,Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional
Performance
Chapter 2 — Standards of Practice — Standard 2:
Diagnosis
Chapter & Section: Chapter 3 — Standards of Practice:
Standard
1. Assessment
Key Concept: Comprehensive data collection
ANA Standard(s): Standard 1: Assessment
Nursing Process: Assessment
Cognitive Level / Difficulty: Remember / Easy
,Stem: Which action best reflects the RN’s primary responsibility
under Standard 1, Assessment?
Options:
A. Delegating initial data collection to unlicensed assistive
personnel (UAP).
B. Collecting comprehensive, culturally relevant health data
from the client.
C. Completing only vital signs and leaving psychosocial
screening to others.
D. Documenting a plan of care without corroborating data.
Correct Answer: B — Collect comprehensive culturally relevant
data
Rationale:
Correct (2–3 sentences): Standard 1 directs the RN to collect
comprehensive and culturally relevant data about the client’s
health status to inform subsequent nursing judgments and care
planning. This aligns with ANA guidance that assessment is the
foundation of the nursing process. (ANA)
A (incorrect): Delegation of initial data collection may be
appropriate for specific tasks, but the RN retains responsibility
for ensuring assessment completeness and accuracy; full
assessment is the RN’s role. (NCSBN)
C (incorrect): Limiting assessment to vital signs neglects
psychosocial, cultural, and functional data required by Standard
1. (ANA)
, D (incorrect): Planning without corroborated assessment data
risks unsafe, nonindividualized care and violates Standard 1
requirements. (ANA)
Teaching Point: Comprehensive, culturally sensitive data
collection is the essential first step in nursing care.
Question 2:
Chapter & Section: Chapter 3 — Standards of Practice: Standard
1. Assessment
Key Concept: Use of validated assessment tools
ANA Standard(s): Standard 1: Assessment; Standard 5:
Evidence-Based Practice
Nursing Process: Assessment
Cognitive Level / Difficulty: Apply / Medium
Stem: A nurse is assessing fall risk for an older adult. Which is
the best action to satisfy Standard 1 and evidence-based
practice?
Options:
A. Rely on the nurse’s unaided clinical impression only.
B. Use a validated fall-risk screening tool and document
findings.
C. Ask family members if the patient “looks steady.”
D. Defer fall-risk assessment to the physical therapist.
Standards of Practice & Standards of Professional
Performance
Chapter 2 — Standards of Practice — Standard 2:
Diagnosis
Chapter & Section: Chapter 3 — Standards of Practice:
Standard
1. Assessment
Key Concept: Comprehensive data collection
ANA Standard(s): Standard 1: Assessment
Nursing Process: Assessment
Cognitive Level / Difficulty: Remember / Easy
,Stem: Which action best reflects the RN’s primary responsibility
under Standard 1, Assessment?
Options:
A. Delegating initial data collection to unlicensed assistive
personnel (UAP).
B. Collecting comprehensive, culturally relevant health data
from the client.
C. Completing only vital signs and leaving psychosocial
screening to others.
D. Documenting a plan of care without corroborating data.
Correct Answer: B — Collect comprehensive culturally relevant
data
Rationale:
Correct (2–3 sentences): Standard 1 directs the RN to collect
comprehensive and culturally relevant data about the client’s
health status to inform subsequent nursing judgments and care
planning. This aligns with ANA guidance that assessment is the
foundation of the nursing process. (ANA)
A (incorrect): Delegation of initial data collection may be
appropriate for specific tasks, but the RN retains responsibility
for ensuring assessment completeness and accuracy; full
assessment is the RN’s role. (NCSBN)
C (incorrect): Limiting assessment to vital signs neglects
psychosocial, cultural, and functional data required by Standard
1. (ANA)
, D (incorrect): Planning without corroborated assessment data
risks unsafe, nonindividualized care and violates Standard 1
requirements. (ANA)
Teaching Point: Comprehensive, culturally sensitive data
collection is the essential first step in nursing care.
Question 2:
Chapter & Section: Chapter 3 — Standards of Practice: Standard
1. Assessment
Key Concept: Use of validated assessment tools
ANA Standard(s): Standard 1: Assessment; Standard 5:
Evidence-Based Practice
Nursing Process: Assessment
Cognitive Level / Difficulty: Apply / Medium
Stem: A nurse is assessing fall risk for an older adult. Which is
the best action to satisfy Standard 1 and evidence-based
practice?
Options:
A. Rely on the nurse’s unaided clinical impression only.
B. Use a validated fall-risk screening tool and document
findings.
C. Ask family members if the patient “looks steady.”
D. Defer fall-risk assessment to the physical therapist.
