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 asked to perform a
health assessment on a patient with multiple chronic
conditions. Which action best reflects the RN’s role as a
provider of care during this assessment?
A. Prescribing a change in medication dosage.
B. Performing a thorough history and focused physical exam
and communicating findings to the team.
C. Referring the patient for specialty care without documenting
findings.
D. Making a definitive medical diagnosis to guide treatment.
Correct Answer: B
Rationale (Correct): Option B describes core RN responsibilities:
collecting history and objective data and communicating
findings to inform care. This aligns with the RN’s role as
provider of care in assessment.
,Rationale (A): Prescribing medications is outside the RN scope
unless the RN is an APRN with prescriptive authority.
Rationale (C): Referrals without documentation omit essential
communication and continuity of care.
Rationale (D): Making definitive medical diagnoses is primarily
a provider/physician/APRN function; RNs contribute through
assessment and diagnostic reasoning.
Teaching Point: RNs gather data, interpret findings, and
communicate to inform patient care.
Citation: 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: A hospital requests an assessment by an
advanced practice registered nurse (APRN) for a patient with
complex heart failure. Which task best demonstrates why an
APRN is requested instead of an RN?
A. Completing a basic head-to-toe assessment and recording
vital signs.
B. Initiating independent diagnostic testing and adjusting
medications per protocol.
C. Providing patient education about diet and exercise only.
D. Assisting with activities of daily living.
Correct Answer: B
Rationale (Correct): APRNs have advanced assessment and
,diagnostic authority, including ordering tests and modifying
therapy within scope, making option B correct.
Rationale (A): Basic assessments and vitals are RN tasks and do
not require APRN scope.
Rationale (C): Education is important but does not reflect the
expanded clinical decision-making expected of APRNs.
Rationale (D): Assisting with ADLs is a fundamental nursing task
and not specific to APRNs.
Teaching Point: APRNs perform advanced diagnostic and
therapeutic functions beyond RN scope.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During a postpartum visit, a nurse assesses
breastfeeding technique and counsels the mother on lactation.
Which statement by the nurse best reflects effective health-
promotion teaching?
A. “Stop breastfeeding if the baby seems fussy.”
B. “Here are two evidence-based techniques to improve latch;
let’s practice together.”
C. “You don’t need to worry about nipple soreness.”
D. “I’ll tell you what to do — just follow my instructions.”
Correct Answer: B
Rationale (Correct): Option B uses evidence-based techniques
, and hands-on teaching, aligning with teaching and health
promotion principles.
Rationale (A): Advising to stop breastfeeding without
assessment undermines promotion and not evidence-based.
Rationale (C): Dismissing concerns is inappropriate and may
ignore significant problems.
Rationale (D): Directive teaching without collaboration reduces
patient engagement and learning.
Teaching Point: Use evidence-based, collaborative teaching
with demonstration and practice.
Citation: Ch. 1, Section: Teaching and Health Promotion
4.
Reference: Ch. 2, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: A community clinic serves many patients with
uncontrolled diabetes who have limited access to healthy food.
Which assessment finding best represents a social determinant
of health affecting wellness?
A. Elevated fasting glucose level.
B. Lack of access to affordable, nutritious food.
C. Family history of diabetes.
D. Elevated hemoglobin A1c.
Correct Answer: B
Rationale (Correct): Option B is a social determinant (food
insecurity) that influences health behaviors and outcomes, a
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 asked to perform a
health assessment on a patient with multiple chronic
conditions. Which action best reflects the RN’s role as a
provider of care during this assessment?
A. Prescribing a change in medication dosage.
B. Performing a thorough history and focused physical exam
and communicating findings to the team.
C. Referring the patient for specialty care without documenting
findings.
D. Making a definitive medical diagnosis to guide treatment.
Correct Answer: B
Rationale (Correct): Option B describes core RN responsibilities:
collecting history and objective data and communicating
findings to inform care. This aligns with the RN’s role as
provider of care in assessment.
,Rationale (A): Prescribing medications is outside the RN scope
unless the RN is an APRN with prescriptive authority.
Rationale (C): Referrals without documentation omit essential
communication and continuity of care.
Rationale (D): Making definitive medical diagnoses is primarily
a provider/physician/APRN function; RNs contribute through
assessment and diagnostic reasoning.
Teaching Point: RNs gather data, interpret findings, and
communicate to inform patient care.
Citation: 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: A hospital requests an assessment by an
advanced practice registered nurse (APRN) for a patient with
complex heart failure. Which task best demonstrates why an
APRN is requested instead of an RN?
A. Completing a basic head-to-toe assessment and recording
vital signs.
B. Initiating independent diagnostic testing and adjusting
medications per protocol.
C. Providing patient education about diet and exercise only.
D. Assisting with activities of daily living.
Correct Answer: B
Rationale (Correct): APRNs have advanced assessment and
,diagnostic authority, including ordering tests and modifying
therapy within scope, making option B correct.
Rationale (A): Basic assessments and vitals are RN tasks and do
not require APRN scope.
Rationale (C): Education is important but does not reflect the
expanded clinical decision-making expected of APRNs.
Rationale (D): Assisting with ADLs is a fundamental nursing task
and not specific to APRNs.
Teaching Point: APRNs perform advanced diagnostic and
therapeutic functions beyond RN scope.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
3.
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: During a postpartum visit, a nurse assesses
breastfeeding technique and counsels the mother on lactation.
Which statement by the nurse best reflects effective health-
promotion teaching?
A. “Stop breastfeeding if the baby seems fussy.”
B. “Here are two evidence-based techniques to improve latch;
let’s practice together.”
C. “You don’t need to worry about nipple soreness.”
D. “I’ll tell you what to do — just follow my instructions.”
Correct Answer: B
Rationale (Correct): Option B uses evidence-based techniques
, and hands-on teaching, aligning with teaching and health
promotion principles.
Rationale (A): Advising to stop breastfeeding without
assessment undermines promotion and not evidence-based.
Rationale (C): Dismissing concerns is inappropriate and may
ignore significant problems.
Rationale (D): Directive teaching without collaboration reduces
patient engagement and learning.
Teaching Point: Use evidence-based, collaborative teaching
with demonstration and practice.
Citation: Ch. 1, Section: Teaching and Health Promotion
4.
Reference: Ch. 2, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: A community clinic serves many patients with
uncontrolled diabetes who have limited access to healthy food.
Which assessment finding best represents a social determinant
of health affecting wellness?
A. Elevated fasting glucose level.
B. Lack of access to affordable, nutritious food.
C. Family history of diabetes.
D. Elevated hemoglobin A1c.
Correct Answer: B
Rationale (Correct): Option B is a social determinant (food
insecurity) that influences health behaviors and outcomes, a
