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:
An RN in an outpatient clinic is obtaining a health history and
performing a focused respiratory assessment. A patient asks
whether the nurse can diagnose asthma and prescribe inhalers.
Which statement best explains the RN’s role compared with an
APRN?
A. RNs can make medical diagnoses and write prescriptions
when working under a physician’s orders.
B. RNs collect and interpret assessment data for nursing
diagnoses; APRNs can make medical diagnoses and prescribe.
C. RNs and APRNs have identical scopes of practice regarding
diagnosis and prescribing.
D. RNs should avoid clinical judgment and only document what
the APRN or physician decides.
,Correct Answer: B
Rationales:
• Correct (B): RNs primarily collect assessment data, identify
nursing diagnoses, and implement nursing interventions;
APRNs have advanced training and authority to make
medical diagnoses and prescribe medications. This aligns
with distinctions between RN and APRN roles.
• A (incorrect): While RNs may work under orders, they do
not independently make medical diagnoses or routinely
prescribe medications; that is within the APRN/physician
scope.
• C (incorrect): RN and APRN scopes differ legally and
educationally; they are not identical.
• D (incorrect): RNs must use clinical judgment and
contribute to patient care decisions rather than simply
deferring all judgments.
Teaching Point: RNs assess and identify nursing problems;
APRNs diagnose and prescribe.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role in
Health Assessment.
2
Reference: Ch. 1, Section: Teaching and Health Promotion
,Question Stem:
A 52-year-old man with newly diagnosed hypertension says he
will “try to eat better,” but reports low income and limited
transportation. What should the nurse assess first to plan
effective teaching?
A. Patient’s baseline blood pressure values only.
B. Patient’s readiness to change, health literacy, and social
determinants of health.
C. Strict dietary rules and a standard low-sodium handout.
D. Whether the patient can be seen by a specialist immediately.
Correct Answer: B
Rationales:
• Correct (B): Effective teaching begins with assessing
readiness to change, health literacy, and social
determinants (income, transportation) that influence
feasibility of recommendations.
• A (incorrect): Baseline BP is important, but alone it doesn’t
guide individualized teaching or identify barriers.
• C (incorrect): Providing materials without assessing
literacy, readiness, and barriers may be ineffective.
• D (incorrect): Specialist referral may be appropriate later,
but first assess the patient’s context to tailor teaching.
Teaching Point: Assess readiness and social determinants
before planning health teaching.
, Citation: Jensen & Smock, Ch. 1, Section: Teaching and Health
Promotion.
3
Reference: Ch. 3, Section: Types of Nursing Assessments
Question Stem:
A patient in the emergency department complains of sudden,
severe shortness of breath and audible wheeze. The nurse must
decide which assessment type is needed immediately. Which is
most appropriate?
A. Comprehensive head-to-toe assessment.
B. Focused respiratory assessment for airway and breathing.
C. Complete functional assessment (ADLs and IADLs).
D. Routine vital sign check only.
Correct Answer: B
Rationales:
• Correct (B): In acute respiratory distress, a focused
assessment addressing airway and breathing is priority to
identify life-threatening issues.
• A (incorrect): A comprehensive assessment is too time-
consuming and not priority in acute distress.
• C (incorrect): Functional assessments are for baseline or
discharge planning, not immediate respiratory
compromise.
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:
An RN in an outpatient clinic is obtaining a health history and
performing a focused respiratory assessment. A patient asks
whether the nurse can diagnose asthma and prescribe inhalers.
Which statement best explains the RN’s role compared with an
APRN?
A. RNs can make medical diagnoses and write prescriptions
when working under a physician’s orders.
B. RNs collect and interpret assessment data for nursing
diagnoses; APRNs can make medical diagnoses and prescribe.
C. RNs and APRNs have identical scopes of practice regarding
diagnosis and prescribing.
D. RNs should avoid clinical judgment and only document what
the APRN or physician decides.
,Correct Answer: B
Rationales:
• Correct (B): RNs primarily collect assessment data, identify
nursing diagnoses, and implement nursing interventions;
APRNs have advanced training and authority to make
medical diagnoses and prescribe medications. This aligns
with distinctions between RN and APRN roles.
• A (incorrect): While RNs may work under orders, they do
not independently make medical diagnoses or routinely
prescribe medications; that is within the APRN/physician
scope.
• C (incorrect): RN and APRN scopes differ legally and
educationally; they are not identical.
• D (incorrect): RNs must use clinical judgment and
contribute to patient care decisions rather than simply
deferring all judgments.
Teaching Point: RNs assess and identify nursing problems;
APRNs diagnose and prescribe.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role in
Health Assessment.
2
Reference: Ch. 1, Section: Teaching and Health Promotion
,Question Stem:
A 52-year-old man with newly diagnosed hypertension says he
will “try to eat better,” but reports low income and limited
transportation. What should the nurse assess first to plan
effective teaching?
A. Patient’s baseline blood pressure values only.
B. Patient’s readiness to change, health literacy, and social
determinants of health.
C. Strict dietary rules and a standard low-sodium handout.
D. Whether the patient can be seen by a specialist immediately.
Correct Answer: B
Rationales:
• Correct (B): Effective teaching begins with assessing
readiness to change, health literacy, and social
determinants (income, transportation) that influence
feasibility of recommendations.
• A (incorrect): Baseline BP is important, but alone it doesn’t
guide individualized teaching or identify barriers.
• C (incorrect): Providing materials without assessing
literacy, readiness, and barriers may be ineffective.
• D (incorrect): Specialist referral may be appropriate later,
but first assess the patient’s context to tailor teaching.
Teaching Point: Assess readiness and social determinants
before planning health teaching.
, Citation: Jensen & Smock, Ch. 1, Section: Teaching and Health
Promotion.
3
Reference: Ch. 3, Section: Types of Nursing Assessments
Question Stem:
A patient in the emergency department complains of sudden,
severe shortness of breath and audible wheeze. The nurse must
decide which assessment type is needed immediately. Which is
most appropriate?
A. Comprehensive head-to-toe assessment.
B. Focused respiratory assessment for airway and breathing.
C. Complete functional assessment (ADLs and IADLs).
D. Routine vital sign check only.
Correct Answer: B
Rationales:
• Correct (B): In acute respiratory distress, a focused
assessment addressing airway and breathing is priority to
identify life-threatening issues.
• A (incorrect): A comprehensive assessment is too time-
consuming and not priority in acute distress.
• C (incorrect): Functional assessments are for baseline or
discharge planning, not immediate respiratory
compromise.
