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 newly licensed RN is assigned to admit a
patient. Which activity best demonstrates the nurse acting as a
provider of care during the admission assessment?
A. Coordinating referrals to social work and case management.
B. Conducting a focused pain and vital sign assessment and
initiating analgesia per protocol.
C. Updating unit staffing assignments and delegating tasks to
assistive personnel.
D. Presenting a poster on cultural competence at the hospital
in-service.
Correct Answer: B
Rationale — Correct: Conducting a focused clinical assessment
and initiating indicated interventions (e.g., analgesia per
protocol) is direct patient care, a primary function of the nurse
as provider of care and aligns with nursing assessment-to-
,intervention flow.
Rationale — A: Coordinating referrals is managerial/advocacy
work and fits the manager/advocate role rather than direct
bedside provision of care.
Rationale — C: Staffing and delegation are managerial
responsibilities, not direct provider activities.
Rationale — D: Educational outreach to staff is a
professional/educator activity, not immediate direct patient
care.
Teaching Point: Provider of care focuses on direct assessment
and treatment actions.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 1, Section: The Nurse’s Role in Health Assessment
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
(APRN) Role
Question Stem: An APRN performing a specialty assessment
differs from a general RN assessment primarily because the
APRN:
A. Focuses only on psychosocial history.
B. Performs a broader, more in-depth assessment tied to
diagnostic and prescriptive authority.
C. Avoids documenting normal findings.
D. Only delegates assessments to licensed practical nurses.
,Correct Answer: B
Rationale — Correct: APRNs conduct advanced, often
differential-diagnosis–focused assessments that support
diagnostic reasoning and prescriptive decisions within their
scope.
Rationale — A: APRNs do not focus only on psychosocial
history; they perform comprehensive, organ/system and
diagnostic assessments.
Rationale — C: Documenting normal findings remains essential
for continuity of care; omission is inappropriate.
Rationale — D: APRNs may delegate portions of care but are
responsible for the advanced assessment; they do not limit
themselves to delegation.
Teaching Point: APRN assessments are deeper and support
diagnosis and treatment decisions.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 1, Section: The Advanced Practice Registered Nurse
3
Reference: Ch. 2, Section: Nursing Process — Assess & Diagnose
Question Stem: A patient reports new-onset shortness of
breath and increased work of breathing. Which immediate
nursing action best follows the assess step of the nursing
process?
A. Document the subjective complaint and wait for the provider
, to evaluate.
B. Perform a focused respiratory exam including vital signs, lung
auscultation, and oxygen saturation.
C. Initiate discharge teaching about energy conservation.
D. Call social work to evaluate home oxygen needs.
Correct Answer: B
Rationale — Correct: The assess step requires focused objective
assessment (vitals, lung sounds, SpO₂) to gather data for
diagnostic reasoning and immediate intervention.
Rationale — A: Simply documenting without objective
assessment delays necessary data collection and intervention.
Rationale — C: Discharge teaching is inappropriate until acute
respiratory status is stabilized and cause identified.
Rationale — D: Social work is not the immediate resource for
an acute physiologic change.
Teaching Point: Acute symptoms require focused objective
assessment before planning.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 2, Section: Nursing Process — Assess
4
Reference: Ch. 2, Section: Identify Outcomes & Plan Care
Question Stem: After completing a comprehensive assessment,
which outcome is most appropriate and measurable for a
patient with orthostatic hypotension?
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 newly licensed RN is assigned to admit a
patient. Which activity best demonstrates the nurse acting as a
provider of care during the admission assessment?
A. Coordinating referrals to social work and case management.
B. Conducting a focused pain and vital sign assessment and
initiating analgesia per protocol.
C. Updating unit staffing assignments and delegating tasks to
assistive personnel.
D. Presenting a poster on cultural competence at the hospital
in-service.
Correct Answer: B
Rationale — Correct: Conducting a focused clinical assessment
and initiating indicated interventions (e.g., analgesia per
protocol) is direct patient care, a primary function of the nurse
as provider of care and aligns with nursing assessment-to-
,intervention flow.
Rationale — A: Coordinating referrals is managerial/advocacy
work and fits the manager/advocate role rather than direct
bedside provision of care.
Rationale — C: Staffing and delegation are managerial
responsibilities, not direct provider activities.
Rationale — D: Educational outreach to staff is a
professional/educator activity, not immediate direct patient
care.
Teaching Point: Provider of care focuses on direct assessment
and treatment actions.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 1, Section: The Nurse’s Role in Health Assessment
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
(APRN) Role
Question Stem: An APRN performing a specialty assessment
differs from a general RN assessment primarily because the
APRN:
A. Focuses only on psychosocial history.
B. Performs a broader, more in-depth assessment tied to
diagnostic and prescriptive authority.
C. Avoids documenting normal findings.
D. Only delegates assessments to licensed practical nurses.
,Correct Answer: B
Rationale — Correct: APRNs conduct advanced, often
differential-diagnosis–focused assessments that support
diagnostic reasoning and prescriptive decisions within their
scope.
Rationale — A: APRNs do not focus only on psychosocial
history; they perform comprehensive, organ/system and
diagnostic assessments.
Rationale — C: Documenting normal findings remains essential
for continuity of care; omission is inappropriate.
Rationale — D: APRNs may delegate portions of care but are
responsible for the advanced assessment; they do not limit
themselves to delegation.
Teaching Point: APRN assessments are deeper and support
diagnosis and treatment decisions.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 1, Section: The Advanced Practice Registered Nurse
3
Reference: Ch. 2, Section: Nursing Process — Assess & Diagnose
Question Stem: A patient reports new-onset shortness of
breath and increased work of breathing. Which immediate
nursing action best follows the assess step of the nursing
process?
A. Document the subjective complaint and wait for the provider
, to evaluate.
B. Perform a focused respiratory exam including vital signs, lung
auscultation, and oxygen saturation.
C. Initiate discharge teaching about energy conservation.
D. Call social work to evaluate home oxygen needs.
Correct Answer: B
Rationale — Correct: The assess step requires focused objective
assessment (vitals, lung sounds, SpO₂) to gather data for
diagnostic reasoning and immediate intervention.
Rationale — A: Simply documenting without objective
assessment delays necessary data collection and intervention.
Rationale — C: Discharge teaching is inappropriate until acute
respiratory status is stabilized and cause identified.
Rationale — D: Social work is not the immediate resource for
an acute physiologic change.
Teaching Point: Acute symptoms require focused objective
assessment before planning.
Citation: Jensen & Smock, Nursing Health Assessment, 4th Ed.,
Ch. 2, Section: Nursing Process — Assess
4
Reference: Ch. 2, Section: Identify Outcomes & Plan Care
Question Stem: After completing a comprehensive assessment,
which outcome is most appropriate and measurable for a
patient with orthostatic hypotension?
