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 (Roles of the Professional Nurse — Provider of Care)
Question Stem: A 72-year-old man arrives with a two-day
history of increasing shortness of breath and productive cough.
As the primary nurse performing the admission assessment,
which action best reflects the nurse’s role as a provider of care?
A. Teach the patient about smoking cessation resources.
B. Delegate respiratory assessment to an LPN and document
findings.
C. Perform a focused cardiopulmonary assessment and notify
the provider of abnormal findings.
D. Complete a literature search on community pneumonia
rates.
Correct Answer: C
Rationales:
, • Correct (C): Performing a focused cardiopulmonary
assessment and communicating abnormal findings is direct
patient care and clinical decision-making expected of the
RN as a provider of care. This aligns with assessment,
interpretation, and alerting the team. (Jensen & Smock,
Ch.1).
• A: Teaching is important but focuses on health promotion,
not the immediate provider role needed for acute
respiratory changes.
• B: Delegating the entire respiratory assessment could miss
critical cues; RNs retain responsibility for assessment and
interpretation.
• D: Researching population data is a
professional/managerial activity but does not address the
patient’s acute needs now.
Teaching Point: Immediate assessment and communication are
primary RN provider responsibilities.
Citation: Jensen & Smock, Nursing Health Assessment: A
Clinical Judgment Approach, 4th Ed., Ch. 1, Section: The Nurse’s
Role in Health Assessment.
2
Reference: Ch. 1, Section: Roles of the Professional Nurse
(Manager of Care)
,Question Stem: As the charge RN on a busy medical unit, you
must assign morning assessments. Which assignment best
demonstrates effective management of care?
A. Assign the least experienced nurse all unstable patients to
promote learning.
B. Match patient acuity to nurse skill and ensure time for
thorough assessments.
C. Require all nurses to complete full head-to-toe assessments
on every patient regardless of condition.
D. Ask the LPN to make clinical judgments about changing care
plans.
Correct Answer: B
Rationales:
• Correct (B): Managing care includes assigning based on
acuity and skill so assessments are safe and
comprehensive. This optimizes outcomes and workflow.
• A: Placing unstable patients with inexperienced staff
increases risk and is poor management.
• C: Universal full assessments may waste resources and
reduce efficiency when focused assessments would suffice.
• D: LPNs have defined roles; RNs retain responsibility for
making clinical judgments and care planning.
Teaching Point: Assign by acuity and skill to ensure safe,
efficient assessments.
, Citation: Jensen & Smock, 4th Ed., Ch. 1, Section: Roles of the
Professional Nurse.
3
Reference: Ch. 2, Section: What Is Health Assessment?
(Wellness and Illness; Teaching and Health Promotion)
Question Stem: A 45-year-old patient with hypertension asks
how often they should have follow-up BP checks at home.
Which recommendation best integrates health promotion and
assessment?
A. Check BP once monthly and bring values to next annual visit.
B. Do not check at home; rely on clinic measurements only.
C. Measure BP twice daily, record values, and share trends with
the nurse or provider.
D. Check BP only when feeling symptomatic.
Correct Answer: C
Rationales:
• Correct (C): Twice-daily home BP monitoring with record
sharing promotes self-management, early detection of
problems, and informs clinical decision-making.
• A: Monthly checks are insufficient for HTN management
and risk assessment.
• B: Ignoring home monitoring misses valuable longitudinal
data for control.
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 (Roles of the Professional Nurse — Provider of Care)
Question Stem: A 72-year-old man arrives with a two-day
history of increasing shortness of breath and productive cough.
As the primary nurse performing the admission assessment,
which action best reflects the nurse’s role as a provider of care?
A. Teach the patient about smoking cessation resources.
B. Delegate respiratory assessment to an LPN and document
findings.
C. Perform a focused cardiopulmonary assessment and notify
the provider of abnormal findings.
D. Complete a literature search on community pneumonia
rates.
Correct Answer: C
Rationales:
, • Correct (C): Performing a focused cardiopulmonary
assessment and communicating abnormal findings is direct
patient care and clinical decision-making expected of the
RN as a provider of care. This aligns with assessment,
interpretation, and alerting the team. (Jensen & Smock,
Ch.1).
• A: Teaching is important but focuses on health promotion,
not the immediate provider role needed for acute
respiratory changes.
• B: Delegating the entire respiratory assessment could miss
critical cues; RNs retain responsibility for assessment and
interpretation.
• D: Researching population data is a
professional/managerial activity but does not address the
patient’s acute needs now.
Teaching Point: Immediate assessment and communication are
primary RN provider responsibilities.
Citation: Jensen & Smock, Nursing Health Assessment: A
Clinical Judgment Approach, 4th Ed., Ch. 1, Section: The Nurse’s
Role in Health Assessment.
2
Reference: Ch. 1, Section: Roles of the Professional Nurse
(Manager of Care)
,Question Stem: As the charge RN on a busy medical unit, you
must assign morning assessments. Which assignment best
demonstrates effective management of care?
A. Assign the least experienced nurse all unstable patients to
promote learning.
B. Match patient acuity to nurse skill and ensure time for
thorough assessments.
C. Require all nurses to complete full head-to-toe assessments
on every patient regardless of condition.
D. Ask the LPN to make clinical judgments about changing care
plans.
Correct Answer: B
Rationales:
• Correct (B): Managing care includes assigning based on
acuity and skill so assessments are safe and
comprehensive. This optimizes outcomes and workflow.
• A: Placing unstable patients with inexperienced staff
increases risk and is poor management.
• C: Universal full assessments may waste resources and
reduce efficiency when focused assessments would suffice.
• D: LPNs have defined roles; RNs retain responsibility for
making clinical judgments and care planning.
Teaching Point: Assign by acuity and skill to ensure safe,
efficient assessments.
, Citation: Jensen & Smock, 4th Ed., Ch. 1, Section: Roles of the
Professional Nurse.
3
Reference: Ch. 2, Section: What Is Health Assessment?
(Wellness and Illness; Teaching and Health Promotion)
Question Stem: A 45-year-old patient with hypertension asks
how often they should have follow-up BP checks at home.
Which recommendation best integrates health promotion and
assessment?
A. Check BP once monthly and bring values to next annual visit.
B. Do not check at home; rely on clinic measurements only.
C. Measure BP twice daily, record values, and share trends with
the nurse or provider.
D. Check BP only when feeling symptomatic.
Correct Answer: C
Rationales:
• Correct (C): Twice-daily home BP monitoring with record
sharing promotes self-management, early detection of
problems, and informs clinical decision-making.
• A: Monthly checks are insufficient for HTN management
and risk assessment.
• B: Ignoring home monitoring misses valuable longitudinal
data for control.
