Test Bank For Nursing Health Assessment A Clinical
Judgment Approach 4th Edition by SHARON JENSEN
A nurse wishes to obtain data about a new patient's self-esteem. To gain the clearest picture, the
nurse uses which assessment technique? - (ANSWER)Interviewing the patient in an unstructured
format
A nursing instructor assigns their clinical group the task of writing a journal depicting the
student's clinical day. What is the most likely rationale for this assignment? -
(ANSWER)Journaling allows reflection, an important critical thinking skill.
Which statement is included in the clinical reasoning communication category? -
(ANSWER)Relying heavily on analytic reasoning that requires systematically breaking a
situation down into parts, examining alternatives, and weighing options.
An interpretivist nurse is caring for a patient in the hospital setting. Which of the following
factors will the interpretivist consider when caring for this patient? - (ANSWER)Context of care
Information from significant others and friends
The nurse's previous experiences, values, and emotions
You are a new graduate nurse working with a nurse who has been out of school for 10 years. The
seasoned nurse states, "I don't see the difference between this clinical reasoning and the nursing
process." Which of the following statements would be an appropriate response? -
(ANSWER)Clinical reasoning is an iterative process of noticing, interpreting, and responding—
reasoning in transition with a fine attunement to the patient and how the patient responds to the
nurse's actions.
Clinical reasoning is the thinking process by which a nurse reaches a clinical judgment.
, Clinical reasoning involves reflecting on interventions and reevaluating the plan of care based on
the results of reflection
- (ANSWER)
1. Question: What is the primary purpose of conducting a health assessment in nursing?
Answer:
The primary purpose of conducting a health assessment is to gather comprehensive data about
the patient's health status, identify any potential health issues, and establish a baseline for future
evaluations. It includes physical examinations, health history, and ongoing observations to
support clinical judgment and decision-making.
2. Question: During a head-to-toe assessment, what are the key steps in evaluating the
cardiovascular system?
Answer:
To evaluate the cardiovascular system in a head-to-toe assessment, the nurse should:
• Inspect for visible pulsations or abnormal findings on the chest.
• Palpate peripheral pulses (e.g., radial, brachial, dorsalis pedis).
• Assess the capillary refill and skin temperature.
• Auscultate the heart using a stethoscope to identify normal and abnormal heart sounds
(S1, S2, murmurs).
• Check for jugular vein distention (JVD), which may indicate heart failure.
3. Question: What are the four primary techniques used during a physical assessment?
Answer:
The four primary techniques used during a physical assessment are:
1. Inspection: Visually examining the patient for abnormalities or signs of illness.
2. Palpation: Using hands to feel for abnormalities in texture, temperature, moisture, and
shape.
3. Percussion: Tapping on the body surface to listen for sounds that indicate the presence of
fluids, air, or solid masses.
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