,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 8th Edition
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MULTIPLE CHOICE $d
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
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a heart attack.‖ What is the nurse‘s top priority at this time?
$d $d $d $d $d $d $d $d $d $d $d
a. Determine the patient‘s personal data and insurance coverage. $d $d $d $d $d $d $d
b. Ask the patient to take a seat in the waiting room until his name is called.
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
c. Request that a nurse collect data for a comprehensive history.
$d $d $d $d $d $d $d $d $d
d. Ask a nurse to start a focused assessment of this patient now.
$d $d $d $d $d $d $d $d $d $d $d
ANS: D $ d
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
cardiovascular system. The type of health assessment performed by the nurse is also driven
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dby patient need. Personal data and insurance information will be obtained, but in this situat
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ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
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y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
urse needs to begin data collection, such as vital signs, immediately to determine the patien
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
t‘s health status. Complications can be prevented if an immediate assessment is made to an
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
his time. Some subjective data will be collected, such as allergies and medical history relat
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
$d $d $d $d $d $d $d $d $d $d $d $d $d
essment is not a priority at this time. $d $d $d $d $d $d $d
DIF:Cognitive Level: Apply REF: Box 1- $d $d $ d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
2. Which situation illustrates a screening assessment?
$d $d $d $d $d
a. A patient visits an obstetric clinic for the first time and the nurse conduct
$d $d $d $d $d $d $d $d $d $d $d $d $d
s a detailed history and physical examination.
$d $d $d $d $d $d
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
od pressure checks to mall patrons.
$d $d $d $d $d
c. The nurse in an urgent care center checks the vital signs of a patient who
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
is complaining of leg pain.
$d $d $d $d $d
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
$d $d $d $d $d $d $d $d $d $d $d $d
od glucose level. $d $d
ANS: B $ d
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
ple of a screening assessment focused on disease detection. A detailed history and physical
$d $d $d $d $d $d $d $d $d $d $d $d $d $
dexamination conducted during a first- $d $d $d $d
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
patient complaining of leg pain in the triage area of an urgent care center is an example of
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da problem-
$d
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
$d $d $d $d $d $d $d $d $d $d $d $d
to report fasting blood glucose levels is an example of an episodic or follow-
$d $d $d $d $d $d $d $d $d $d $d $d $d
up assessment.
$d
DIF:Cognitive Level: Understand $d $d REF: Box 1-3 $d $d
, TOP:Nursing Process: Assessment $d $d
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
$d $d $d $d $d $d $d $d
3. For which person is a screening assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
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ANS: B $d
A screening assessment is performed for the purpose of disease detection. In this case this
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
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ring admission to a facility to obtain a detailed history and complete physical examination.
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
An episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedur
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e.
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
4. For which person is a shift assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: A $d
A shift assessment is most appropriate for the person who is recovering in the hospital from
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
$dsurgery. A screening assessment is performed for the purpose of disease detection, in this c
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
$d $d $d $d $d $d $d $d $d $d $d $d
ty to obtain a detailed history and complete physical examination. An episodic or follow-
$d $d $d $d $d $d $d $d $d $d $d $d $d
up assessment is performed after knee replacement to evaluate the outcome of the procedure
$d $d $d $d $d $d $d $d $d $d $d $d $d
.
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
5. For which person is a comprehensive assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
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ANS: C $d
A comprehensive assessment is performed during admission to a facility to obtain a detaile
$d $d $d $d $d $d $d $d $d $d $d $d $d
d history and complete physical examination. A shift assessment is most appropriate for th
$d $d $d $d $d $d $d $d $d $d $d $d $d
e person who is recovering in the hospital from surgery. A screening assessment is perfor
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
$d $d $d $d $d $d $d $d $d $d $d $d $d
re.
, DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
6. For which person is an episodic or follow-up assessment indicated?
$d $d $d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: D $d
An episodic or follow-
$d $d $d
up assessment is performed after the knee replacement to evaluate the outcome of the proc
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
edure. A shift assessment is most appropriate for the person who is recovering in the hospi
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
tal from surgery. A screening assessment is performed for the purpose of disease detection,
$d $d $d $d $d $d $d $d $d $d $d $d $d $
din this case diabetes mellitus. A comprehensive assessment is performed during admission
$d $d $d $d $d $d $d $d $d $d $d $d
to a facility to obtain a detailed history and complete physical examination.
$d $d $d $d $d $d $d $d $d $d $d
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A $d
The lack of hair and shiny skin over both shins are objective data or signs that are part of
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the physical examination. A patient‘s concerns about lack of money are subjective data an
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d are part of the health history. A patient‘s complaints of tingling sensations in the feet are
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subjective data and are part of the health history. A patient‘s family statements are conside
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red secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- $d $d $ d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
$d $d $d $d $d $d $d $d $d $d $
Assessments
d
8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.$d $d $d $d
ANS: D $d
$d $d $d $d $d
Wilson: Health Assessment for Nursing Practice, 8th Edition
$d $d $d $d $d $d $d
MULTIPLE CHOICE $d
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
a heart attack.‖ What is the nurse‘s top priority at this time?
$d $d $d $d $d $d $d $d $d $d $d
a. Determine the patient‘s personal data and insurance coverage. $d $d $d $d $d $d $d
b. Ask the patient to take a seat in the waiting room until his name is called.
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
c. Request that a nurse collect data for a comprehensive history.
$d $d $d $d $d $d $d $d $d
d. Ask a nurse to start a focused assessment of this patient now.
$d $d $d $d $d $d $d $d $d $d $d
ANS: D $ d
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
cardiovascular system. The type of health assessment performed by the nurse is also driven
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $
dby patient need. Personal data and insurance information will be obtained, but in this situat
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
urse needs to begin data collection, such as vital signs, immediately to determine the patien
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
t‘s health status. Complications can be prevented if an immediate assessment is made to an
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
his time. Some subjective data will be collected, such as allergies and medical history relat
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
$d $d $d $d $d $d $d $d $d $d $d $d $d
essment is not a priority at this time. $d $d $d $d $d $d $d
DIF:Cognitive Level: Apply REF: Box 1- $d $d $ d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
2. Which situation illustrates a screening assessment?
$d $d $d $d $d
a. A patient visits an obstetric clinic for the first time and the nurse conduct
$d $d $d $d $d $d $d $d $d $d $d $d $d
s a detailed history and physical examination.
$d $d $d $d $d $d
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
od pressure checks to mall patrons.
$d $d $d $d $d
c. The nurse in an urgent care center checks the vital signs of a patient who
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
is complaining of leg pain.
$d $d $d $d $d
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
$d $d $d $d $d $d $d $d $d $d $d $d
od glucose level. $d $d
ANS: B $ d
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
ple of a screening assessment focused on disease detection. A detailed history and physical
$d $d $d $d $d $d $d $d $d $d $d $d $d $
dexamination conducted during a first- $d $d $d $d
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
patient complaining of leg pain in the triage area of an urgent care center is an example of
$d $d $d $d $d $d $d $d $d $ d $d $d $d $d $d $d $d $
da problem-
$d
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
$d $d $d $d $d $d $d $d $d $d $d $d
to report fasting blood glucose levels is an example of an episodic or follow-
$d $d $d $d $d $d $d $d $d $d $d $d $d
up assessment.
$d
DIF:Cognitive Level: Understand $d $d REF: Box 1-3 $d $d
, TOP:Nursing Process: Assessment $d $d
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
$d $d $d $d $d $d $d $d
3. For which person is a screening assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: B $d
A screening assessment is performed for the purpose of disease detection. In this case this
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
$d $d $d $d $d $d $d $d $d $d $d $d $d
ring admission to a facility to obtain a detailed history and complete physical examination.
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
An episodic or follow-
$d $d $d
up assessment is performed after knee replacement to evaluate the outcome of the procedur
$d $d $d $d $d $d $d $d $d $d $d $d $d
e.
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
4. For which person is a shift assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: A $d
A shift assessment is most appropriate for the person who is recovering in the hospital from
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
$dsurgery. A screening assessment is performed for the purpose of disease detection, in this c
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
$d $d $d $d $d $d $d $d $d $d $d $d
ty to obtain a detailed history and complete physical examination. An episodic or follow-
$d $d $d $d $d $d $d $d $d $d $d $d $d
up assessment is performed after knee replacement to evaluate the outcome of the procedure
$d $d $d $d $d $d $d $d $d $d $d $d $d
.
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
5. For which person is a comprehensive assessment indicated?
$d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: C $d
A comprehensive assessment is performed during admission to a facility to obtain a detaile
$d $d $d $d $d $d $d $d $d $d $d $d $d
d history and complete physical examination. A shift assessment is most appropriate for th
$d $d $d $d $d $d $d $d $d $d $d $d $d
e person who is recovering in the hospital from surgery. A screening assessment is perfor
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
$d $d $d $d $d $d $d $d $d $d $d $d $d
re.
, DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
6. For which person is an episodic or follow-up assessment indicated?
$d $d $d $d $d $d $d $d $d
a. The person who had abdominal surgery yesterday
$d $d $d $d $d $d
b. The person who is unaware of his high serum glucose levels
$d $d $d $d $d $d $d $d $d $d
c. The person who is being admitted to a long-term care facility
$d $d $d $d $d $d $d $d $d $d
d. The person who is beginning rehabilitation after a knee replacement
$d $d $d $d $d $d $d $d $d
ANS: D $d
An episodic or follow-
$d $d $d
up assessment is performed after the knee replacement to evaluate the outcome of the proc
$d $d $d $d $d $d $d $d $d $d $d $d $d $d
edure. A shift assessment is most appropriate for the person who is recovering in the hospi
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
tal from surgery. A screening assessment is performed for the purpose of disease detection,
$d $d $d $d $d $d $d $d $d $d $d $d $d $
din this case diabetes mellitus. A comprehensive assessment is performed during admission
$d $d $d $d $d $d $d $d $d $d $d $d
to a facility to obtain a detailed history and complete physical examination.
$d $d $d $d $d $d $d $d $d $d $d
DIF:Cognitive Level: Understand REF: Box 1- $d $d $d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
$d $d $d $d $d $d $d $d $d $d $d
hing Priorities $d
7. Which is an example of data a nurse collects during a physical examination?
$d $d $d $d $d $d $d $d $d $d $d $d
a. The patient‘s lack of hair and shiny skin over both shins
$d $d $d $d $d $d $d $d $d $d
b. The patient‘s stated concern about lack of money for prescriptions
$d $d $d $d $d $d $d $d $d
c. The patient‘s complaints of tingling sensations in the feet
$d $d $d $d $d $d $d $d
d. The patient‘s mother‘s statements that the patient is very nervous lately
$d $d $d $d $d $d $d $d $d $d
ANS: A $d
The lack of hair and shiny skin over both shins are objective data or signs that are part of
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
the physical examination. A patient‘s concerns about lack of money are subjective data an
$d $d $d $d $d $d $d $d $d $d $d $d $d
d are part of the health history. A patient‘s complaints of tingling sensations in the feet are
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
subjective data and are part of the health history. A patient‘s family statements are conside
$d $d $d $d $d $d $d $d $d $d $d $d $d $d $d
red secondary data, are subjective data, and are part of the health history.
$d $d $d $d $d $d $d $d $d $d $d $d
DIF:Cognitive Level: Apply REF: Box 1- $d $d $ d $d
3 TOP:Nursing Process: Assessment
$d $d $d
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
$d $d $d $d $d $d $d $d $d $d $
Assessments
d
8. The nurse documents which information in the patient‘s history?
$d $d $d $d $d $d $d $d
a. The patient‘s skin feels warm to the touch.
$d $d $d $d $d $d $d
b. The patient is scratching his arm.
$d $d $d $d $d
c. The patient‘s temperature is 100 F.
$d $d $d $d $d
d. The patient complains of itching.$d $d $d $d
ANS: D $d
