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 — Roles of the Professional Nurse
Question Stem: A newly hired RN in a primary care clinic is
asked to perform an intake health assessment on a 52-year-old
patient. Which statement best reflects the RN’s role in health
assessment compared with an APRN?
A. The RN conducts independent differential diagnoses and
prescribes medication.
B. The RN collects subjective and objective data and
collaborates with the team for planning care.
C. The RN focuses only on data collection and does not
participate in patient education.
D. The RN performs specialty assessments that replace referrals
to advanced practice clinicians.
Correct Answer: B
Rationales:
, • Correct (B): RNs are responsible for collecting
comprehensive subjective and objective data, using clinical
judgment to identify problems, and collaborating with
other providers to plan and implement care. This aligns
with the RN’s role as provider/manager of care.
• A: Incorrect — ordering prescriptions and making
independent diagnoses are typically APRN scope activities,
not standard RN responsibilities.
• C: Incorrect — RNs have a role in teaching and health
promotion; they do more than data collection.
• D: Incorrect — RNs may perform focused assessments but
do not generally replace specialty referrals.
Teaching Point: RNs collect data, apply judgment, and
collaborate; APRNs extend to diagnosis/prescribing.
Citation: Ch. 1, “Roles of the Professional Nurse” (Nursing
Health Assessment: A Clinical Judgment Approach).
2.
Reference: Ch. 1, Section: Provider of Care / Manager of Care
Question Stem: While admitting a postoperative patient, the
RN notes shallow respirations and SpO₂ 89% on room air. Which
action demonstrates appropriate priority setting?
A. Document the finding and reassess in 4 hours.
B. Apply oxygen, call the surgeon immediately, and stay with the
patient.
,C. Encourage deep breathing and ambulation before contacting
anyone.
D. Wait for the next scheduled vital sign check and then notify.
Correct Answer: B
Rationales:
• Correct (B): Hypoxemia (SpO₂ < 90%) with shallow
respirations is an immediate threat to airway/oxygenation
— applying oxygen and notifying the team while remaining
with the patient addresses airway/breathing priorities.
• A: Incorrect — delaying action for documentation and
reassessment risks deterioration.
• C: Incorrect — while deep breathing helps, immediate
oxygen and escalation are required for an SpO₂ of 89%.
• D: Incorrect — waiting is unsafe; this is an urgent finding
needing immediate response.
Teaching Point: Treat airway/oxygenation problems
immediately (ABCs first).
Citation: Ch. 8, Section: Priority Setting — “Airway,
Breathing, Circulation” (Unit 1 content).
3.
Reference: Ch. 2, Section: What Is Health Assessment? —
Subjective vs Objective Cues
Question Stem: A 30-year-old reports “shortness of breath for 2
days” (subjective). On exam, you observe intercostal retractions
, and audible wheeze (objective). Which is the best nurse
interpretation?
A. Subjective and objective findings are conflicting; treat as
anxiety.
B. Objective cues validate the subjective complaint and suggest
respiratory distress.
C. Only objective data matter for diagnosis; subjective report
can be ignored.
D. Subjective report indicates pain, while objective findings
indicate cardiac failure.
Correct Answer: B
Rationales:
• Correct (B): The subjective complaint paired with objective
signs (retractions, wheeze) corroborates respiratory
compromise and guides urgent assessment/intervention.
• A: Incorrect — findings are consistent rather than
conflicting; anxiety should not be assumed.
• C: Incorrect — both cue types are essential; subjective data
inform the assessment.
• D: Incorrect — intercostal retractions and wheeze primarily
indicate airway/respiratory issues, not specifically pain or
isolated cardiac failure.
Teaching Point: Combine subjective and objective cues to
form accurate nursing judgments.
Citation: Ch. 2, “Subjective and Objective Cues.”
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 — Roles of the Professional Nurse
Question Stem: A newly hired RN in a primary care clinic is
asked to perform an intake health assessment on a 52-year-old
patient. Which statement best reflects the RN’s role in health
assessment compared with an APRN?
A. The RN conducts independent differential diagnoses and
prescribes medication.
B. The RN collects subjective and objective data and
collaborates with the team for planning care.
C. The RN focuses only on data collection and does not
participate in patient education.
D. The RN performs specialty assessments that replace referrals
to advanced practice clinicians.
Correct Answer: B
Rationales:
, • Correct (B): RNs are responsible for collecting
comprehensive subjective and objective data, using clinical
judgment to identify problems, and collaborating with
other providers to plan and implement care. This aligns
with the RN’s role as provider/manager of care.
• A: Incorrect — ordering prescriptions and making
independent diagnoses are typically APRN scope activities,
not standard RN responsibilities.
• C: Incorrect — RNs have a role in teaching and health
promotion; they do more than data collection.
• D: Incorrect — RNs may perform focused assessments but
do not generally replace specialty referrals.
Teaching Point: RNs collect data, apply judgment, and
collaborate; APRNs extend to diagnosis/prescribing.
Citation: Ch. 1, “Roles of the Professional Nurse” (Nursing
Health Assessment: A Clinical Judgment Approach).
2.
Reference: Ch. 1, Section: Provider of Care / Manager of Care
Question Stem: While admitting a postoperative patient, the
RN notes shallow respirations and SpO₂ 89% on room air. Which
action demonstrates appropriate priority setting?
A. Document the finding and reassess in 4 hours.
B. Apply oxygen, call the surgeon immediately, and stay with the
patient.
,C. Encourage deep breathing and ambulation before contacting
anyone.
D. Wait for the next scheduled vital sign check and then notify.
Correct Answer: B
Rationales:
• Correct (B): Hypoxemia (SpO₂ < 90%) with shallow
respirations is an immediate threat to airway/oxygenation
— applying oxygen and notifying the team while remaining
with the patient addresses airway/breathing priorities.
• A: Incorrect — delaying action for documentation and
reassessment risks deterioration.
• C: Incorrect — while deep breathing helps, immediate
oxygen and escalation are required for an SpO₂ of 89%.
• D: Incorrect — waiting is unsafe; this is an urgent finding
needing immediate response.
Teaching Point: Treat airway/oxygenation problems
immediately (ABCs first).
Citation: Ch. 8, Section: Priority Setting — “Airway,
Breathing, Circulation” (Unit 1 content).
3.
Reference: Ch. 2, Section: What Is Health Assessment? —
Subjective vs Objective Cues
Question Stem: A 30-year-old reports “shortness of breath for 2
days” (subjective). On exam, you observe intercostal retractions
, and audible wheeze (objective). Which is the best nurse
interpretation?
A. Subjective and objective findings are conflicting; treat as
anxiety.
B. Objective cues validate the subjective complaint and suggest
respiratory distress.
C. Only objective data matter for diagnosis; subjective report
can be ignored.
D. Subjective report indicates pain, while objective findings
indicate cardiac failure.
Correct Answer: B
Rationales:
• Correct (B): The subjective complaint paired with objective
signs (retractions, wheeze) corroborates respiratory
compromise and guides urgent assessment/intervention.
• A: Incorrect — findings are consistent rather than
conflicting; anxiety should not be assumed.
• C: Incorrect — both cue types are essential; subjective data
inform the assessment.
• D: Incorrect — intercostal retractions and wheeze primarily
indicate airway/respiratory issues, not specifically pain or
isolated cardiac failure.
Teaching Point: Combine subjective and objective cues to
form accurate nursing judgments.
Citation: Ch. 2, “Subjective and Objective Cues.”
