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 newly licensed RN is performing a
comprehensive health assessment on admission. Which activity
best reflects the RN’s role as a provider of care during the
assessment?
A. Designing a new departmental policy for admission timing
B. Performing a physical examination and collecting subjective
history
C. Delegating the entire assessment to nursing assistive
personnel
D. Approving a student's clinical evaluation form
Correct Answer: B
Rationales:
• Correct (B): Performing a physical examination and
collecting the patient’s history are direct patient-care
activities central to the RN’s role as a provider of care;
, these produce the data used for clinical decision-making.
This aligns with the RN’s hands-on assessment
responsibilities.
• A: Designing policy is a managerial/professional activity,
not direct provision of bedside assessment.
• C: Delegating the entire assessment inappropriately
relinquishes clinical judgment the RN is expected to
exercise.
• D: Approving student evaluations is
educational/administrative and not direct patient
assessment.
Teaching Point: The RN as provider performs direct assessment
and collects data for care decisions.
Citation: Ch. 1, Section: The Nurse’s Role in Health Assessment
(Jensen & Smock).
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment action best differentiates an
APRN from a staff RN in scope of practice?
A. Documenting vital signs and intake/output on the chart
B. Completing an initial pain assessment using a standardized
tool
C. Ordering diagnostic tests and interpreting results to diagnose
,a new condition
D. Teaching wound care to a patient and family
Correct Answer: C
Rationales:
• Correct (C): Ordering diagnostic tests and interpreting
them to formulate a medical diagnosis falls within APRN
advanced assessment and diagnostic authority,
distinguishing APRN scope from staff RN.
• A: Recording vitals and I&O are routine RN assessment
tasks within basic scope.
• B: Using standardized tools for pain assessment is essential
RN practice but not unique to APRNs.
• D: Teaching wound care is a core RN function and not
specific to APRN advanced assessment.
Teaching Point: APRNs have expanded diagnostic and ordering
authority beyond staff RN duties.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 58-year-old patient with type 2 diabetes
expresses low motivation to change diet. Which nursing
assessment finding most directly guides a health-promotion
, teaching plan?
A. Patient’s hemoglobin A1c is 8.9%
B. Patient states meals are mostly fast food due to work
schedule
C. Presence of mild peripheral neuropathy on exam
D. Family history of cardiovascular disease
Correct Answer: B
Rationales:
• Correct (B): The patient’s reported eating patterns reveal a
modifiable behavioral barrier and directly inform tailored
teaching and realistic goal setting.
• A: A1c indicates disease control but doesn’t specify
behavior change barriers or readiness.
• C: Neuropathy is an objective complication that should be
addressed, but it doesn’t specify daily habits to shape
teaching.
• D: Family history is a risk factor but offers less immediate
guidance for individualized teaching strategies.
Teaching Point: Patient-reported behaviors identify teachable,
modifiable targets for health promotion.
Citation: Ch. 1, Section: Teaching and Health Promotion.
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 newly licensed RN is performing a
comprehensive health assessment on admission. Which activity
best reflects the RN’s role as a provider of care during the
assessment?
A. Designing a new departmental policy for admission timing
B. Performing a physical examination and collecting subjective
history
C. Delegating the entire assessment to nursing assistive
personnel
D. Approving a student's clinical evaluation form
Correct Answer: B
Rationales:
• Correct (B): Performing a physical examination and
collecting the patient’s history are direct patient-care
activities central to the RN’s role as a provider of care;
, these produce the data used for clinical decision-making.
This aligns with the RN’s hands-on assessment
responsibilities.
• A: Designing policy is a managerial/professional activity,
not direct provision of bedside assessment.
• C: Delegating the entire assessment inappropriately
relinquishes clinical judgment the RN is expected to
exercise.
• D: Approving student evaluations is
educational/administrative and not direct patient
assessment.
Teaching Point: The RN as provider performs direct assessment
and collects data for care decisions.
Citation: Ch. 1, Section: The Nurse’s Role in Health Assessment
(Jensen & Smock).
2.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment action best differentiates an
APRN from a staff RN in scope of practice?
A. Documenting vital signs and intake/output on the chart
B. Completing an initial pain assessment using a standardized
tool
C. Ordering diagnostic tests and interpreting results to diagnose
,a new condition
D. Teaching wound care to a patient and family
Correct Answer: C
Rationales:
• Correct (C): Ordering diagnostic tests and interpreting
them to formulate a medical diagnosis falls within APRN
advanced assessment and diagnostic authority,
distinguishing APRN scope from staff RN.
• A: Recording vitals and I&O are routine RN assessment
tasks within basic scope.
• B: Using standardized tools for pain assessment is essential
RN practice but not unique to APRNs.
• D: Teaching wound care is a core RN function and not
specific to APRN advanced assessment.
Teaching Point: APRNs have expanded diagnostic and ordering
authority beyond staff RN duties.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments.
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 58-year-old patient with type 2 diabetes
expresses low motivation to change diet. Which nursing
assessment finding most directly guides a health-promotion
, teaching plan?
A. Patient’s hemoglobin A1c is 8.9%
B. Patient states meals are mostly fast food due to work
schedule
C. Presence of mild peripheral neuropathy on exam
D. Family history of cardiovascular disease
Correct Answer: B
Rationales:
• Correct (B): The patient’s reported eating patterns reveal a
modifiable behavioral barrier and directly inform tailored
teaching and realistic goal setting.
• A: A1c indicates disease control but doesn’t specify
behavior change barriers or readiness.
• C: Neuropathy is an objective complication that should be
addressed, but it doesn’t specify daily habits to shape
teaching.
• D: Family history is a risk factor but offers less immediate
guidance for individualized teaching strategies.
Teaching Point: Patient-reported behaviors identify teachable,
modifiable targets for health promotion.
Citation: Ch. 1, Section: Teaching and Health Promotion.
4.
