COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Chapter 1 – The Nurse’s Role in Health Assessment
Theme: Responsibility in collecting accurate, relevant health data; clinical
judgment; critical thinking; patient-centered care; professional ethics; scope
of practice; legal considerations.
1.
A 45-year-old patient arrives at the outpatient clinic for a routine check-up.
The patient has multiple chronic conditions, including hypertension and
early-stage chronic kidney disease. The nurse begins the assessment by
reviewing the patient’s history and current medications.
Which nursing action best demonstrates the nurse’s responsibility in
conducting an accurate and relevant health assessment?
A. Asking only about the patient’s current symptoms
B. Reviewing previous medical records, medications, lifestyle factors, and
comorbidities
C. Delegating all history-taking to a medical assistant
D. Relying solely on the patient’s verbal report without verification
✅ Answer: B
Rationale: Collecting comprehensive data—including medical history,
medications, lifestyle, and comorbidities—is essential for accurate
assessment, clinical judgment, and patient-centered care. Verification through
records ensures reliability.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts:
Comprehensive Assessment; Bloom’s: Application
2.
A new nurse is assigned to assess a patient admitted with pneumonia. The
charge nurse reminds the nurse to follow legal and ethical standards while
documenting findings.
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Which practice best aligns with professional ethics and legal considerations
in health assessment?
A. Documenting the patient’s symptoms as subjective impressions without
verification
B. Altering assessment data to reflect better outcomes
C. Recording objective findings accurately and notifying the provider of
critical results
D. Leaving gaps in the documentation to save time
✅ Answer: C
Rationale: Accurate documentation of objective findings, including timely
communication of critical results, ensures ethical practice, legal compliance,
and safe patient care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts:
Legal/Ethical Practice; Bloom’s: Analysis
3.
A 32-year-old pregnant patient expresses concern about potential side effects
of her prenatal supplements. The nurse evaluates her understanding and
addresses her concerns.
Which approach best demonstrates patient-centered assessment and clinical
judgment?
A. Ignoring the patient’s questions to save time
B. Providing tailored education and assessing comprehension
C. Telling the patient to follow instructions blindly
D. Delegating education entirely to another staff member
✅ Answer: B
Rationale: Patient-centered assessment requires addressing patient concerns,
evaluating understanding, and adapting education to individual needs to
support informed decision-making.
Keywords: Client Needs: Health Promotion; Systems Concepts: Patient-
Centered Care; Bloom’s: Application
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
4.
During an initial assessment, a nurse notices inconsistencies between a
patient’s reported pain and vital signs.
Which nursing action demonstrates critical thinking and clinical judgment in
data collection?
A. Accepting the patient’s report without further evaluation
B. Ignoring discrepancies and proceeding with the standard plan
C. Reassessing the patient, reviewing history, and considering underlying
causes
D. Assuming the patient is exaggerating symptoms
✅ Answer: C
Rationale: Critical thinking requires analyzing discrepancies, reassessing,
and considering underlying causes to guide safe, accurate, and patient-
centered interventions.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts: Clinical
Reasoning; Bloom’s: Analysis
5.
A nurse is evaluating a patient’s ability to perform self-care at home. The
patient has limited mobility and early cognitive decline.
Which assessment strategy best integrates systems thinking?
A. Evaluating only physical mobility
B. Assessing mobility, cognition, home environment, and support systems
C. Asking the patient to describe mobility without observation
D. Scheduling a follow-up without documenting the initial assessment
✅ Answer: B
Rationale: Systems thinking requires assessment of interconnected factors—
physical, cognitive, environmental, and social—to create a comprehensive
plan of care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Integrated
Assessment; Bloom’s: Application
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
6.
A nurse is preparing to assess a patient recently discharged after heart
surgery. The nurse recalls that scope of practice defines professional
boundaries.
Which action is within the nurse’s scope of practice?
A. Diagnosing heart failure based on assessment
B. Collecting subjective and objective data and reporting findings to the
provider
C. Prescribing medications for post-surgical pain
D. Performing invasive procedures without provider orders
✅ Answer: B
Rationale: Nurses are responsible for assessment and reporting; diagnosis
and prescriptions are outside the nursing scope, which maintains legal
compliance and patient safety.
Keywords: Client Needs: Safe Care; Systems Concepts: Scope of Practice;
Bloom’s: Comprehension
7.
A 60-year-old patient with diabetes visits for routine follow-up. The nurse
notices the patient appears fatigued and reports new numbness in the feet.
Which approach demonstrates effective use of clinical judgment in initial
assessment?
A. Documenting only the fatigue
B. Conducting a focused assessment on neurological, vascular, and metabolic
systems
C. Assuming the symptoms are normal for age
D. Ignoring the new findings until the next visit
✅ Answer: B
Rationale: Effective clinical judgment involves assessing relevant systems
comprehensively to identify complications early and guide timely
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
interventions.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts: Multi-
System Assessment; Bloom’s: Analysis
8.
A nurse is collecting data from a patient who speaks limited English. The
nurse uses a professional medical interpreter rather than relying on a family
member.
Why is this approach important for patient-centered assessment?
A. It is faster than using translation apps
B. Ensures accurate communication, informed consent, and ethical standards
C. Avoids asking the patient direct questions
D. Delegates responsibility to family members
✅ Answer: B
Rationale: Professional interpreters improve accuracy, protect patient rights,
ensure informed consent, and uphold ethical standards in health assessment.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts:
Communication & Ethics; Bloom’s: Application
9.
During a home visit, the nurse observes signs of potential elder neglect.
Which action best reflects professional ethics and legal responsibility?
A. Document findings and report to appropriate authorities
B. Confront the family aggressively
C. Ignore observations to maintain patient rapport
D. Only discuss findings with other nurses
✅ Answer: A
Rationale: Ethical practice requires recognizing abuse, documenting
objectively, and reporting to appropriate authorities to protect patient safety
and comply with legal requirements.
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Chapter 1 – The Nurse’s Role in Health Assessment
Theme: Responsibility in collecting accurate, relevant health data; clinical
judgment; critical thinking; patient-centered care; professional ethics; scope
of practice; legal considerations.
1.
A 45-year-old patient arrives at the outpatient clinic for a routine check-up.
The patient has multiple chronic conditions, including hypertension and
early-stage chronic kidney disease. The nurse begins the assessment by
reviewing the patient’s history and current medications.
Which nursing action best demonstrates the nurse’s responsibility in
conducting an accurate and relevant health assessment?
A. Asking only about the patient’s current symptoms
B. Reviewing previous medical records, medications, lifestyle factors, and
comorbidities
C. Delegating all history-taking to a medical assistant
D. Relying solely on the patient’s verbal report without verification
✅ Answer: B
Rationale: Collecting comprehensive data—including medical history,
medications, lifestyle, and comorbidities—is essential for accurate
assessment, clinical judgment, and patient-centered care. Verification through
records ensures reliability.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts:
Comprehensive Assessment; Bloom’s: Application
2.
A new nurse is assigned to assess a patient admitted with pneumonia. The
charge nurse reminds the nurse to follow legal and ethical standards while
documenting findings.
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
Which practice best aligns with professional ethics and legal considerations
in health assessment?
A. Documenting the patient’s symptoms as subjective impressions without
verification
B. Altering assessment data to reflect better outcomes
C. Recording objective findings accurately and notifying the provider of
critical results
D. Leaving gaps in the documentation to save time
✅ Answer: C
Rationale: Accurate documentation of objective findings, including timely
communication of critical results, ensures ethical practice, legal compliance,
and safe patient care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts:
Legal/Ethical Practice; Bloom’s: Analysis
3.
A 32-year-old pregnant patient expresses concern about potential side effects
of her prenatal supplements. The nurse evaluates her understanding and
addresses her concerns.
Which approach best demonstrates patient-centered assessment and clinical
judgment?
A. Ignoring the patient’s questions to save time
B. Providing tailored education and assessing comprehension
C. Telling the patient to follow instructions blindly
D. Delegating education entirely to another staff member
✅ Answer: B
Rationale: Patient-centered assessment requires addressing patient concerns,
evaluating understanding, and adapting education to individual needs to
support informed decision-making.
Keywords: Client Needs: Health Promotion; Systems Concepts: Patient-
Centered Care; Bloom’s: Application
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
4.
During an initial assessment, a nurse notices inconsistencies between a
patient’s reported pain and vital signs.
Which nursing action demonstrates critical thinking and clinical judgment in
data collection?
A. Accepting the patient’s report without further evaluation
B. Ignoring discrepancies and proceeding with the standard plan
C. Reassessing the patient, reviewing history, and considering underlying
causes
D. Assuming the patient is exaggerating symptoms
✅ Answer: C
Rationale: Critical thinking requires analyzing discrepancies, reassessing,
and considering underlying causes to guide safe, accurate, and patient-
centered interventions.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts: Clinical
Reasoning; Bloom’s: Analysis
5.
A nurse is evaluating a patient’s ability to perform self-care at home. The
patient has limited mobility and early cognitive decline.
Which assessment strategy best integrates systems thinking?
A. Evaluating only physical mobility
B. Assessing mobility, cognition, home environment, and support systems
C. Asking the patient to describe mobility without observation
D. Scheduling a follow-up without documenting the initial assessment
✅ Answer: B
Rationale: Systems thinking requires assessment of interconnected factors—
physical, cognitive, environmental, and social—to create a comprehensive
plan of care.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts: Integrated
Assessment; Bloom’s: Application
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
6.
A nurse is preparing to assess a patient recently discharged after heart
surgery. The nurse recalls that scope of practice defines professional
boundaries.
Which action is within the nurse’s scope of practice?
A. Diagnosing heart failure based on assessment
B. Collecting subjective and objective data and reporting findings to the
provider
C. Prescribing medications for post-surgical pain
D. Performing invasive procedures without provider orders
✅ Answer: B
Rationale: Nurses are responsible for assessment and reporting; diagnosis
and prescriptions are outside the nursing scope, which maintains legal
compliance and patient safety.
Keywords: Client Needs: Safe Care; Systems Concepts: Scope of Practice;
Bloom’s: Comprehension
7.
A 60-year-old patient with diabetes visits for routine follow-up. The nurse
notices the patient appears fatigued and reports new numbness in the feet.
Which approach demonstrates effective use of clinical judgment in initial
assessment?
A. Documenting only the fatigue
B. Conducting a focused assessment on neurological, vascular, and metabolic
systems
C. Assuming the symptoms are normal for age
D. Ignoring the new findings until the next visit
✅ Answer: B
Rationale: Effective clinical judgment involves assessing relevant systems
comprehensively to identify complications early and guide timely
, COMPLETE TEST BANK FOR
Nursing Health Assessment A Clinical Judgement Approach 4th Edition Jensen
interventions.
Keywords: Client Needs: Physiologic Integrity; Systems Concepts: Multi-
System Assessment; Bloom’s: Analysis
8.
A nurse is collecting data from a patient who speaks limited English. The
nurse uses a professional medical interpreter rather than relying on a family
member.
Why is this approach important for patient-centered assessment?
A. It is faster than using translation apps
B. Ensures accurate communication, informed consent, and ethical standards
C. Avoids asking the patient direct questions
D. Delegates responsibility to family members
✅ Answer: B
Rationale: Professional interpreters improve accuracy, protect patient rights,
ensure informed consent, and uphold ethical standards in health assessment.
Keywords: Client Needs: Safe, Effective Care; Systems Concepts:
Communication & Ethics; Bloom’s: Application
9.
During a home visit, the nurse observes signs of potential elder neglect.
Which action best reflects professional ethics and legal responsibility?
A. Document findings and report to appropriate authorities
B. Confront the family aggressively
C. Ignore observations to maintain patient rapport
D. Only discuss findings with other nurses
✅ Answer: A
Rationale: Ethical practice requires recognizing abuse, documenting
objectively, and reporting to appropriate authorities to protect patient safety
and comply with legal requirements.
