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. shop.lww.com
Question Stem: A newly licensed RN is preparing to perform a
comprehensive admission assessment on a stable adult. Which
action best reflects the RN’s role as provider of care during this
assessment?
A. Delegating the entire admission history to a nursing assistant.
B. Completing a focused exam only on the system the patient
complains about.
C. Performing a full head-to-toe physical exam and
documenting findings.
D. Referring the patient immediately to an advanced practice
provider for diagnosis.
Correct Answer: C
Rationale — Correct: Performing a full head-to-toe exam and
documenting is central to the RN’s provider role, collecting data
to plan care (Ch.1).
,Rationale — A: Delegating the entire history to a nursing
assistant abandons professional responsibility; RNs must collect
or directly validate assessment data.
Rationale — B: A focused exam may be appropriate sometimes,
but a comprehensive admission requires head-to-toe
assessment for baseline data.
Rationale — D: Referring is appropriate for scope issues, but
routine comprehensive assessment is within the RN’s role and
needed before referral.
Teaching Point: RN conducts and documents comprehensive
baseline assessments.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
2. Reference: Ch. 1, Section: Advanced Practice Registered
Nurse (APRN) vs RN assessments. shop.lww.com
Question Stem: A patient asks why an APRN is conducting a
diagnostic procedure while the RN only performs nursing
assessments. Which explanation best describes the difference?
A. APRNs focus solely on psychosocial needs; RNs only record
vitals.
B. APRNs can diagnose and prescribe; RNs assess, identify
problems, and implement nursing interventions.
C. RNs are not qualified to perform physical exams.
D. APRNs and RNs have identical legal scopes of practice in all
settings.
,Correct Answer: B
Rationale — Correct: APRNs have authority to diagnose and
prescribe; RNs focus on assessment, nursing diagnoses, and
interventions within their scope.
Rationale — A: Incorrect — roles are not limited to those
extremes; both consider psychosocial needs and vitals.
Rationale — C: Incorrect — RNs routinely perform physical
exams and assessment techniques within their scope.
Rationale — D: Incorrect — scopes differ by licensure and
regulations; they are not identical.
Teaching Point: APRNs diagnose/prescribe; RNs assess and
implement nursing care.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
3. Reference: Ch. 1, Section: Teaching and Health Promotion;
Wellness and Illness. shop.lww.com
Question Stem: During discharge teaching, the nurse identifies
the patient’s stage of illness and readiness to learn. Which
action best demonstrates evidence-based health promotion?
A. Providing a detailed 20-page leaflet regardless of literacy
level.
B. Tailoring teaching to the patient’s readiness, culture, and
health literacy.
C. Assuming the family will learn and not providing patient
education.
, D. Scheduling teaching only once at discharge without follow-
up.
Correct Answer: B
Rationale — Correct: Evidence-based health promotion tailors
teaching to readiness, cultural context, and literacy to enhance
learning and outcomes.
Rationale — A: One-size, dense materials ignore literacy and are
ineffective.
Rationale — C: Assuming others will learn abdicates the nurse’s
teaching role.
Rationale — D: Education often requires repetition and follow-
up for retention and behavior change.
Teaching Point: Tailor teaching to readiness, culture, and health
literacy.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion; Wellness and Illness. shop.lww.com
4. Reference: Ch. 1, Section: Social Determinants of Health;
Healthy People 2030. shop.lww.com
Question Stem: A nurse documents barriers to follow-up care
related to a patient’s housing instability and transportation. This
best reflects the nurse’s role in assessing which concept?
A. Only biologic risk factors.
B. Social determinants of health affecting outcomes.
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. shop.lww.com
Question Stem: A newly licensed RN is preparing to perform a
comprehensive admission assessment on a stable adult. Which
action best reflects the RN’s role as provider of care during this
assessment?
A. Delegating the entire admission history to a nursing assistant.
B. Completing a focused exam only on the system the patient
complains about.
C. Performing a full head-to-toe physical exam and
documenting findings.
D. Referring the patient immediately to an advanced practice
provider for diagnosis.
Correct Answer: C
Rationale — Correct: Performing a full head-to-toe exam and
documenting is central to the RN’s provider role, collecting data
to plan care (Ch.1).
,Rationale — A: Delegating the entire history to a nursing
assistant abandons professional responsibility; RNs must collect
or directly validate assessment data.
Rationale — B: A focused exam may be appropriate sometimes,
but a comprehensive admission requires head-to-toe
assessment for baseline data.
Rationale — D: Referring is appropriate for scope issues, but
routine comprehensive assessment is within the RN’s role and
needed before referral.
Teaching Point: RN conducts and documents comprehensive
baseline assessments.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
2. Reference: Ch. 1, Section: Advanced Practice Registered
Nurse (APRN) vs RN assessments. shop.lww.com
Question Stem: A patient asks why an APRN is conducting a
diagnostic procedure while the RN only performs nursing
assessments. Which explanation best describes the difference?
A. APRNs focus solely on psychosocial needs; RNs only record
vitals.
B. APRNs can diagnose and prescribe; RNs assess, identify
problems, and implement nursing interventions.
C. RNs are not qualified to perform physical exams.
D. APRNs and RNs have identical legal scopes of practice in all
settings.
,Correct Answer: B
Rationale — Correct: APRNs have authority to diagnose and
prescribe; RNs focus on assessment, nursing diagnoses, and
interventions within their scope.
Rationale — A: Incorrect — roles are not limited to those
extremes; both consider psychosocial needs and vitals.
Rationale — C: Incorrect — RNs routinely perform physical
exams and assessment techniques within their scope.
Rationale — D: Incorrect — scopes differ by licensure and
regulations; they are not identical.
Teaching Point: APRNs diagnose/prescribe; RNs assess and
implement nursing care.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
3. Reference: Ch. 1, Section: Teaching and Health Promotion;
Wellness and Illness. shop.lww.com
Question Stem: During discharge teaching, the nurse identifies
the patient’s stage of illness and readiness to learn. Which
action best demonstrates evidence-based health promotion?
A. Providing a detailed 20-page leaflet regardless of literacy
level.
B. Tailoring teaching to the patient’s readiness, culture, and
health literacy.
C. Assuming the family will learn and not providing patient
education.
, D. Scheduling teaching only once at discharge without follow-
up.
Correct Answer: B
Rationale — Correct: Evidence-based health promotion tailors
teaching to readiness, cultural context, and literacy to enhance
learning and outcomes.
Rationale — A: One-size, dense materials ignore literacy and are
ineffective.
Rationale — C: Assuming others will learn abdicates the nurse’s
teaching role.
Rationale — D: Education often requires repetition and follow-
up for retention and behavior change.
Teaching Point: Tailor teaching to readiness, culture, and health
literacy.
Citation: Jensen & Smock, Ch. 1, Teaching and Health
Promotion; Wellness and Illness. shop.lww.com
4. Reference: Ch. 1, Section: Social Determinants of Health;
Healthy People 2030. shop.lww.com
Question Stem: A nurse documents barriers to follow-up care
related to a patient’s housing instability and transportation. This
best reflects the nurse’s role in assessing which concept?
A. Only biologic risk factors.
B. Social determinants of health affecting outcomes.
