Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider of Care
Question Stem: A 68-year-old man is admitted with shortness
of breath and new pedal edema. As the provider of care, which
action by the registered nurse best reflects an initial assessment
priority?
A. Complete a comprehensive head-to-toe assessment
immediately.
B. Focused assessment of airway, breathing, and circulation and
obtain vital signs.
C. Schedule teaching on heart failure self-management for
discharge.
D. Document family history of cardiac disease in the electronic
record.
Correct Answer: B
Rationales:
, • Correct (B): Prioritizing airway, breathing, and circulation
(ABCs) and obtaining vital signs is the immediate
assessment action for a patient with cardiopulmonary
symptoms; aligns with provider role to ensure safety and
physiologic stability. (2 sentences)
• A: A comprehensive head-to-toe is important but not the
initial priority when there are acute cardiopulmonary
signs; a focused urgent assessment is indicated first. (1
sentence)
• C: Teaching is important but should occur after the patient
is stabilized and immediate assessment/treatment needs
are met. (1 sentence)
• D: Documenting family history is relevant but not an
immediate intervention for acute shortness of breath and
edema. (1 sentence)
Teaching Point: In acute presentations, prioritize ABCs and
vital signs first.
Citation: Jensen & Smock, Ch. 1, Roles of the Professional
Nurse — Provider of Care.
2.
Reference: Ch. 1, Section: Registered Nurse Versus Advanced
Practice Assessments
Question Stem: A patient presents with new onset confusion
and high fever. The RN recognizes when to escalate assessment
,findings to an APRN or physician. Which finding best warrants
immediate escalation?
A. Temperature 38.3°C (100.9°F) with slight disorientation.
B. Patient reports mild headache and fatigue.
C. Sudden obtundation with inability to follow commands.
D. Blood pressure 130/80 mm Hg and heart rate 84 bpm.
Correct Answer: C
Rationales:
• Correct (C): Sudden decreased level of consciousness and
inability to follow commands are red flags requiring
immediate escalation and advanced
assessment/treatment. (2 sentences)
• A: A moderate fever and slight disorientation require
monitoring and assessment but are not as urgent as
sudden obtundation. (1 sentence)
• B: Mild headache and fatigue are non-specific and do not
alone indicate need for immediate escalation. (1 sentence)
• D: Vital signs in normal range are not urgent findings in this
context. (1 sentence)
Teaching Point: Escalate sudden neurologic deterioration
immediately.
Citation: Jensen & Smock, Ch. 1, Registered Nurse Versus
Advanced Practice Assessments.
, 3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse assesses a 45-year-old patient who
smokes 1 pack per day and has elevated blood pressure. Which
is the most appropriate health-promotion priority to include in
the initial plan of care?
A. Provide detailed smoking-cessation pharmacotherapy
options immediately.
B. Offer brief counseling on smoking cessation and schedule
follow-up.
C. Delay smoking discussion until blood pressure is normalized.
D. Advise the patient that smoking is only a minor risk factor
compared with hypertension.
Correct Answer: B
Rationales:
• Correct (B): Brief counseling and arranging follow-up is an
evidence-based, feasible first step in health promotion that
integrates into nursing care and motivates change. (2
sentences)
• A: Pharmacotherapy may be appropriate but requires
assessment, readiness to quit, and often prescriber
involvement; counseling first is more immediately
implementable. (1 sentence)
• C: Delaying behavior change counseling reduces
opportunities for intervention; it should begin while
monitoring blood pressure. (1 sentence)
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider of Care
Question Stem: A 68-year-old man is admitted with shortness
of breath and new pedal edema. As the provider of care, which
action by the registered nurse best reflects an initial assessment
priority?
A. Complete a comprehensive head-to-toe assessment
immediately.
B. Focused assessment of airway, breathing, and circulation and
obtain vital signs.
C. Schedule teaching on heart failure self-management for
discharge.
D. Document family history of cardiac disease in the electronic
record.
Correct Answer: B
Rationales:
, • Correct (B): Prioritizing airway, breathing, and circulation
(ABCs) and obtaining vital signs is the immediate
assessment action for a patient with cardiopulmonary
symptoms; aligns with provider role to ensure safety and
physiologic stability. (2 sentences)
• A: A comprehensive head-to-toe is important but not the
initial priority when there are acute cardiopulmonary
signs; a focused urgent assessment is indicated first. (1
sentence)
• C: Teaching is important but should occur after the patient
is stabilized and immediate assessment/treatment needs
are met. (1 sentence)
• D: Documenting family history is relevant but not an
immediate intervention for acute shortness of breath and
edema. (1 sentence)
Teaching Point: In acute presentations, prioritize ABCs and
vital signs first.
Citation: Jensen & Smock, Ch. 1, Roles of the Professional
Nurse — Provider of Care.
2.
Reference: Ch. 1, Section: Registered Nurse Versus Advanced
Practice Assessments
Question Stem: A patient presents with new onset confusion
and high fever. The RN recognizes when to escalate assessment
,findings to an APRN or physician. Which finding best warrants
immediate escalation?
A. Temperature 38.3°C (100.9°F) with slight disorientation.
B. Patient reports mild headache and fatigue.
C. Sudden obtundation with inability to follow commands.
D. Blood pressure 130/80 mm Hg and heart rate 84 bpm.
Correct Answer: C
Rationales:
• Correct (C): Sudden decreased level of consciousness and
inability to follow commands are red flags requiring
immediate escalation and advanced
assessment/treatment. (2 sentences)
• A: A moderate fever and slight disorientation require
monitoring and assessment but are not as urgent as
sudden obtundation. (1 sentence)
• B: Mild headache and fatigue are non-specific and do not
alone indicate need for immediate escalation. (1 sentence)
• D: Vital signs in normal range are not urgent findings in this
context. (1 sentence)
Teaching Point: Escalate sudden neurologic deterioration
immediately.
Citation: Jensen & Smock, Ch. 1, Registered Nurse Versus
Advanced Practice Assessments.
, 3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse assesses a 45-year-old patient who
smokes 1 pack per day and has elevated blood pressure. Which
is the most appropriate health-promotion priority to include in
the initial plan of care?
A. Provide detailed smoking-cessation pharmacotherapy
options immediately.
B. Offer brief counseling on smoking cessation and schedule
follow-up.
C. Delay smoking discussion until blood pressure is normalized.
D. Advise the patient that smoking is only a minor risk factor
compared with hypertension.
Correct Answer: B
Rationales:
• Correct (B): Brief counseling and arranging follow-up is an
evidence-based, feasible first step in health promotion that
integrates into nursing care and motivates change. (2
sentences)
• A: Pharmacotherapy may be appropriate but requires
assessment, readiness to quit, and often prescriber
involvement; counseling first is more immediately
implementable. (1 sentence)
• C: Delaying behavior change counseling reduces
opportunities for intervention; it should begin while
monitoring blood pressure. (1 sentence)
