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
Question Stem: A registered nurse admits a patient after a
motor vehicle collision. Which activity best reflects the RN’s role
during the initial health assessment?
A. Performing a complete head-to-toe examination and
documenting baseline findings.
B. Ordering a CT scan to rule out intracranial injury.
C. Delegating assessment of airway patency to unlicensed
assistive personnel (UAP).
D. Initiating and interpreting advanced hemodynamic
monitoring.
Correct Answer: A
Rationale — Correct: The RN is responsible for performing
comprehensive baseline assessments that identify immediate
problems and guide care planning; this aligns with the RN's
provider-of-care role. (2 sentences)
,Rationale — B: Ordering diagnostic tests is typically within a
provider or APRN scope; RNs collaborate to obtain tests but do
not independently order them. (1 sentence)
Rationale — C: Delegating airway assessment to UAP is unsafe;
airway patency assessment requires RN judgment and skill. (1
sentence)
Rationale — D: Initiating and interpreting advanced
hemodynamic monitoring is usually an APRN or specialty role;
RNs should understand and implement monitoring per policy
but not independently assume advanced provider functions. (1
sentence)
Teaching Point: RNs perform comprehensive assessments to
establish baseline data and guide care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: The Advanced Practice Registered
Nurse
Question Stem: A patient asks whether an APRN or RN will
manage their chronic pain clinic visit. Which statement correctly
explains the APRN’s role?
A. APRNs can diagnose and manage chronic conditions
independently within their scope and state regulations.
B. APRNs only provide education and cannot prescribe
medications.
,C. APRNs function identically to bedside RNs and do not do
diagnostic reasoning.
D. APRNs are limited to performing physical assessments but
not forming diagnoses.
Correct Answer: A
Rationale — Correct: APRNs have graduate education and,
depending on state scope, can diagnose, treat, and prescribe
for chronic conditions; this delineation is a key distinction from
the RN role. (2 sentences)
Rationale — B: APRNs often have prescriptive authority and
provide more than education; this statement is false. (1
sentence)
Rationale — C: APRNs engage in advanced clinical reasoning
and management beyond bedside RN duties. (1 sentence)
Rationale — D: Formulating diagnoses is within the APRN scope
of practice when appropriately credentialed. (1 sentence)
Teaching Point: APRNs have advanced training enabling
diagnosis and management within scope and regulation.
Citation: Jensen & Smock, Ch. 1, Section: The Advanced Practice
Registered Nurse
3.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A nurse is doing a focused cardiac assessment
in a clinic. Which action best distinguishes a specialty (cardiac)
, assessment from a routine RN assessment?
A. Obtaining a detailed family cardiac history and performing
focused auscultation for murmurs.
B. Measuring blood pressure once and documenting only the
value.
C. Delegating auscultation to a medical assistant.
D. Entering the single BP reading into the electronic record with
no further assessment.
Correct Answer: A
Rationale — Correct: Specialty assessments add depth (e.g.,
detailed cardiac history, focused auscultation) beyond routine
RN assessments and reflect targeted expertise. (2 sentences)
Rationale — B: A single BP value is part of basic assessment but
lacks the depth of a specialty cardiac assessment. (1 sentence)
Rationale — C: Delegating auscultation to unlicensed staff is
inappropriate when specialized assessment is required. (1
sentence)
Rationale — D: Documenting BP only without targeted
assessment misses clinically relevant cardiac information. (1
sentence)
Teaching Point: Specialty assessments deepen focus on system-
specific history and exam.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
4.
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
Question Stem: A registered nurse admits a patient after a
motor vehicle collision. Which activity best reflects the RN’s role
during the initial health assessment?
A. Performing a complete head-to-toe examination and
documenting baseline findings.
B. Ordering a CT scan to rule out intracranial injury.
C. Delegating assessment of airway patency to unlicensed
assistive personnel (UAP).
D. Initiating and interpreting advanced hemodynamic
monitoring.
Correct Answer: A
Rationale — Correct: The RN is responsible for performing
comprehensive baseline assessments that identify immediate
problems and guide care planning; this aligns with the RN's
provider-of-care role. (2 sentences)
,Rationale — B: Ordering diagnostic tests is typically within a
provider or APRN scope; RNs collaborate to obtain tests but do
not independently order them. (1 sentence)
Rationale — C: Delegating airway assessment to UAP is unsafe;
airway patency assessment requires RN judgment and skill. (1
sentence)
Rationale — D: Initiating and interpreting advanced
hemodynamic monitoring is usually an APRN or specialty role;
RNs should understand and implement monitoring per policy
but not independently assume advanced provider functions. (1
sentence)
Teaching Point: RNs perform comprehensive assessments to
establish baseline data and guide care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: The Advanced Practice Registered
Nurse
Question Stem: A patient asks whether an APRN or RN will
manage their chronic pain clinic visit. Which statement correctly
explains the APRN’s role?
A. APRNs can diagnose and manage chronic conditions
independently within their scope and state regulations.
B. APRNs only provide education and cannot prescribe
medications.
,C. APRNs function identically to bedside RNs and do not do
diagnostic reasoning.
D. APRNs are limited to performing physical assessments but
not forming diagnoses.
Correct Answer: A
Rationale — Correct: APRNs have graduate education and,
depending on state scope, can diagnose, treat, and prescribe
for chronic conditions; this delineation is a key distinction from
the RN role. (2 sentences)
Rationale — B: APRNs often have prescriptive authority and
provide more than education; this statement is false. (1
sentence)
Rationale — C: APRNs engage in advanced clinical reasoning
and management beyond bedside RN duties. (1 sentence)
Rationale — D: Formulating diagnoses is within the APRN scope
of practice when appropriately credentialed. (1 sentence)
Teaching Point: APRNs have advanced training enabling
diagnosis and management within scope and regulation.
Citation: Jensen & Smock, Ch. 1, Section: The Advanced Practice
Registered Nurse
3.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A nurse is doing a focused cardiac assessment
in a clinic. Which action best distinguishes a specialty (cardiac)
, assessment from a routine RN assessment?
A. Obtaining a detailed family cardiac history and performing
focused auscultation for murmurs.
B. Measuring blood pressure once and documenting only the
value.
C. Delegating auscultation to a medical assistant.
D. Entering the single BP reading into the electronic record with
no further assessment.
Correct Answer: A
Rationale — Correct: Specialty assessments add depth (e.g.,
detailed cardiac history, focused auscultation) beyond routine
RN assessments and reflect targeted expertise. (2 sentences)
Rationale — B: A single BP value is part of basic assessment but
lacks the depth of a specialty cardiac assessment. (1 sentence)
Rationale — C: Delegating auscultation to unlicensed staff is
inappropriate when specialized assessment is required. (1
sentence)
Rationale — D: Documenting BP only without targeted
assessment misses clinically relevant cardiac information. (1
sentence)
Teaching Point: Specialty assessments deepen focus on system-
specific history and exam.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
4.
