Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider of Care
Question Stem: A 68-year-old man is admitted with shortness
of breath. Which action best exemplifies the registered nurse’s
role as provider of care during the health assessment?
A. Delegating full respiratory assessment to a licensed practical
nurse.
B. Performing a focused respiratory assessment and initiating
oxygen per protocol.
C. Revising departmental staffing assignments for the shift.
D. Writing a hospital policy about respiratory assessment
frequency.
Correct Answer: B
Rationales:
, • Correct (B): The RN as provider performs direct
assessments and initiates evidence-based interventions
(e.g., focused respiratory exam, oxygen) within scope of
practice. This aligns with the nurse’s clinical role in
assessment and immediate care.
• A: Delegation may be appropriate for parts of care, but the
RN retains responsibility for assessment and decision
making—especially for a new acute complaint.
• C: Staffing/assignment is a managerial task, not immediate
direct patient care.
• D: Policy development is a professional/organizational role,
not the immediate provider role at bedside.
Teaching Point: RN providers perform assessments and initiate
necessary, evidence-based interventions.
Citation: Jensen & Smock — Ch. 1, Section: Roles of the
Professional Nurse (Provider of Care).
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
— Registered Nurse Versus Specialty or Advanced Practice
Assessments
Question Stem: A patient requests a medication refill during a
routine follow-up. Which action indicates the RN should
escalate the request to an APRN rather than manage
independently?
,A. Patient requests education about OTC sleep aids.
B. Patient asks for a refill of a controlled substance not on
current prescriptions.
C. Patient needs blood pressure measured and documented.
D. Patient asks for teaching on a new inhaler technique.
Correct Answer: B
Rationales:
• Correct (B): APRNs have prescriptive authority; RNs must
escalate requests involving initiating controlled
prescriptions or medication changes outside standing
orders.
• A: Education about OTC options falls within RN
teaching/health promotion.
• C: Measuring and documenting vitals is a basic RN
assessment task.
• D: Teaching inhaler technique is a nursing education
responsibility.
Teaching Point: Escalate medication initiation/prescription
decisions to APRNs/MDs per scope.
Citation: Jensen & Smock — Ch. 1, Section: Advanced Practice
Registered Nurse / RN vs APRN assessments.
3
, Reference: Ch. 2, Section: Teaching and Health Promotion —
Wellness and Illness
Question Stem: During a wellness visit, a 45-year-old patient
with well-controlled hypertension asks about lifestyle changes
to reduce cardiovascular risk. Which recommendation best
reflects nursing health promotion?
A. Begin a statin immediately without discussing lifestyle.
B. Counsel on DASH diet, physical activity, and smoking
cessation.
C. Reassure patient no changes are needed because vitals are
normal today.
D. Refer to cardiology for all lifestyle counseling.
Correct Answer: B
Rationales:
• Correct (B): Nursing health promotion focuses on
education and behavior change (DASH diet, exercise, stop
smoking) to reduce risk.
• A: Medication changes/prescriptions should follow
provider/APRN evaluation and shared decision making.
• C: Normal vitals at one visit do not obviate prevention
counseling in at-risk patients.
• D: Referral may be appropriate for complex cases, but
primary nursing health promotion includes counseling and
initial guidance.
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1
Reference: Ch. 1, Section: Roles of the Professional Nurse —
Provider of Care
Question Stem: A 68-year-old man is admitted with shortness
of breath. Which action best exemplifies the registered nurse’s
role as provider of care during the health assessment?
A. Delegating full respiratory assessment to a licensed practical
nurse.
B. Performing a focused respiratory assessment and initiating
oxygen per protocol.
C. Revising departmental staffing assignments for the shift.
D. Writing a hospital policy about respiratory assessment
frequency.
Correct Answer: B
Rationales:
, • Correct (B): The RN as provider performs direct
assessments and initiates evidence-based interventions
(e.g., focused respiratory exam, oxygen) within scope of
practice. This aligns with the nurse’s clinical role in
assessment and immediate care.
• A: Delegation may be appropriate for parts of care, but the
RN retains responsibility for assessment and decision
making—especially for a new acute complaint.
• C: Staffing/assignment is a managerial task, not immediate
direct patient care.
• D: Policy development is a professional/organizational role,
not the immediate provider role at bedside.
Teaching Point: RN providers perform assessments and initiate
necessary, evidence-based interventions.
Citation: Jensen & Smock — Ch. 1, Section: Roles of the
Professional Nurse (Provider of Care).
2
Reference: Ch. 1, Section: Advanced Practice Registered Nurse
— Registered Nurse Versus Specialty or Advanced Practice
Assessments
Question Stem: A patient requests a medication refill during a
routine follow-up. Which action indicates the RN should
escalate the request to an APRN rather than manage
independently?
,A. Patient requests education about OTC sleep aids.
B. Patient asks for a refill of a controlled substance not on
current prescriptions.
C. Patient needs blood pressure measured and documented.
D. Patient asks for teaching on a new inhaler technique.
Correct Answer: B
Rationales:
• Correct (B): APRNs have prescriptive authority; RNs must
escalate requests involving initiating controlled
prescriptions or medication changes outside standing
orders.
• A: Education about OTC options falls within RN
teaching/health promotion.
• C: Measuring and documenting vitals is a basic RN
assessment task.
• D: Teaching inhaler technique is a nursing education
responsibility.
Teaching Point: Escalate medication initiation/prescription
decisions to APRNs/MDs per scope.
Citation: Jensen & Smock — Ch. 1, Section: Advanced Practice
Registered Nurse / RN vs APRN assessments.
3
, Reference: Ch. 2, Section: Teaching and Health Promotion —
Wellness and Illness
Question Stem: During a wellness visit, a 45-year-old patient
with well-controlled hypertension asks about lifestyle changes
to reduce cardiovascular risk. Which recommendation best
reflects nursing health promotion?
A. Begin a statin immediately without discussing lifestyle.
B. Counsel on DASH diet, physical activity, and smoking
cessation.
C. Reassure patient no changes are needed because vitals are
normal today.
D. Refer to cardiology for all lifestyle counseling.
Correct Answer: B
Rationales:
• Correct (B): Nursing health promotion focuses on
education and behavior change (DASH diet, exercise, stop
smoking) to reduce risk.
• A: Medication changes/prescriptions should follow
provider/APRN evaluation and shared decision making.
• C: Normal vitals at one visit do not obviate prevention
counseling in at-risk patients.
• D: Referral may be appropriate for complex cases, but
primary nursing health promotion includes counseling and
initial guidance.
