Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Nurse's Role and Scope of Practice
Reference: Ch. 1, Section: Roles of the Professional Nurse –
Provider of Care
Question Stem:
A 68-year-old patient is admitted to the medical unit after
falling at home. The patient reports dizziness and has visible
abrasions on their forearm. Which action should the registered
nurse perform first as the primary provider of care?
Options:
• A. Arrange a home safety evaluation with physical therapy
• B. Perform a focused assessment of neurological status
and vital signs
• C. Document the details of the fall in the electronic health
record
, • D. Refer the patient to an advanced practice nurse for
medication review
Correct Answer: B
Rationales:
• Correct (B): Performing a focused assessment addresses
the immediate physiological concerns (dizziness and
potential injury) following a fall. This direct hands-on
intervention exemplifies the RN's role as provider of care
by gathering essential clinical data to guide subsequent
care decisions .
• Incorrect (A): While arranging a home safety evaluation is
important, it falls under the nurse's role as manager of
care and is not the immediate priority when physiological
stability needs assessment.
• Incorrect (C): Documentation is an essential responsibility
but should occur after addressing potential acute needs
and collecting key assessment data.
• Incorrect (D): Referring to an advanced practice provider
may be warranted later, but the RN must first complete
their own assessment to identify the need for such a
referral.
Teaching Point: Always prioritize focused physiological
assessment after an incident to identify immediate risks.
2. RN versus APRN Scope of Practice
,Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem:
A patient with hypertension requests a prescription refill for
lisinopril during a routine clinic visit. Which action by the
registered nurse is most appropriate?
Options:
• A. Deny the request and instruct the patient to see their
primary care physician
• B. Collect a focused health history and current blood
pressure reading
• C. Adjust the current medication dosage based on the
patient's report
• D. Provide a 30-day refill using standing clinic protocols
Correct Answer: B
Rationales:
• Correct (B): Collecting relevant assessment data (health
history and vital signs) is within the RN's scope and
provides necessary information for the prescribing
provider to make an informed decision .
• Incorrect (A): Denying the request without assessment
fails to gather essential information and does not utilize
nursing assessment skills effectively.
, • Incorrect (C): Medication adjustment is outside the RN's
scope of practice and requires advanced prescribing
authority.
• Incorrect (D): Prescribing medications, even under
protocols, typically requires advanced practice credentials.
Teaching Point: RNs assess and monitor; prescribing decisions
require advanced licensure.
3. Teaching and Health Promotion
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem:
A nurse is planning health promotion teaching for a 45-year-old
patient with a body mass index of 32 and sedentary lifestyle.
Which approach represents the most effective initial strategy?
Options:
• A. Provide detailed education on all cardiovascular risk
factors
• B. Collaborate with the patient to set one achievable
physical activity goal
• C. Schedule consultation with a bariatric surgeon for
weight loss options
• D. Delay discussion until the patient demonstrates
readiness to change
Correct Answer: B
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Nurse's Role and Scope of Practice
Reference: Ch. 1, Section: Roles of the Professional Nurse –
Provider of Care
Question Stem:
A 68-year-old patient is admitted to the medical unit after
falling at home. The patient reports dizziness and has visible
abrasions on their forearm. Which action should the registered
nurse perform first as the primary provider of care?
Options:
• A. Arrange a home safety evaluation with physical therapy
• B. Perform a focused assessment of neurological status
and vital signs
• C. Document the details of the fall in the electronic health
record
, • D. Refer the patient to an advanced practice nurse for
medication review
Correct Answer: B
Rationales:
• Correct (B): Performing a focused assessment addresses
the immediate physiological concerns (dizziness and
potential injury) following a fall. This direct hands-on
intervention exemplifies the RN's role as provider of care
by gathering essential clinical data to guide subsequent
care decisions .
• Incorrect (A): While arranging a home safety evaluation is
important, it falls under the nurse's role as manager of
care and is not the immediate priority when physiological
stability needs assessment.
• Incorrect (C): Documentation is an essential responsibility
but should occur after addressing potential acute needs
and collecting key assessment data.
• Incorrect (D): Referring to an advanced practice provider
may be warranted later, but the RN must first complete
their own assessment to identify the need for such a
referral.
Teaching Point: Always prioritize focused physiological
assessment after an incident to identify immediate risks.
2. RN versus APRN Scope of Practice
,Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem:
A patient with hypertension requests a prescription refill for
lisinopril during a routine clinic visit. Which action by the
registered nurse is most appropriate?
Options:
• A. Deny the request and instruct the patient to see their
primary care physician
• B. Collect a focused health history and current blood
pressure reading
• C. Adjust the current medication dosage based on the
patient's report
• D. Provide a 30-day refill using standing clinic protocols
Correct Answer: B
Rationales:
• Correct (B): Collecting relevant assessment data (health
history and vital signs) is within the RN's scope and
provides necessary information for the prescribing
provider to make an informed decision .
• Incorrect (A): Denying the request without assessment
fails to gather essential information and does not utilize
nursing assessment skills effectively.
, • Incorrect (C): Medication adjustment is outside the RN's
scope of practice and requires advanced prescribing
authority.
• Incorrect (D): Prescribing medications, even under
protocols, typically requires advanced practice credentials.
Teaching Point: RNs assess and monitor; prescribing decisions
require advanced licensure.
3. Teaching and Health Promotion
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem:
A nurse is planning health promotion teaching for a 45-year-old
patient with a body mass index of 32 and sedentary lifestyle.
Which approach represents the most effective initial strategy?
Options:
• A. Provide detailed education on all cardiovascular risk
factors
• B. Collaborate with the patient to set one achievable
physical activity goal
• C. Schedule consultation with a bariatric surgeon for
weight loss options
• D. Delay discussion until the patient demonstrates
readiness to change
Correct Answer: B
