Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Nursing Roles & Scope of Practice
Question 1
Reference: Ch. 1, Section: Roles of the Professional Nurse -
Provider of Care
Question Stem: A 68-year-old man is admitted to the medical
unit after a fall at home. As the registered nurse performing the
initial health assessment, which action best demonstrates the
nurse's role as a provider of care?
• A. Arranging a home safety evaluation with social work
• B. Performing an immediate focused assessment of airway,
breathing, and circulation
• C. Referring the patient to an advanced practice nurse for
medication adjustment
• D. Teaching the patient about fall-prevention devices
before discharge
,Correct Answer: B
Rationales:
• Correct (B): Performing an immediate focused ABC
assessment is a direct, hands-on intervention that
exemplifies the RN's role as provider of care by addressing
immediate physiological needs and ensuring patient
stability.
• A: Arranging home services aligns with the nurse's role as
manager/coordinator of care, not the immediate provider
role during initial assessment.
• C: Referring to an APRN involves delegation of advanced
clinical decisions rather than the RN's direct provider role
in initial stabilization.
• D: Patient teaching is an important provider function but is
lower priority than immediate physiological assessment
after a traumatic event like a fall.
Teaching Point: Immediate ABC assessment is the RN's primary
provider responsibility in acute situations.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
Ch. 1, Section: Roles of the Professional Nurse - Provider of Care
Question 2
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
,Question Stem: During a clinic admission, a patient requests a
prescription refill for a hypertension medication. Which
statement reflects appropriate scope of practice and
assessment by an RN before involving an APRN or physician?
• A. The RN refuses and tells the patient to contact the
physician directly
• B. The RN completes a focused medication history and
documents current symptoms
• C. The RN prescribes a short medication supply based on
prior orders
• D. The RN modifies the dosage and provides the
medication to the patient
Correct Answer: B
Rationales:
• Correct (B): Completing a focused medication history and
documenting symptoms is within the RN's scope and
provides necessary data for prescribers to make informed
decisions.
• A: Refusing without assessment neglects professional
responsibilities and fails to gather essential information for
prescribers.
• C & D: Prescribing or modifying medications exceeds the
RN's scope; such actions are reserved for APRNs or
physicians.
, Teaching Point: RNs assess and document; prescriptive
decisions require licensed providers.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
Ch. 1, Section: Registered Nurse Versus Specialty or Advanced
Practice Assessments
Question 3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 22-year-old woman with no chronic illness
attends a community health center for a wellness visit. Which
assessment finding most strongly indicates a need for targeted
health promotion teaching?
• A. She smokes 4-5 cigarettes monthly at social events
• B. She reports daily fruit and vegetable intake
• C. She exercises 30 minutes three times weekly
• D. She received all routine childhood vaccinations
Correct Answer: A
Rationales:
• Correct (A): Even occasional tobacco use represents a
modifiable risk factor and provides an opportunity for
targeted health promotion and cessation counseling.
• B & C: Adequate diet and moderate exercise are positive
health behaviors requiring reinforcement rather than
immediate targeted intervention.
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Nursing Roles & Scope of Practice
Question 1
Reference: Ch. 1, Section: Roles of the Professional Nurse -
Provider of Care
Question Stem: A 68-year-old man is admitted to the medical
unit after a fall at home. As the registered nurse performing the
initial health assessment, which action best demonstrates the
nurse's role as a provider of care?
• A. Arranging a home safety evaluation with social work
• B. Performing an immediate focused assessment of airway,
breathing, and circulation
• C. Referring the patient to an advanced practice nurse for
medication adjustment
• D. Teaching the patient about fall-prevention devices
before discharge
,Correct Answer: B
Rationales:
• Correct (B): Performing an immediate focused ABC
assessment is a direct, hands-on intervention that
exemplifies the RN's role as provider of care by addressing
immediate physiological needs and ensuring patient
stability.
• A: Arranging home services aligns with the nurse's role as
manager/coordinator of care, not the immediate provider
role during initial assessment.
• C: Referring to an APRN involves delegation of advanced
clinical decisions rather than the RN's direct provider role
in initial stabilization.
• D: Patient teaching is an important provider function but is
lower priority than immediate physiological assessment
after a traumatic event like a fall.
Teaching Point: Immediate ABC assessment is the RN's primary
provider responsibility in acute situations.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
Ch. 1, Section: Roles of the Professional Nurse - Provider of Care
Question 2
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
,Question Stem: During a clinic admission, a patient requests a
prescription refill for a hypertension medication. Which
statement reflects appropriate scope of practice and
assessment by an RN before involving an APRN or physician?
• A. The RN refuses and tells the patient to contact the
physician directly
• B. The RN completes a focused medication history and
documents current symptoms
• C. The RN prescribes a short medication supply based on
prior orders
• D. The RN modifies the dosage and provides the
medication to the patient
Correct Answer: B
Rationales:
• Correct (B): Completing a focused medication history and
documenting symptoms is within the RN's scope and
provides necessary data for prescribers to make informed
decisions.
• A: Refusing without assessment neglects professional
responsibilities and fails to gather essential information for
prescribers.
• C & D: Prescribing or modifying medications exceeds the
RN's scope; such actions are reserved for APRNs or
physicians.
, Teaching Point: RNs assess and document; prescriptive
decisions require licensed providers.
Citation: Jensen & Smock, Nursing Health Assessment, 4th ed.,
Ch. 1, Section: Registered Nurse Versus Specialty or Advanced
Practice Assessments
Question 3
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A 22-year-old woman with no chronic illness
attends a community health center for a wellness visit. Which
assessment finding most strongly indicates a need for targeted
health promotion teaching?
• A. She smokes 4-5 cigarettes monthly at social events
• B. She reports daily fruit and vegetable intake
• C. She exercises 30 minutes three times weekly
• D. She received all routine childhood vaccinations
Correct Answer: A
Rationales:
• Correct (A): Even occasional tobacco use represents a
modifiable risk factor and provides an opportunity for
targeted health promotion and cessation counseling.
• B & C: Adequate diet and moderate exercise are positive
health behaviors requiring reinforcement rather than
immediate targeted intervention.
