prioritize assessment and anticipate
potential complications.
C. Delegating the entire assessment to a nursing assistant to save time.
D. Collecting data but ignoring the patient’s expressed concerns about new symptoms.
✅ Answer: B
Rationale: Clinical judgment involves using knowledge of the patient’s history, current
presentation, and risk factors to make informed decisions about assessment priorities.
Anticipating potential complications ensures proactive and patient-centered care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Clinical Judgment; Bloom’s:
Analysis
2.
A nurse is conducting an initial assessment on a new patient who appears anxious. The patient
has a complex medical history including diabetes and asthma.
How should the nurse integrate patient-centered care into the assessment?
A. Focus solely on collecting objective data such as vitals and lab results.
B. Address the patient’s concerns, ask open-ended questions, and involve them in the
discussion of their health.
C. Limit interaction to only what is required for the electronic health record.
D. Perform a rapid assessment to reduce time spent with the patient.
✅ Answer: B
Rationale: Patient-centered care prioritizes understanding the patient’s experience, concerns,
and preferences. Open-ended questions and active engagement improve trust, accuracy of
information, and therapeutic rapport.
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Keywords: Client Needs: Psychosocial Integrity; Integrated Process: Patient-Centered Care;
Bloom’s: Application
3.
During a home visit, a nurse is aware of legal and ethical considerations in health assessment.
The patient requests the nurse not document sensitive information about lifestyle habits.
What is the nurse’s best course of action?
A. Respect the request completely and omit the information from the record.
B. Document only vague information without context.
C. Explain the importance of accurate documentation for safe care and confidentiality, while
maintaining transparency.
D. Record the information anyway without discussing it with the patient.
✅ Answer: C
Rationale: Nurses must balance ethical respect for patient autonomy with legal obligations to
document accurate health data. Transparency and patient education support both patient-
centered care and professional accountability.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Ethics/Legal; Bloom’s:
Evaluation
4.
A nurse is assigned to assess a patient in the emergency department who has multiple
comorbidities.
Which approach best demonstrates integration of critical thinking and systems-based
assessment?
A. Completing only the focused assessment for the presenting complaint.
B. Gathering data about all body systems and synthesizing information to identify patterns and
risks.
C. Waiting for the physician to provide a checklist for assessment.
D. Asking the patient’s family to provide all assessment information without verification.
✅ Answer: B
Rationale: Critical thinking and systems-based assessment require comprehensive data
collection, pattern recognition, and anticipation of interconnected health risks, allowing for
informed decision-making and holistic care.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
5.
A 45-year-old patient with chronic kidney disease expresses frustration about multiple
medications and dietary restrictions.
Which nursing action reflects professional ethical practice in assessment?
A. Ignoring the patient’s emotional response to focus on objective measures.
B. Documenting only lab values without context.
C. Engaging in empathetic conversation, acknowledging concerns, and assessing adherence and
understanding.
D. Advising the patient to comply without discussion.
✅ Answer: C
Rationale: Ethical practice involves respecting patient perspectives, assessing psychosocial
aspects, and integrating emotional, social, and behavioral factors into care planning.
Keywords: Client Needs: Psychosocial Integrity; Integrated Process: Ethics; Bloom’s: Application
6.
A new graduate nurse is preparing to perform a health assessment and is unsure about the
scope of practice in their state.
What is the most appropriate action?
A. Perform the assessment without clarification to avoid delaying care.
B. Review state regulations and institutional policies to ensure the assessment aligns with legal
scope of practice.
C. Delegate all assessment tasks to another nurse.
D. Limit assessment to only vital signs.
✅ Answer: B
Rationale: Understanding scope of practice ensures legally compliant and safe care. Nurses
must reference state and institutional guidelines before performing assessments outside their
competencies.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Scope of Practice; Bloom’s:
Application
7.
A nurse observes a patient displaying signs of possible neglect during a home assessment.
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Which step demonstrates ethical responsibility and systems-based thinking?
A. Ignore the signs because the patient did not explicitly report abuse.
B. Document observations objectively and notify the appropriate authorities following
institutional policy.
C. Confront the patient aggressively about the suspected neglect.
D. Wait until the next routine visit to assess further.
✅ Answer: B
Rationale: Ethical and professional responsibility includes objective documentation and
reporting of potential harm. Integrating systems knowledge ensures patient safety and
compliance with legal requirements.
Keywords: Client Needs: Safe, Effective Care; Integrated Process: Ethics/Clinical Judgment;
Bloom’s: Application
8.
A patient presents with nonspecific symptoms such as fatigue and mild shortness of breath. The
nurse recognizes the need for holistic assessment.
Which approach best reflects systems-oriented clinical reasoning?
A. Focus only on the respiratory system due to the shortness of breath.
B. Collect information across multiple systems (cardiovascular, hematologic, endocrine) to
identify underlying patterns.
C. Order lab tests without gathering patient history.
D. Limit assessment to the patient’s chief complaint.
✅ Answer: B
Rationale: Systems-oriented assessment integrates data from multiple body systems,
identifying interconnected factors and facilitating accurate clinical judgment and intervention
planning.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
9.
During a clinic visit, a patient asks the nurse why certain questions about lifestyle habits are
necessary.
What is the best response reflecting patient-centered assessment?
A. “These questions are required for documentation only.”
B. “Understanding your habits helps us identify risks and create a personalized care plan.”
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
C. “Please answer; it is mandatory.”
D. “We ask everyone the same questions; it does not affect your care.”
✅ Answer: B
Rationale: Explaining the rationale for questions enhances transparency, fosters trust, and
integrates patient-centered reasoning into assessment and care planning.
Keywords: Client Needs: Health Promotion & Maintenance; Integrated Process: Patient-
Centered Care; Bloom’s: Comprehension
10.
A nurse is reviewing a patient’s previous assessments and identifies inconsistent data entries.
Which action reflects critical thinking and ethical responsibility?
A. Ignore the inconsistencies.
B. Correct the records without documentation of the change.
C. Verify the information with the patient and clarify discrepancies in the documentation.
D. Assume the previous nurse made an error and continue assessment.
✅ Answer: C
Rationale: Ethical assessment requires verifying conflicting information and documenting
accurately. Critical thinking ensures reliable data for clinical decision-making and patient safety.
Keywords: Client Needs: Safe, Effective Care; Integrated Process: Ethics/Clinical Reasoning;
Bloom’s: Analysis
11.
A patient with multiple chronic conditions is admitted for evaluation.
Which strategy demonstrates effective integration of systems-based thinking?
A. Assess only the acute presenting symptom.
B. Review prior medical history, medications, and recent lab results to inform a comprehensive
assessment plan.
C. Collect information solely from the patient’s verbal report.
D. Focus only on physical assessment findings.
✅ Answer: B
Rationale: Systems-based thinking considers interconnected factors including past history,
medications, and lab results, enabling comprehensive assessment and informed clinical
judgment.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
CONTENT
Unit 1: Foundations of Health Assessment
Chapter 1 — The Nurse’s Role in Health Assessment
Chapter 2 — Health History and Interview
Chapter 3 — Assessment Techniques, Safety, and Infection Control
Chapter 4 — Documentation and Interprofessional Communication
Unit 2: General Examinations
Chapter 5 — Vital Signs and General Survey
Chapter 6 — Pain Assessment
Chapter 7 — Nutrition Assessment
Chapter 8 — Assessment of Developmental Stages
Chapter 9 — Mental Health, Violence, and Substance Use Disorder
Chapter 10 — Cultural Assessment
Unit 3: Regional Examinations
Chapter 11 — Skin, Hair, and Nails
Chapter 12 — Head and Neck, with Vision and Hearing Basics
Chapter 13 — Eye Assessment for Advanced and Specialty Practice
Chapter 14 — Ear Assessment for Advanced and Specialty Practice
Chapter 15 — Nose, Sinuses, Mouth, and Throat
Chapter 16 — Thorax and Lungs
Chapter 17 — Heart and Neck Vessels
Chapter 18 — Peripheral Vascular with Lymphatics
Chapter 19 — Breast and Axillae Assessment
Chapter 20 — Abdominal Assessment
Chapter 21 — Musculoskeletal Assessment
Chapter 22 — Neurological and Mental Status
Chapter 23 — Male Genitalia and Rectum
Chapter 24 — Female Genitalia and Rectum
Unit 4: Special Populations and Foci
Chapter 25 — Pregnancy
Chapter 26 — Newborns and Infants
Chapter 27 — Children and Adolescents
Chapter 28 — Older Adults
Unit 5: Putting It All Together
Chapter 29 — Assessment of the Hospitalized Adult
Chapter 30 — Head-to-Toe Assessment of Adult
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Chapter 1 – The Nurse’s Role in Health Assessment
Theme: Nurse’s responsibility in collecting accurate health data, clinical judgment, patient-
centered care, ethics, scope of practice, legal considerations.
1.
A 32-year-old patient with a history of hypertension arrives for a routine check-up. The nurse
reviews the patient’s records and prepares to perform a health assessment.
Which action demonstrates the nurse’s use of clinical judgment in this context?
A. Immediately performing all assessment steps in a fixed sequence without considering the
patient’s history.
B. Using the patient’s history and current symptoms to prioritize assessment and anticipate
potential complications.
C. Delegating the entire assessment to a nursing assistant to save time.
D. Collecting data but ignoring the patient’s expressed concerns about new symptoms.
✅ Answer: B
Rationale: Clinical judgment involves using knowledge of the patient’s history, current
presentation, and risk factors to make informed decisions about assessment priorities.
Anticipating potential complications ensures proactive and patient-centered care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Clinical Judgment; Bloom’s:
Analysis
2.
A nurse is conducting an initial assessment on a new patient who appears anxious. The patient
has a complex medical history including diabetes and asthma.
How should the nurse integrate patient-centered care into the assessment?
A. Focus solely on collecting objective data such as vitals and lab results.
B. Address the patient’s concerns, ask open-ended questions, and involve them in the
discussion of their health.
C. Limit interaction to only what is required for the electronic health record.
D. Perform a rapid assessment to reduce time spent with the patient.
✅ Answer: B
Rationale: Patient-centered care prioritizes understanding the patient’s experience, concerns,
and preferences. Open-ended questions and active engagement improve trust, accuracy of
information, and therapeutic rapport.
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Keywords: Client Needs: Psychosocial Integrity; Integrated Process: Patient-Centered Care;
Bloom’s: Application
3.
During a home visit, a nurse is aware of legal and ethical considerations in health assessment.
The patient requests the nurse not document sensitive information about lifestyle habits.
What is the nurse’s best course of action?
A. Respect the request completely and omit the information from the record.
B. Document only vague information without context.
C. Explain the importance of accurate documentation for safe care and confidentiality, while
maintaining transparency.
D. Record the information anyway without discussing it with the patient.
✅ Answer: C
Rationale: Nurses must balance ethical respect for patient autonomy with legal obligations to
document accurate health data. Transparency and patient education support both patient-
centered care and professional accountability.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Ethics/Legal; Bloom’s:
Evaluation
4.
A nurse is assigned to assess a patient in the emergency department who has multiple
comorbidities.
Which approach best demonstrates integration of critical thinking and systems-based
assessment?
A. Completing only the focused assessment for the presenting complaint.
B. Gathering data about all body systems and synthesizing information to identify patterns and
risks.
C. Waiting for the physician to provide a checklist for assessment.
D. Asking the patient’s family to provide all assessment information without verification.
✅ Answer: B
Rationale: Critical thinking and systems-based assessment require comprehensive data
collection, pattern recognition, and anticipation of interconnected health risks, allowing for
informed decision-making and holistic care.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
5.
A 45-year-old patient with chronic kidney disease expresses frustration about multiple
medications and dietary restrictions.
Which nursing action reflects professional ethical practice in assessment?
A. Ignoring the patient’s emotional response to focus on objective measures.
B. Documenting only lab values without context.
C. Engaging in empathetic conversation, acknowledging concerns, and assessing adherence and
understanding.
D. Advising the patient to comply without discussion.
✅ Answer: C
Rationale: Ethical practice involves respecting patient perspectives, assessing psychosocial
aspects, and integrating emotional, social, and behavioral factors into care planning.
Keywords: Client Needs: Psychosocial Integrity; Integrated Process: Ethics; Bloom’s: Application
6.
A new graduate nurse is preparing to perform a health assessment and is unsure about the
scope of practice in their state.
What is the most appropriate action?
A. Perform the assessment without clarification to avoid delaying care.
B. Review state regulations and institutional policies to ensure the assessment aligns with legal
scope of practice.
C. Delegate all assessment tasks to another nurse.
D. Limit assessment to only vital signs.
✅ Answer: B
Rationale: Understanding scope of practice ensures legally compliant and safe care. Nurses
must reference state and institutional guidelines before performing assessments outside their
competencies.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Scope of Practice; Bloom’s:
Application
7.
A nurse observes a patient displaying signs of possible neglect during a home assessment.
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Which step demonstrates ethical responsibility and systems-based thinking?
A. Ignore the signs because the patient did not explicitly report abuse.
B. Document observations objectively and notify the appropriate authorities following
institutional policy.
C. Confront the patient aggressively about the suspected neglect.
D. Wait until the next routine visit to assess further.
✅ Answer: B
Rationale: Ethical and professional responsibility includes objective documentation and
reporting of potential harm. Integrating systems knowledge ensures patient safety and
compliance with legal requirements.
Keywords: Client Needs: Safe, Effective Care; Integrated Process: Ethics/Clinical Judgment;
Bloom’s: Application
8.
A patient presents with nonspecific symptoms such as fatigue and mild shortness of breath. The
nurse recognizes the need for holistic assessment.
Which approach best reflects systems-oriented clinical reasoning?
A. Focus only on the respiratory system due to the shortness of breath.
B. Collect information across multiple systems (cardiovascular, hematologic, endocrine) to
identify underlying patterns.
C. Order lab tests without gathering patient history.
D. Limit assessment to the patient’s chief complaint.
✅ Answer: B
Rationale: Systems-oriented assessment integrates data from multiple body systems,
identifying interconnected factors and facilitating accurate clinical judgment and intervention
planning.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
9.
During a clinic visit, a patient asks the nurse why certain questions about lifestyle habits are
necessary.
What is the best response reflecting patient-centered assessment?
A. “These questions are required for documentation only.”
B. “Understanding your habits helps us identify risks and create a personalized care plan.”
, ALL Chapters test bank
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
C. “Please answer; it is mandatory.”
D. “We ask everyone the same questions; it does not affect your care.”
✅ Answer: B
Rationale: Explaining the rationale for questions enhances transparency, fosters trust, and
integrates patient-centered reasoning into assessment and care planning.
Keywords: Client Needs: Health Promotion & Maintenance; Integrated Process: Patient-
Centered Care; Bloom’s: Comprehension
10.
A nurse is reviewing a patient’s previous assessments and identifies inconsistent data entries.
Which action reflects critical thinking and ethical responsibility?
A. Ignore the inconsistencies.
B. Correct the records without documentation of the change.
C. Verify the information with the patient and clarify discrepancies in the documentation.
D. Assume the previous nurse made an error and continue assessment.
✅ Answer: C
Rationale: Ethical assessment requires verifying conflicting information and documenting
accurately. Critical thinking ensures reliable data for clinical decision-making and patient safety.
Keywords: Client Needs: Safe, Effective Care; Integrated Process: Ethics/Clinical Reasoning;
Bloom’s: Analysis
11.
A patient with multiple chronic conditions is admitted for evaluation.
Which strategy demonstrates effective integration of systems-based thinking?
A. Assess only the acute presenting symptom.
B. Review prior medical history, medications, and recent lab results to inform a comprehensive
assessment plan.
C. Collect information solely from the patient’s verbal report.
D. Focus only on physical assessment findings.
✅ Answer: B
Rationale: Systems-based thinking considers interconnected factors including past history,
medications, and lab results, enabling comprehensive assessment and informed clinical
judgment.
Keywords: Client Needs: Physiological Integrity; Integrated Process: Clinical Reasoning;
Bloom’s: Analysis
