Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A 68-year-old man is admitted after a fall at
home. As the RN performing the initial health assessment,
which action best demonstrates the role of the nurse as a
provider of care?
A. Arranging a home safety evaluation with social work.
B. Performing an immediate focused assessment of airway,
breathing, and circulation.
C. Referring the patient to an advanced practice nurse for
medication adjustment.
D. Teaching the patient about fall-prevention devices before
discharge.
Correct Answer: B
Rationales:
• Correct (B): Performing an immediate focused ABC
assessment is a direct, hands-on intervention and
, exemplifies the RN’s role as provider of care by addressing
immediate physiological needs. This aligns with the
textbook’s emphasis on nurse responsibilities during initial
assessments.
• A: Arranging home services is appropriate for the nurse as
manager/coordinator of care, but it is not the immediate
provider action during initial assessment.
• C: Referring to APRN is delegation of advanced clinical
decisions, not the RN’s direct provider role in initial
stabilization.
• D: Patient teaching is a provider role but is lower priority
than immediate physiologic assessment after a fall.
Teaching Point: Immediate ABC assessment is the RN’s
primary provider responsibility in acute situations.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: The Nurse’s Role in Health Assessment.
2. Reference: Ch. 1, Section: Registered Nurse Versus Specialty
or Advanced Practice Assessments
Question Stem: During admission, a patient requests a
prescription refill. Which statement reflects appropriate scope
of practice and assessment by an RN before involving an APRN
or physician?
A. The RN refuses and tells the patient to contact the physician
directly.
,B. The RN completes a focused medication history and
documents current symptoms.
C. The RN prescribes a short supply based on prior orders.
D. The RN modifies the dose and provides the medication to the
patient.
Correct Answer: B
Rationales:
• Correct (B): Completing a focused medication history and
documenting symptoms is within RN scope and provides
necessary data for prescribers; it aligns with RN
assessment responsibilities.
• A: Refusing without assessment neglects professional
responsibilities and fails to gather information for
prescribers.
• C & D: Prescribing or modifying medications exceeds the
RN’s scope; such actions are reserved for APRNs or
physicians.
Teaching Point: RNs assess and document; prescriptive
decisions require licensed providers.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3. Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 22-year-old woman with no chronic illness
, attends a wellness visit. Which assessment finding most
strongly indicates a need for targeted health promotion
teaching?
A. She smokes 4–5 cigarettes monthly at social events.
B. She reports daily fruit and vegetable intake.
C. She exercises 30 minutes three times weekly.
D. She received all routine childhood vaccinations.
Correct Answer: A
Rationales:
• Correct (A): Even occasional tobacco use is a modifiable
risk and an opportunity for targeted health promotion and
cessation counseling; textbook emphasizes addressing risk
behaviors.
• B & C: Adequate diet and moderate exercise are positive
health behaviors requiring reinforcement rather than
immediate targeted intervention.
• D: Up-to-date vaccinations are protective; no immediate
health promotion is needed.
Teaching Point: Even infrequent tobacco use warrants
targeted counseling for health promotion.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: Teaching and Health Promotion.
4. Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A 68-year-old man is admitted after a fall at
home. As the RN performing the initial health assessment,
which action best demonstrates the role of the nurse as a
provider of care?
A. Arranging a home safety evaluation with social work.
B. Performing an immediate focused assessment of airway,
breathing, and circulation.
C. Referring the patient to an advanced practice nurse for
medication adjustment.
D. Teaching the patient about fall-prevention devices before
discharge.
Correct Answer: B
Rationales:
• Correct (B): Performing an immediate focused ABC
assessment is a direct, hands-on intervention and
, exemplifies the RN’s role as provider of care by addressing
immediate physiological needs. This aligns with the
textbook’s emphasis on nurse responsibilities during initial
assessments.
• A: Arranging home services is appropriate for the nurse as
manager/coordinator of care, but it is not the immediate
provider action during initial assessment.
• C: Referring to APRN is delegation of advanced clinical
decisions, not the RN’s direct provider role in initial
stabilization.
• D: Patient teaching is a provider role but is lower priority
than immediate physiologic assessment after a fall.
Teaching Point: Immediate ABC assessment is the RN’s
primary provider responsibility in acute situations.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: The Nurse’s Role in Health Assessment.
2. Reference: Ch. 1, Section: Registered Nurse Versus Specialty
or Advanced Practice Assessments
Question Stem: During admission, a patient requests a
prescription refill. Which statement reflects appropriate scope
of practice and assessment by an RN before involving an APRN
or physician?
A. The RN refuses and tells the patient to contact the physician
directly.
,B. The RN completes a focused medication history and
documents current symptoms.
C. The RN prescribes a short supply based on prior orders.
D. The RN modifies the dose and provides the medication to the
patient.
Correct Answer: B
Rationales:
• Correct (B): Completing a focused medication history and
documenting symptoms is within RN scope and provides
necessary data for prescribers; it aligns with RN
assessment responsibilities.
• A: Refusing without assessment neglects professional
responsibilities and fails to gather information for
prescribers.
• C & D: Prescribing or modifying medications exceeds the
RN’s scope; such actions are reserved for APRNs or
physicians.
Teaching Point: RNs assess and document; prescriptive
decisions require licensed providers.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3. Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 22-year-old woman with no chronic illness
, attends a wellness visit. Which assessment finding most
strongly indicates a need for targeted health promotion
teaching?
A. She smokes 4–5 cigarettes monthly at social events.
B. She reports daily fruit and vegetable intake.
C. She exercises 30 minutes three times weekly.
D. She received all routine childhood vaccinations.
Correct Answer: A
Rationales:
• Correct (A): Even occasional tobacco use is a modifiable
risk and an opportunity for targeted health promotion and
cessation counseling; textbook emphasizes addressing risk
behaviors.
• B & C: Adequate diet and moderate exercise are positive
health behaviors requiring reinforcement rather than
immediate targeted intervention.
• D: Up-to-date vaccinations are protective; no immediate
health promotion is needed.
Teaching Point: Even infrequent tobacco use warrants
targeted counseling for health promotion.
Citation: Jensen & Smock, Nursing Health Assessment, 4th
ed., Ch. 1, Section: Teaching and Health Promotion.
4. Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
