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 — Roles of the Professional Nurse
Question Stem: A hospitalized patient asks why the RN is
performing a comprehensive intake exam rather than waiting
for an APRN. Which explanation best reflects the RN’s role?
A. “RNs perform comprehensive assessments to collect data for
planning and coordinating patient care.”
B. “RNs only perform basic vital signs; advanced diagnostic
exams are for APRNs.”
C. “RNs can diagnose complex conditions and prescribe
treatments independently.”
D. “RNs should defer all clinical assessments to the physician for
accuracy.”
Correct Answer: A
Rationales:
, • A (correct): RNs perform comprehensive assessments to
gather subjective and objective data, inform nursing
diagnoses, plan and coordinate care, and identify needs—
core RN responsibilities. (2 sentences)
• B: Incorrect — RNs do more than take vitals; they
synthesize assessment data and contribute to care
planning. (1 sentence)
• C: Incorrect — Diagnosing complex medical conditions and
independent prescribing are outside typical RN scope (they
are APRN/advanced practice functions). (1 sentence)
• D: Incorrect — RNs collaborate with physicians but do not
simply defer assessments; nursing assessment is
autonomous and essential. (1 sentence)
Teaching Point: RNs gather data and coordinate care;
assessment is a core nursing role.
Citation: Ch. 1, Section: Roles of the Professional Nurse
2)
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment task most appropriately
requires referral to an APRN rather than being completed solely
by an RN?
A. Collecting a complete medication history and current
symptoms.
,B. Performing a focused wound inspection and documenting
drainage.
C. Initiating a differential diagnosis and ordering opioid therapy.
D. Teaching incision care and scheduling follow-up dressing
changes.
Correct Answer: C
Rationales:
• C (correct): Initiating a differential diagnosis and ordering
controlled medications typically falls within
APRN/advanced practice scope and requires prescriptive
authority. (2 sentences)
• A: Incorrect — RNs routinely collect medication histories
and symptom data as part of assessment. (1 sentence)
• B: Incorrect — Focused wound inspection and
documentation are within RN assessment responsibilities.
(1 sentence)
• D: Incorrect — Patient education and arranging follow-up
are core RN tasks. (1 sentence)
Teaching Point: APRNs manage diagnoses and prescribing; RNs
collect and interpret assessment data.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
, 3)
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse identifies low health literacy during a
routine assessment. Which approach best supports effective
teaching?
A. Provide a patient education pamphlet with medical
terminology.
B. Use plain language, teach-back, and short demonstration
sessions.
C. Ask the patient to read the discharge instructions aloud and
correct errors.
D. Delay teaching until a physician provides the same
information.
Correct Answer: B
Rationales:
• B (correct): Plain language, teach-back, and brief
demonstrations align with health literacy best practices to
confirm understanding. (2 sentences)
• A: Incorrect — Pamphlets with medical jargon risk
misunderstanding and are poor for low literacy. (1
sentence)
• C: Incorrect — Having patients read medical text is not an
evidence-based way to ensure comprehension without
teach-back and simplification. (1 sentence)
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 — Roles of the Professional Nurse
Question Stem: A hospitalized patient asks why the RN is
performing a comprehensive intake exam rather than waiting
for an APRN. Which explanation best reflects the RN’s role?
A. “RNs perform comprehensive assessments to collect data for
planning and coordinating patient care.”
B. “RNs only perform basic vital signs; advanced diagnostic
exams are for APRNs.”
C. “RNs can diagnose complex conditions and prescribe
treatments independently.”
D. “RNs should defer all clinical assessments to the physician for
accuracy.”
Correct Answer: A
Rationales:
, • A (correct): RNs perform comprehensive assessments to
gather subjective and objective data, inform nursing
diagnoses, plan and coordinate care, and identify needs—
core RN responsibilities. (2 sentences)
• B: Incorrect — RNs do more than take vitals; they
synthesize assessment data and contribute to care
planning. (1 sentence)
• C: Incorrect — Diagnosing complex medical conditions and
independent prescribing are outside typical RN scope (they
are APRN/advanced practice functions). (1 sentence)
• D: Incorrect — RNs collaborate with physicians but do not
simply defer assessments; nursing assessment is
autonomous and essential. (1 sentence)
Teaching Point: RNs gather data and coordinate care;
assessment is a core nursing role.
Citation: Ch. 1, Section: Roles of the Professional Nurse
2)
Reference: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment task most appropriately
requires referral to an APRN rather than being completed solely
by an RN?
A. Collecting a complete medication history and current
symptoms.
,B. Performing a focused wound inspection and documenting
drainage.
C. Initiating a differential diagnosis and ordering opioid therapy.
D. Teaching incision care and scheduling follow-up dressing
changes.
Correct Answer: C
Rationales:
• C (correct): Initiating a differential diagnosis and ordering
controlled medications typically falls within
APRN/advanced practice scope and requires prescriptive
authority. (2 sentences)
• A: Incorrect — RNs routinely collect medication histories
and symptom data as part of assessment. (1 sentence)
• B: Incorrect — Focused wound inspection and
documentation are within RN assessment responsibilities.
(1 sentence)
• D: Incorrect — Patient education and arranging follow-up
are core RN tasks. (1 sentence)
Teaching Point: APRNs manage diagnoses and prescribing; RNs
collect and interpret assessment data.
Citation: Ch. 1, Section: Registered Nurse Versus Specialty or
Advanced Practice Assessments
, 3)
Reference: Ch. 1, Section: Teaching and Health Promotion
Question Stem: A nurse identifies low health literacy during a
routine assessment. Which approach best supports effective
teaching?
A. Provide a patient education pamphlet with medical
terminology.
B. Use plain language, teach-back, and short demonstration
sessions.
C. Ask the patient to read the discharge instructions aloud and
correct errors.
D. Delay teaching until a physician provides the same
information.
Correct Answer: B
Rationales:
• B (correct): Plain language, teach-back, and brief
demonstrations align with health literacy best practices to
confirm understanding. (2 sentences)
• A: Incorrect — Pamphlets with medical jargon risk
misunderstanding and are poor for low literacy. (1
sentence)
• C: Incorrect — Having patients read medical text is not an
evidence-based way to ensure comprehension without
teach-back and simplification. (1 sentence)
