Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A newly graduated RN is performing an initial
assessment on a patient admitted for community-acquired
pneumonia. Which statement best reflects the RN’s role during
this health assessment?
A. The RN should focus only on collecting objective data to
allow the physician to make the diagnosis.
B. The RN integrates subjective and objective data and uses
clinical judgment to identify nursing priorities.
C. The RN documents only abnormal findings and delegates
normal assessments to assistive personnel.
D. The RN’s role is limited to completing standardized checklists
without interpreting findings.
Correct Answer: B
Rationales:
, • Correct (B): The RN synthesizes both subjective and
objective cues and applies clinical judgment to identify
nursing diagnoses and priorities; assessment is
foundational to the nursing process. (2 sentences)
• A: Incorrect — RNs collect and interpret both objective
and subjective data for nursing diagnoses, not only for
physician diagnosis. (1 sentence)
• C: Incorrect — RNs document comprehensive findings and
cannot simply delegate the entire normal/abnormal
interpretation; delegation must follow scope and
supervision rules. (1 sentence)
• D: Incorrect — While standardized tools help, nursing
assessment requires interpretation and decision-making
beyond checklist completion. (1 sentence)
Teaching Point: RN assessment integrates cues and clinical
judgment to set nursing priorities.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role
in Health Assessment
2.
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider/Manager/Member of Profession
Question Stem: During discharge planning for a patient with
heart failure, which action best demonstrates the RN acting as a
manager of care?
,A. Prescribing a diuretic dose adjustment.
B. Teaching the patient how to weigh daily and when to call.
C. Coordinating home health referrals, medication
reconciliation, and follow-up appointments.
D. Performing the daily focused cardiovascular assessment.
Correct Answer: C
Rationales:
• Correct (C): Managing care involves coordinating services,
ensuring continuity, and organizing resources to meet
patient needs at transitions of care. (2 sentences)
• A: Incorrect — Prescribing is within APRN/physician scope,
not the RN manager role. (1 sentence)
• B: Incorrect — Teaching is a provider-of-care role, not
specifically care management. (1 sentence)
• D: Incorrect — Performing assessments is provider-of-care;
management emphasizes coordination and planning. (1
sentence)
Teaching Point: Care management organizes resources and
continuity across transitions.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
3.
Reference: Ch. 1, Section: The Registered Nurse Versus
Advanced Practice Registered Nurse
, Question Stem: A patient presents to the clinic with poorly
controlled diabetes asking about medication changes. Which
action is within the RN’s scope and which requires
APRN/physician involvement?
A. RN adjusts insulin regimen; APRN provides education.
B. RN refers medication adjustment to APRN/physician and
provides diabetes self-care education.
C. RN prescribes oral hypoglycemics; APRN administers
injections.
D. RN independently diagnoses and prescribes based on
assessment.
Correct Answer: B
Rationales:
• Correct (B): RNs provide assessment, education, and
referral; medication regimen changes and prescriptions
require APRN or physician authority. (2 sentences)
• A: Incorrect — Adjusting prescriptions is beyond RN scope
in most settings. (1 sentence)
• C: Incorrect — Prescribing is APRN/physician responsibility;
RNs may administer but not prescribe. (1 sentence)
• D: Incorrect — Independent diagnosing and prescribing are
not RN scope; they require advanced practice licensure. (1
sentence)
Teaching Point: RNs educate and refer; prescribing is
APRN/physician scope.
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1.
Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment
Question Stem: A newly graduated RN is performing an initial
assessment on a patient admitted for community-acquired
pneumonia. Which statement best reflects the RN’s role during
this health assessment?
A. The RN should focus only on collecting objective data to
allow the physician to make the diagnosis.
B. The RN integrates subjective and objective data and uses
clinical judgment to identify nursing priorities.
C. The RN documents only abnormal findings and delegates
normal assessments to assistive personnel.
D. The RN’s role is limited to completing standardized checklists
without interpreting findings.
Correct Answer: B
Rationales:
, • Correct (B): The RN synthesizes both subjective and
objective cues and applies clinical judgment to identify
nursing diagnoses and priorities; assessment is
foundational to the nursing process. (2 sentences)
• A: Incorrect — RNs collect and interpret both objective
and subjective data for nursing diagnoses, not only for
physician diagnosis. (1 sentence)
• C: Incorrect — RNs document comprehensive findings and
cannot simply delegate the entire normal/abnormal
interpretation; delegation must follow scope and
supervision rules. (1 sentence)
• D: Incorrect — While standardized tools help, nursing
assessment requires interpretation and decision-making
beyond checklist completion. (1 sentence)
Teaching Point: RN assessment integrates cues and clinical
judgment to set nursing priorities.
Citation: Jensen & Smock, Ch. 1, Section: The Nurse’s Role
in Health Assessment
2.
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider/Manager/Member of Profession
Question Stem: During discharge planning for a patient with
heart failure, which action best demonstrates the RN acting as a
manager of care?
,A. Prescribing a diuretic dose adjustment.
B. Teaching the patient how to weigh daily and when to call.
C. Coordinating home health referrals, medication
reconciliation, and follow-up appointments.
D. Performing the daily focused cardiovascular assessment.
Correct Answer: C
Rationales:
• Correct (C): Managing care involves coordinating services,
ensuring continuity, and organizing resources to meet
patient needs at transitions of care. (2 sentences)
• A: Incorrect — Prescribing is within APRN/physician scope,
not the RN manager role. (1 sentence)
• B: Incorrect — Teaching is a provider-of-care role, not
specifically care management. (1 sentence)
• D: Incorrect — Performing assessments is provider-of-care;
management emphasizes coordination and planning. (1
sentence)
Teaching Point: Care management organizes resources and
continuity across transitions.
Citation: Jensen & Smock, Ch. 1, Section: Roles of the
Professional Nurse
3.
Reference: Ch. 1, Section: The Registered Nurse Versus
Advanced Practice Registered Nurse
, Question Stem: A patient presents to the clinic with poorly
controlled diabetes asking about medication changes. Which
action is within the RN’s scope and which requires
APRN/physician involvement?
A. RN adjusts insulin regimen; APRN provides education.
B. RN refers medication adjustment to APRN/physician and
provides diabetes self-care education.
C. RN prescribes oral hypoglycemics; APRN administers
injections.
D. RN independently diagnoses and prescribes based on
assessment.
Correct Answer: B
Rationales:
• Correct (B): RNs provide assessment, education, and
referral; medication regimen changes and prescriptions
require APRN or physician authority. (2 sentences)
• A: Incorrect — Adjusting prescriptions is beyond RN scope
in most settings. (1 sentence)
• C: Incorrect — Prescribing is APRN/physician responsibility;
RNs may administer but not prescribe. (1 sentence)
• D: Incorrect — Independent diagnosing and prescribing are
not RN scope; they require advanced practice licensure. (1
sentence)
Teaching Point: RNs educate and refer; prescribing is
APRN/physician scope.
