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 admitted 68-year-old patient with
COPD reports increased shortness of breath. Which action best
reflects the registered nurse’s role in the initial health
assessment?
A. Order a chest x-ray to evaluate for pneumonia.
B. Perform a focused respiratory assessment and notify the
provider of abnormal findings.
C. Prescribe bronchodilator therapy based on clinical judgment.
D. Document only subjective complaints and defer objective
assessment to respiratory therapy.
Correct Answer: B
Rationales:
• Correct (B): The RN performs focused assessments,
interprets findings, and communicates abnormalities to
, the health care team — central RN responsibilities in
assessment and care coordination. (2 sentences)
• A: Ordering diagnostic tests is typically a provider or
advanced practice responsibility, not an initial RN action. (1
sentence)
• C: Prescribing medications is outside the RN scope unless
functioning as an APRN with prescriptive authority. (1
sentence)
• D: Deferring objective assessment delays care; RNs must
collect both subjective and objective data. (1 sentence)
Teaching Point: RNs assess, interpret, and escalate abnormal
findings promptly.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. LWW Official Store
Item 2
Reference: Ch. 1, Section: Nursing Process — Assess
Question Stem: During the health history, a 45-year-old reports
fatigue and 10-lb weight loss over 2 months. Which follow-up
question best demonstrates effective assessment technique?
A. “Do you exercise regularly?”
B. “Have you noticed any other symptoms like night sweats or
fevers?”
,C. “When did you last see a nutritionist?”
D. “Are you sure you aren’t exaggerating your weight change?”
Correct Answer: B
Rationales:
• Correct (B): Asking about accompanying systemic
symptoms helps differentiate possible causes (e.g.,
infection, malignancy, endocrine), reflecting diagnostic
reasoning in assessment. (2 sentences)
• A: Exercise habits are relevant but do not directly explore
red-flag systemic symptoms for unexplained weight loss. (1
sentence)
• C: Referral history is premature without clarifying
associated symptoms and likely causes. (1 sentence)
• D: Challenging the patient is dismissive and undermines
therapeutic communication. (1 sentence)
Teaching Point: Probe for associated symptoms to clarify causes
of unexplained weight loss.
Citation: Jensen & Smock, Ch. 1, Nursing Process — Assess.
LWW Official Store
Item 3
Reference: Ch. 1, Section: Subjective Cues vs Objective Cues
, Question Stem: A patient reports dizziness; vital signs are stable
but pulse oximetry is 88% on room air. How should the nurse
prioritize this information?
A. Treat the low SpO₂ as an objective red flag and initiate
oxygen per protocol.
B. Rely on stable vital signs and continue monitoring without
intervention.
C. Document the subjective complaint only and notify the
provider if it worsens.
D. Encourage the patient to lie down and reassess in 24 hours.
Correct Answer: A
Rationales:
• Correct (A): SpO₂ of 88% is an objective abnormality
indicating hypoxemia and requires immediate intervention
according to priority-setting frameworks (ABCs). (2
sentences)
• B: Stable other vitals do not negate significant hypoxemia;
action is warranted. (1 sentence)
• C: Objective hypoxemia requires immediate action rather
than waiting for deterioration. (1 sentence)
• D: Delaying action for 24 hours risks harm from persistent
hypoxemia. (1 sentence)
Teaching Point: Objective hypoxemia demands immediate
response (ABCs first).
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 admitted 68-year-old patient with
COPD reports increased shortness of breath. Which action best
reflects the registered nurse’s role in the initial health
assessment?
A. Order a chest x-ray to evaluate for pneumonia.
B. Perform a focused respiratory assessment and notify the
provider of abnormal findings.
C. Prescribe bronchodilator therapy based on clinical judgment.
D. Document only subjective complaints and defer objective
assessment to respiratory therapy.
Correct Answer: B
Rationales:
• Correct (B): The RN performs focused assessments,
interprets findings, and communicates abnormalities to
, the health care team — central RN responsibilities in
assessment and care coordination. (2 sentences)
• A: Ordering diagnostic tests is typically a provider or
advanced practice responsibility, not an initial RN action. (1
sentence)
• C: Prescribing medications is outside the RN scope unless
functioning as an APRN with prescriptive authority. (1
sentence)
• D: Deferring objective assessment delays care; RNs must
collect both subjective and objective data. (1 sentence)
Teaching Point: RNs assess, interpret, and escalate abnormal
findings promptly.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. LWW Official Store
Item 2
Reference: Ch. 1, Section: Nursing Process — Assess
Question Stem: During the health history, a 45-year-old reports
fatigue and 10-lb weight loss over 2 months. Which follow-up
question best demonstrates effective assessment technique?
A. “Do you exercise regularly?”
B. “Have you noticed any other symptoms like night sweats or
fevers?”
,C. “When did you last see a nutritionist?”
D. “Are you sure you aren’t exaggerating your weight change?”
Correct Answer: B
Rationales:
• Correct (B): Asking about accompanying systemic
symptoms helps differentiate possible causes (e.g.,
infection, malignancy, endocrine), reflecting diagnostic
reasoning in assessment. (2 sentences)
• A: Exercise habits are relevant but do not directly explore
red-flag systemic symptoms for unexplained weight loss. (1
sentence)
• C: Referral history is premature without clarifying
associated symptoms and likely causes. (1 sentence)
• D: Challenging the patient is dismissive and undermines
therapeutic communication. (1 sentence)
Teaching Point: Probe for associated symptoms to clarify causes
of unexplained weight loss.
Citation: Jensen & Smock, Ch. 1, Nursing Process — Assess.
LWW Official Store
Item 3
Reference: Ch. 1, Section: Subjective Cues vs Objective Cues
, Question Stem: A patient reports dizziness; vital signs are stable
but pulse oximetry is 88% on room air. How should the nurse
prioritize this information?
A. Treat the low SpO₂ as an objective red flag and initiate
oxygen per protocol.
B. Rely on stable vital signs and continue monitoring without
intervention.
C. Document the subjective complaint only and notify the
provider if it worsens.
D. Encourage the patient to lie down and reassess in 24 hours.
Correct Answer: A
Rationales:
• Correct (A): SpO₂ of 88% is an objective abnormality
indicating hypoxemia and requires immediate intervention
according to priority-setting frameworks (ABCs). (2
sentences)
• B: Stable other vitals do not negate significant hypoxemia;
action is warranted. (1 sentence)
• C: Objective hypoxemia requires immediate action rather
than waiting for deterioration. (1 sentence)
• D: Delaying action for 24 hours risks harm from persistent
hypoxemia. (1 sentence)
Teaching Point: Objective hypoxemia demands immediate
response (ABCs first).
