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 registered nurse admits a patient after a
motor vehicle collision. Which activity best reflects the RN’s role
during the initial health assessment?
A. Performing a complete head-to-toe examination and
documenting baseline findings.
B. Ordering a CT scan to rule out intracranial injury.
C. Delegating assessment of airway patency to unlicensed
assistive personnel (UAP).
D. Initiating and interpreting advanced hemodynamic
monitoring.
Correct Answer: A
Rationale — Correct: The RN is responsible for performing
comprehensive baseline assessments that identify immediate
problems and guide care planning; this aligns with the RN's
provider-of-care role. (2 sentences)
,Rationale — B: Ordering diagnostic tests is typically within a
provider or APRN scope; RNs collaborate to obtain tests but do
not independently order them. (1 sentence)
Rationale — C: Delegating airway assessment to UAP is unsafe;
airway patency assessment requires RN judgment and skill. (1
sentence)
Rationale — D: Initiating and interpreting advanced
hemodynamic monitoring is usually an APRN or specialty role;
RNs should understand and implement monitoring per policy
but not independently assume advanced provider functions. (1
sentence)
Teaching Point: RNs perform comprehensive assessments to
establish baseline data and guide care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: The Advanced Practice Registered
Nurse
Question Stem: A patient asks whether an APRN or RN will
manage their chronic pain clinic visit. Which statement correctly
explains the APRN’s role?
A. APRNs can diagnose and manage chronic conditions
independently within their scope and state regulations.
B. APRNs only provide education and cannot prescribe
medications.
,C. APRNs function identically to bedside RNs and do not do
diagnostic reasoning.
D. APRNs are limited to performing physical assessments but
not forming diagnoses.
Correct Answer: A
Rationale — Correct: APRNs have graduate education and,
depending on state scope, can diagnose, treat, and prescribe
for chronic conditions; this delineation is a key distinction from
the RN role. (2 sentences)
Rationale — B: APRNs often have prescriptive authority and
provide more than education; this statement is false. (1
sentence)
Rationale — C: APRNs engage in advanced clinical reasoning
and management beyond bedside RN duties. (1 sentence)
Rationale — D: Formulating diagnoses is within the APRN scope
of practice when appropriately credentialed. (1 sentence)
Teaching Point: APRNs have advanced training enabling
diagnosis and management within scope and regulation.
Citation: Jensen & Smock, Ch. 1, Section: The Advanced Practice
Registered Nurse
3.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A nurse is doing a focused cardiac assessment
in a clinic. Which action best distinguishes a specialty (cardiac)
,assessment from a routine RN assessment?
A. Obtaining a detailed family cardiac history and performing
focused auscultation for murmurs.
B. Measuring blood pressure once and documenting only the
value.
C. Delegating auscultation to a medical assistant.
D. Entering the single BP reading into the electronic record with
no further assessment.
Correct Answer: A
Rationale — Correct: Specialty assessments add depth (e.g.,
detailed cardiac history, focused auscultation) beyond routine
RN assessments and reflect targeted expertise. (2 sentences)
Rationale — B: A single BP value is part of basic assessment but
lacks the depth of a specialty cardiac assessment. (1 sentence)
Rationale — C: Delegating auscultation to unlicensed staff is
inappropriate when specialized assessment is required. (1
sentence)
Rationale — D: Documenting BP only without targeted
assessment misses clinically relevant cardiac information. (1
sentence)
Teaching Point: Specialty assessments deepen focus on system-
specific history and exam.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
4.
,Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse teaching a patient with newly
diagnosed hypertension focuses on lifestyle changes. Which
teaching priority aligns best with health promotion principles?
A. Discussing sodium reduction, physical activity, and weight
management.
B. Providing a list of prescription antihypertensives only.
C. Telling the patient that lifestyle changes are optional if
medications are used.
D. Avoiding discussion of diet because it’s not part of
assessment.
Correct Answer: A
Rationale — Correct: Health promotion emphasizes lifestyle
modifications (diet, exercise, weight) as primary prevention
strategies in hypertension management. (2 sentences)
Rationale — B: Medication information is important but
insufficient alone; health promotion includes nonpharmacologic
strategies. (1 sentence)
Rationale — C: Minimizing lifestyle changes undermines
evidence-based prevention and control of hypertension. (1
sentence)
Rationale — D: Diet is integral to assessment and teaching for
cardiovascular risk reduction. (1 sentence)
Teaching Point: Promote lifestyle changes alongside medication
to prevent and manage chronic disease.
Citation: Jensen & Smock, Ch. 1, Section: Teaching and Health
Promotion
, 5.
Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: A nurse assesses a patient who is food insecure
and has poorly controlled diabetes. Which intervention best
addresses social determinants of health per Healthy People
2030 principles?
A. Refer the patient to a community food assistance program
and coordinate diabetes education.
B. Increase the insulin dose without addressing access to food.
C. Advise the patient to “just eat healthier” without resources.
D. Discharge the patient without follow-up, assuming
noncompliance.
Correct Answer: A
Rationale — Correct: Addressing social determinants (food
insecurity) by connecting patients to resources and education
supports wellness and improves disease management. (2
sentences)
Rationale — B: Medication changes alone will not solve
underlying access issues that affect glycemic control. (1
sentence)
Rationale — C: Advising change without providing resources is
ineffective and disregards social context. (1 sentence)
Rationale — D: Discharging without follow-up neglects care
coordination and worsens disparities. (1 sentence)
,Teaching Point: Screen for social needs and connect patients
with community resources.
Citation: Jensen & Smock, Ch. 1, Section: Social Determinants of
Health: Healthy People 2030
6.
Reference: Ch. 2, Section: What Is Health Assessment?; Nursing
Process — Assess
Question Stem: During the initial visit, a nurse gathers
subjective data including the patient’s chief complaint and
history of present illness. Which statement best describes the
purpose of collecting subjective cues?
A. To understand the patient’s perception, symptoms, and
concerns to guide further assessment.
B. To replace the need for objective physical examination.
C. To provide only background information irrelevant to clinical
decisions.
D. To document findings that are verifiable by diagnostic tests
only.
Correct Answer: A
Rationale — Correct: Subjective data reflect patient-reported
symptoms and concerns and are essential to guide focused
assessment and clinical reasoning. (2 sentences)
Rationale — B: Subjective data complement, not replace,
objective exam and diagnostic testing. (1 sentence)
Rationale — C: Subjective cues are integral to diagnosis and
,care planning, not irrelevant. (1 sentence)
Rationale — D: Subjective data are not limited to verifiable test
results; they represent the patient’s experience. (1 sentence)
Teaching Point: Use subjective information to guide targeted,
patient-centered assessment.
Citation: Jensen & Smock, Ch. 2, Section: What Is Health
Assessment?; Nursing Process — Assess
7.
Reference: Ch. 2, Section: OBJECTIVE CUES; Documentation and
Communication: Progress Note and SBAR
Question Stem: A nurse documents new onset bibasilar
crackles, respiratory rate 28, and oxygen saturation 88% on
room air. Which immediate communication is most
appropriate?
A. Use SBAR to notify the provider and request evaluation and
possible oxygen/diuretics.
B. Chart the findings and wait until morning rounds to report.
C. Tell the patient to breathe slower and recheck in 4 hours.
D. Call respiratory therapy to perform pulmonary function
testing later in the week.
Correct Answer: A
Rationale — Correct: Low SpO2 and crackles indicate possible
acute decompensation; SBAR to the provider for urgent
intervention (oxygen, evaluation) is appropriate. (2 sentences)
Rationale — B: Delaying communication jeopardizes patient
,safety given abnormal vital signs and hypoxemia. (1 sentence)
Rationale — C: Simply coaching breathing without escalation is
inadequate for objective hypoxemia. (1 sentence)
Rationale — D: PFTs are not urgent diagnostics for acute
respiratory compromise and do not replace immediate
intervention. (1 sentence)
Teaching Point: Use SBAR for timely escalation of acute,
objective abnormalities.
Citation: Jensen & Smock, Ch. 2, Section: Objective Cues;
Documentation and Communication: Progress Note and SBAR
8.
Reference: Ch. 3, Section: Types of Nursing Assessments —
Emergency and Urgent Assessment
Question Stem: A patient arrives unresponsive after an
overdose. What is the priority nursing assessment?
A. Rapid airway, breathing, circulation (ABCs) check and
stabilization.
B. Asking the family about the patient’s sexual history.
C. Performing a full head-to-toe comprehensive assessment
immediately.
D. Documenting past immunizations before interventions.
Correct Answer: A
Rationale — Correct: Emergency assessments prioritize ABCs to
identify life-threatening problems and begin resuscitation. (2
sentences)
, Rationale — B: Sexual history is not immediately relevant and is
lower priority in an unresponsive overdose. (1 sentence)
Rationale — C: A full comprehensive assessment is deferred
until the patient is stabilized. (1 sentence)
Rationale — D: Immunization history is not an immediate
priority compared with stabilizing ABCs. (1 sentence)
Teaching Point: In emergencies, stabilize ABCs first before
comprehensive assessment.
Citation: Jensen & Smock, Ch. 3, Section: Emergency and Urgent
Assessment
9.
Reference: Ch. 3, Section: Comprehensive Assessment; Focused
Assessment
Question Stem: A 68-year-old with new weakness is admitted.
Which scenario best indicates the nurse should perform a
focused rather than comprehensive assessment?
A. The patient’s weakness began acutely; focused neuro and
cardiovascular assessments are needed now.
B. The patient is being seen for an annual wellness exam with
no complaints.
C. The patient requests a full health history and preventive
screening.
D. The patient is stable and being discharged after surgery.
Correct Answer: 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 registered nurse admits a patient after a
motor vehicle collision. Which activity best reflects the RN’s role
during the initial health assessment?
A. Performing a complete head-to-toe examination and
documenting baseline findings.
B. Ordering a CT scan to rule out intracranial injury.
C. Delegating assessment of airway patency to unlicensed
assistive personnel (UAP).
D. Initiating and interpreting advanced hemodynamic
monitoring.
Correct Answer: A
Rationale — Correct: The RN is responsible for performing
comprehensive baseline assessments that identify immediate
problems and guide care planning; this aligns with the RN's
provider-of-care role. (2 sentences)
,Rationale — B: Ordering diagnostic tests is typically within a
provider or APRN scope; RNs collaborate to obtain tests but do
not independently order them. (1 sentence)
Rationale — C: Delegating airway assessment to UAP is unsafe;
airway patency assessment requires RN judgment and skill. (1
sentence)
Rationale — D: Initiating and interpreting advanced
hemodynamic monitoring is usually an APRN or specialty role;
RNs should understand and implement monitoring per policy
but not independently assume advanced provider functions. (1
sentence)
Teaching Point: RNs perform comprehensive assessments to
establish baseline data and guide care.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
2.
Reference: Ch. 1, Section: The Advanced Practice Registered
Nurse
Question Stem: A patient asks whether an APRN or RN will
manage their chronic pain clinic visit. Which statement correctly
explains the APRN’s role?
A. APRNs can diagnose and manage chronic conditions
independently within their scope and state regulations.
B. APRNs only provide education and cannot prescribe
medications.
,C. APRNs function identically to bedside RNs and do not do
diagnostic reasoning.
D. APRNs are limited to performing physical assessments but
not forming diagnoses.
Correct Answer: A
Rationale — Correct: APRNs have graduate education and,
depending on state scope, can diagnose, treat, and prescribe
for chronic conditions; this delineation is a key distinction from
the RN role. (2 sentences)
Rationale — B: APRNs often have prescriptive authority and
provide more than education; this statement is false. (1
sentence)
Rationale — C: APRNs engage in advanced clinical reasoning
and management beyond bedside RN duties. (1 sentence)
Rationale — D: Formulating diagnoses is within the APRN scope
of practice when appropriately credentialed. (1 sentence)
Teaching Point: APRNs have advanced training enabling
diagnosis and management within scope and regulation.
Citation: Jensen & Smock, Ch. 1, Section: The Advanced Practice
Registered Nurse
3.
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: A nurse is doing a focused cardiac assessment
in a clinic. Which action best distinguishes a specialty (cardiac)
,assessment from a routine RN assessment?
A. Obtaining a detailed family cardiac history and performing
focused auscultation for murmurs.
B. Measuring blood pressure once and documenting only the
value.
C. Delegating auscultation to a medical assistant.
D. Entering the single BP reading into the electronic record with
no further assessment.
Correct Answer: A
Rationale — Correct: Specialty assessments add depth (e.g.,
detailed cardiac history, focused auscultation) beyond routine
RN assessments and reflect targeted expertise. (2 sentences)
Rationale — B: A single BP value is part of basic assessment but
lacks the depth of a specialty cardiac assessment. (1 sentence)
Rationale — C: Delegating auscultation to unlicensed staff is
inappropriate when specialized assessment is required. (1
sentence)
Rationale — D: Documenting BP only without targeted
assessment misses clinically relevant cardiac information. (1
sentence)
Teaching Point: Specialty assessments deepen focus on system-
specific history and exam.
Citation: Jensen & Smock, Ch. 1, Section: Registered Nurse
Versus Specialty or Advanced Practice Assessments
4.
,Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse teaching a patient with newly
diagnosed hypertension focuses on lifestyle changes. Which
teaching priority aligns best with health promotion principles?
A. Discussing sodium reduction, physical activity, and weight
management.
B. Providing a list of prescription antihypertensives only.
C. Telling the patient that lifestyle changes are optional if
medications are used.
D. Avoiding discussion of diet because it’s not part of
assessment.
Correct Answer: A
Rationale — Correct: Health promotion emphasizes lifestyle
modifications (diet, exercise, weight) as primary prevention
strategies in hypertension management. (2 sentences)
Rationale — B: Medication information is important but
insufficient alone; health promotion includes nonpharmacologic
strategies. (1 sentence)
Rationale — C: Minimizing lifestyle changes undermines
evidence-based prevention and control of hypertension. (1
sentence)
Rationale — D: Diet is integral to assessment and teaching for
cardiovascular risk reduction. (1 sentence)
Teaching Point: Promote lifestyle changes alongside medication
to prevent and manage chronic disease.
Citation: Jensen & Smock, Ch. 1, Section: Teaching and Health
Promotion
, 5.
Reference: Ch. 1, Section: Wellness and Illness; Social
Determinants of Health: Healthy People 2030
Question Stem: A nurse assesses a patient who is food insecure
and has poorly controlled diabetes. Which intervention best
addresses social determinants of health per Healthy People
2030 principles?
A. Refer the patient to a community food assistance program
and coordinate diabetes education.
B. Increase the insulin dose without addressing access to food.
C. Advise the patient to “just eat healthier” without resources.
D. Discharge the patient without follow-up, assuming
noncompliance.
Correct Answer: A
Rationale — Correct: Addressing social determinants (food
insecurity) by connecting patients to resources and education
supports wellness and improves disease management. (2
sentences)
Rationale — B: Medication changes alone will not solve
underlying access issues that affect glycemic control. (1
sentence)
Rationale — C: Advising change without providing resources is
ineffective and disregards social context. (1 sentence)
Rationale — D: Discharging without follow-up neglects care
coordination and worsens disparities. (1 sentence)
,Teaching Point: Screen for social needs and connect patients
with community resources.
Citation: Jensen & Smock, Ch. 1, Section: Social Determinants of
Health: Healthy People 2030
6.
Reference: Ch. 2, Section: What Is Health Assessment?; Nursing
Process — Assess
Question Stem: During the initial visit, a nurse gathers
subjective data including the patient’s chief complaint and
history of present illness. Which statement best describes the
purpose of collecting subjective cues?
A. To understand the patient’s perception, symptoms, and
concerns to guide further assessment.
B. To replace the need for objective physical examination.
C. To provide only background information irrelevant to clinical
decisions.
D. To document findings that are verifiable by diagnostic tests
only.
Correct Answer: A
Rationale — Correct: Subjective data reflect patient-reported
symptoms and concerns and are essential to guide focused
assessment and clinical reasoning. (2 sentences)
Rationale — B: Subjective data complement, not replace,
objective exam and diagnostic testing. (1 sentence)
Rationale — C: Subjective cues are integral to diagnosis and
,care planning, not irrelevant. (1 sentence)
Rationale — D: Subjective data are not limited to verifiable test
results; they represent the patient’s experience. (1 sentence)
Teaching Point: Use subjective information to guide targeted,
patient-centered assessment.
Citation: Jensen & Smock, Ch. 2, Section: What Is Health
Assessment?; Nursing Process — Assess
7.
Reference: Ch. 2, Section: OBJECTIVE CUES; Documentation and
Communication: Progress Note and SBAR
Question Stem: A nurse documents new onset bibasilar
crackles, respiratory rate 28, and oxygen saturation 88% on
room air. Which immediate communication is most
appropriate?
A. Use SBAR to notify the provider and request evaluation and
possible oxygen/diuretics.
B. Chart the findings and wait until morning rounds to report.
C. Tell the patient to breathe slower and recheck in 4 hours.
D. Call respiratory therapy to perform pulmonary function
testing later in the week.
Correct Answer: A
Rationale — Correct: Low SpO2 and crackles indicate possible
acute decompensation; SBAR to the provider for urgent
intervention (oxygen, evaluation) is appropriate. (2 sentences)
Rationale — B: Delaying communication jeopardizes patient
,safety given abnormal vital signs and hypoxemia. (1 sentence)
Rationale — C: Simply coaching breathing without escalation is
inadequate for objective hypoxemia. (1 sentence)
Rationale — D: PFTs are not urgent diagnostics for acute
respiratory compromise and do not replace immediate
intervention. (1 sentence)
Teaching Point: Use SBAR for timely escalation of acute,
objective abnormalities.
Citation: Jensen & Smock, Ch. 2, Section: Objective Cues;
Documentation and Communication: Progress Note and SBAR
8.
Reference: Ch. 3, Section: Types of Nursing Assessments —
Emergency and Urgent Assessment
Question Stem: A patient arrives unresponsive after an
overdose. What is the priority nursing assessment?
A. Rapid airway, breathing, circulation (ABCs) check and
stabilization.
B. Asking the family about the patient’s sexual history.
C. Performing a full head-to-toe comprehensive assessment
immediately.
D. Documenting past immunizations before interventions.
Correct Answer: A
Rationale — Correct: Emergency assessments prioritize ABCs to
identify life-threatening problems and begin resuscitation. (2
sentences)
, Rationale — B: Sexual history is not immediately relevant and is
lower priority in an unresponsive overdose. (1 sentence)
Rationale — C: A full comprehensive assessment is deferred
until the patient is stabilized. (1 sentence)
Rationale — D: Immunization history is not an immediate
priority compared with stabilizing ABCs. (1 sentence)
Teaching Point: In emergencies, stabilize ABCs first before
comprehensive assessment.
Citation: Jensen & Smock, Ch. 3, Section: Emergency and Urgent
Assessment
9.
Reference: Ch. 3, Section: Comprehensive Assessment; Focused
Assessment
Question Stem: A 68-year-old with new weakness is admitted.
Which scenario best indicates the nurse should perform a
focused rather than comprehensive assessment?
A. The patient’s weakness began acutely; focused neuro and
cardiovascular assessments are needed now.
B. The patient is being seen for an annual wellness exam with
no complaints.
C. The patient requests a full health history and preventive
screening.
D. The patient is stable and being discharged after surgery.
Correct Answer: A
