Nursing Health Assessment
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Reference: Unit 1 — The Nurse’s Role in Health
Assessment (Roles of the Professional Nurse)
Question Stem: A newly graduated RN is assigned to
perform an initial health assessment on a post-op patient.
Which role best describes the nurse’s priority during this
assessment?
A. Manager of care, focusing on staffing and resource
allocation.
B. Provider of care, identifying immediate clinical needs
and interventions.
C. Member of the profession, attending a professional
committee meeting.
D. Advanced Practice Registered Nurse, diagnosing medical
disorders.
Correct Answer: B
Rationale — Correct: As the provider of care, the RN’s
immediate priority in an initial assessment is to identify clinical
,needs and initiate appropriate nursing interventions; this aligns
with bedside assessment responsibilities. (Unit: Roles of the
Professional Nurse).
Rationale — A: Manager activities are important but not the
priority during an individual patient bedside assessment.
Rationale — C: Professional membership is a broader role and
unrelated to conducting an immediate patient assessment.
Rationale — D: APRN diagnostic authority is beyond the scope
of a staff RN’s initial assessment.
Teaching Point: The RN at the bedside first functions as a
provider of care.
Citation: Jensen & Smock, Unit 1 — Roles of the Professional
Nurse.
2. Reference: Unit 1 — Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment task should a staff RN
perform versus referring to an APRN or specialist? A post-
op patient has a new rash; the nurse notices spreading
erythema and pruritus. What is the RN’s best immediate
action?
A. Diagnose contact dermatitis and prescribe topical
steroid.
B. Document findings, implement basic skin care, and
notify the provider for further evaluation.
C. Ignore the rash as a low-priority postoperative issue.
, D. Discharge the patient early to prevent hospital-acquired
infection.
Correct Answer: B
Rationale — Correct: The RN should document objective
findings, initiate appropriate basic nursing interventions (skin
care, monitoring), and notify the provider or APRN for diagnosis
and orders; this differentiates RN and APRN responsibilities.
Rationale — A: Diagnosing and prescribing are beyond the RN’s
scope.
Rationale — C: Ignoring a spreading rash risks patient harm and
misses early recognition of complications.
Rationale — D: Discharging early is unsafe and not indicated for
a new spreading rash.
Teaching Point: RNs assess, initiate nursing care, and escalate
for medical diagnosis/orders.
Citation: Jensen & Smock, Unit 1 — Registered Nurse Versus
Specialty or APRN Assessments.
3. Reference: Unit 1 — Teaching and Health Promotion
(Wellness and Illness)
Question Stem: A 58-year-old patient with controlled
hypertension asks about reducing cardiovascular risk.
Which health-promotion intervention should the nurse
prioritize during the assessment visit?
A. Begin an insulin regimen immediately.
B. Discuss smoking cessation, physical activity, and diet
, tailored to readiness to change.
C. Schedule a CT angiogram today without further
discussion.
D. Tell the patient that no lifestyle change is necessary
because blood pressure is controlled.
Correct Answer: B
Rationale — Correct: Health promotion focuses on patient
education and behavior change; assessing readiness and
providing tailored counseling about smoking cessation, activity,
and diet are priority interventions to reduce cardiovascular risk.
Rationale — A: Initiating insulin is inappropriate without
diabetes diagnosis.
Rationale — C: Ordering advanced imaging without assessment
or indication is unnecessary.
Rationale — D: Assuming no changes are needed is a missed
teaching opportunity despite controlled BP.
Teaching Point: Tailor health-promotion teaching to patient
readiness and risk factors.
Citation: Jensen & Smock, Unit 1 — Teaching and Health
Promotion.
4. Reference: Unit 1 — Social Determinants of Health:
Healthy People 2030
Question Stem: During a clinic assessment, a patient
reports limited transportation and food insecurity. What is
the nurse’s best next step to address these social
A Clinical Judgment Approach
4th Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Reference: Unit 1 — The Nurse’s Role in Health
Assessment (Roles of the Professional Nurse)
Question Stem: A newly graduated RN is assigned to
perform an initial health assessment on a post-op patient.
Which role best describes the nurse’s priority during this
assessment?
A. Manager of care, focusing on staffing and resource
allocation.
B. Provider of care, identifying immediate clinical needs
and interventions.
C. Member of the profession, attending a professional
committee meeting.
D. Advanced Practice Registered Nurse, diagnosing medical
disorders.
Correct Answer: B
Rationale — Correct: As the provider of care, the RN’s
immediate priority in an initial assessment is to identify clinical
,needs and initiate appropriate nursing interventions; this aligns
with bedside assessment responsibilities. (Unit: Roles of the
Professional Nurse).
Rationale — A: Manager activities are important but not the
priority during an individual patient bedside assessment.
Rationale — C: Professional membership is a broader role and
unrelated to conducting an immediate patient assessment.
Rationale — D: APRN diagnostic authority is beyond the scope
of a staff RN’s initial assessment.
Teaching Point: The RN at the bedside first functions as a
provider of care.
Citation: Jensen & Smock, Unit 1 — Roles of the Professional
Nurse.
2. Reference: Unit 1 — Registered Nurse Versus Specialty or
Advanced Practice Assessments
Question Stem: Which assessment task should a staff RN
perform versus referring to an APRN or specialist? A post-
op patient has a new rash; the nurse notices spreading
erythema and pruritus. What is the RN’s best immediate
action?
A. Diagnose contact dermatitis and prescribe topical
steroid.
B. Document findings, implement basic skin care, and
notify the provider for further evaluation.
C. Ignore the rash as a low-priority postoperative issue.
, D. Discharge the patient early to prevent hospital-acquired
infection.
Correct Answer: B
Rationale — Correct: The RN should document objective
findings, initiate appropriate basic nursing interventions (skin
care, monitoring), and notify the provider or APRN for diagnosis
and orders; this differentiates RN and APRN responsibilities.
Rationale — A: Diagnosing and prescribing are beyond the RN’s
scope.
Rationale — C: Ignoring a spreading rash risks patient harm and
misses early recognition of complications.
Rationale — D: Discharging early is unsafe and not indicated for
a new spreading rash.
Teaching Point: RNs assess, initiate nursing care, and escalate
for medical diagnosis/orders.
Citation: Jensen & Smock, Unit 1 — Registered Nurse Versus
Specialty or APRN Assessments.
3. Reference: Unit 1 — Teaching and Health Promotion
(Wellness and Illness)
Question Stem: A 58-year-old patient with controlled
hypertension asks about reducing cardiovascular risk.
Which health-promotion intervention should the nurse
prioritize during the assessment visit?
A. Begin an insulin regimen immediately.
B. Discuss smoking cessation, physical activity, and diet
, tailored to readiness to change.
C. Schedule a CT angiogram today without further
discussion.
D. Tell the patient that no lifestyle change is necessary
because blood pressure is controlled.
Correct Answer: B
Rationale — Correct: Health promotion focuses on patient
education and behavior change; assessing readiness and
providing tailored counseling about smoking cessation, activity,
and diet are priority interventions to reduce cardiovascular risk.
Rationale — A: Initiating insulin is inappropriate without
diabetes diagnosis.
Rationale — C: Ordering advanced imaging without assessment
or indication is unnecessary.
Rationale — D: Assuming no changes are needed is a missed
teaching opportunity despite controlled BP.
Teaching Point: Tailor health-promotion teaching to patient
readiness and risk factors.
Citation: Jensen & Smock, Unit 1 — Teaching and Health
Promotion.
4. Reference: Unit 1 — Social Determinants of Health:
Healthy People 2030
Question Stem: During a clinic assessment, a patient
reports limited transportation and food insecurity. What is
the nurse’s best next step to address these social
