TEST BANK
Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,TABLE OF CONTENTS
Unit I: Foundations for Health Assessment
1. Introduction to Health Assessment
2. Interviewing Patients to Obtain a Health History
3. Techniques and Equipment for Physical Assessment
4. General Inspection and Measurement of Vital Signs
5. Ethnic, Cultural, and Spiritual Considerations
6. Pain Assessment
7. Mental Health and Abusive Behavior Assessment
8. Nutritional Assessment
Unit II: Health Assessment of the Adult
9. Skin, Hair, and Nails
10. Head, Eyes, Ears, Nose, and Throat
11. Lungs and Respiratory System
12. Heart and Peripheral Vascular System
13. Abdomen and Gastrointestinal System
14. Musculoskeletal System
15. Neurologic System
16. Breasts and Axillae
17. Reproductive System and the Perineum
Unit III: Health Assessment Across the Life Span
18. Developmental Assessment Throughout the Life Span
19. Assessment of the Infant, Child, and Adolescent
20. Assessment of the Pregnant Patient
21. Assessment of the Older Adult
Unit IV: Synthesis and Application of Health Assessment
22. Conducting a Head-to-Toe Examination
23. Documenting the Head-to-Toe Health Assessment
24. Adapting Health Assessment
Chapter 01: Introduction to Health Assessment
,MULTIPLE CHOICE
1. A
patient**comes**to**the**emergency**department**and**tells**the**triage**nurse**that**heis**“havi
ng**a**heart**attack.” ** What**is**the**nurse’s**top**priority**at**this**time?
a. Determine **the**patient’s**personal**data**and**i
nsurance**coverage.
b. Ask**the**patient**to**take**a**seat**in**the**waitin
g**room**until**his**name**is**called.
c. Request **that** a** nurse** collect** data** for
acomprehensive* * history.
d. Ask** a** nurse**to** start**a**focused**assessment
of**this**patient**now.
ANSWER: D
The**nurse**needs**to**begin**an**assessment**as**soon**as**possible**that**is**focused**on**this**patient
’s**cardiovascular **system.**The**type**of**health**assessment**performed **by**the**nurse**is**also**d
riven**by**patient**need.**Personal**data**and**insurance**information**will**be**obtained,**but**in*
*this** situation, ** these ** data ** can ** wait** until** after ** the** patient ** is** assessed. ** Based ** also ** on ** Ma
slow’s**hierarchy**of**needs,**physiologic**needs**take**precedence.** Rather **than**asking**the**p
atient**to**wait,**the**nurse**needs**to**begin**data**collection,**such**as**vital**signs,**immediately**t
o**determine **the**patient’s**health**status.**Complications**can**be**prevented **if**an**immediate **
assessment**is** made**to**analyze **the**patient’s**symptoms.** A**comprehensive **history**is**not*
*indicated ** in ** this** situation ** at** this** time. ** Some ** subjective ** data ** will ** be ** collected, ** such ** as** a
llergies**and**medical**history**related**to**cardiovascular**disease.** Eyes,**ears,**or**a**complete
** musculoskeletal ** or ** mental ** health **assessment ** is** not** a ** priority**at** this**time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management
of**Care:Establishing* * Priorities
2. Which** situation**illustrates**a** screening**assessment?
a. A**patient**visits**an**obstetric**clinic**for**the**fir
st
time**and**the**nurse**conducts**a**detailedhistor
y**and**physical**examination.
b. A**hospital**sponsors**a**health**fair**at**a
localmall**and**provides**cholesterol**and**bl
ood**pressure**checks**to**mall**patrons.
c. The**nurse**in**an**urgent**care**center**checks
the**vital**signs**of**a**patient**who**is**complai
ning**of**leg**pain.
, d. A**patient** newly**diagnosed **with
diabetesmellitus**comes**to**test**his**fasting**blo
od**glucose**level.
ANSWER:**B
A**health**fair **at**a**local**mall**that**provides**cholesterol**and**blood **pressure **checks**is**an**e
xample**of**a**screening **assessment**focused **on**disease **detection.**A**detailed **history**and
**physical** examination **conducted ** during **a** first-
time**visit**to**an**obstetric**clinic**is**an**exampleof**a**comprehensive **assessment.**Assessing **
a**patient**complaining **of**leg**pain**in**the**triage**area**of**an**urgent**care**center**is**an**exampl
e**of**a**problem-
based/focused **assessment.**A**patient’s**return**appointment**1**month**after**today’s**offic
e**visit**to**report**fasting**blood**glucose **levels**is**an**example**of**an**episodic**or**follow-
up**assessment.
DIF:* * Cognitive**Level:**Understand REF:**Box**1-
3**|**p.**3**TOP:**Nursing**Process:**Assessment
MSC:**NCLEX**Patient**Needs:** Health**Promotion**and**Maintenance:** Health**Screening
3. For* * which**person**is** a* * screening**assessment* * indicated?
a. The**person**who**had**abdominal**surgery
yesterday
b. The**person**who**is**unaware**of**his**high**
serum**glucose**levels
c. The**person**who**is**being**admitted **to**a
long-term**care**facility
d. The**person**who**is**beginning**rehabilitation
after**a**knee**replacement
ANSWER:**B
A**screening**assessment**is**performed**for**the**purpose**of**disease **detection.**In**this**case**thi
s**person**may**have**diabetes**mellitus.**A**shift**assessment**is**most**appropriate **for**the**per
son**who**is**recovering**in**the**hospital**from**surgery.**A**comprehensive **assessment**is**perfo
rmed**during**admission**to**a**facility**to**obtain**a**detailed**history**and**complete**physical**
examination.**An**episodic**or**follow-
up**assessment**is**performed **after **knee**replacement**to**evaluate**the**outcome**of**the**pro
cedure.
DIF:* * Cognitive**Level:**Understand REF:**Box**1-
3**|**p.**3**TOP:**Nursing**Process:**Assessment
MSC:**NCLEX**Patient**Needs:**Safe**and**Effective**Care**Environment:**Management**of**Care:Establis
hing* * Priorities
4. For** which**person**is**a* * shift** assessment** indicated?
a. The**person**who**had**abdominal**surgery
yesterday
b. The**person**who**is**unaware**of**his**high
serum* * glucose* * levels
c. The**person**who**is**being**admitted **to**a
long-term**care**facility
d. The**person**who**is**beginning**rehabilitation
after**a**knee**replacement
ANSWER:**A
A**shift**assessment**is**most**appropriate **for**the**person **who**is**recovering **in**the**hospital**fro
m**surgery.**A**screening **assessment**is**performed**for**the**purpose **of**disease **detection,**i
n**this**case**diabetes**mellitus.**A**comprehensive **assessment**is**performed **during **admission
**to ** a
Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,TABLE OF CONTENTS
Unit I: Foundations for Health Assessment
1. Introduction to Health Assessment
2. Interviewing Patients to Obtain a Health History
3. Techniques and Equipment for Physical Assessment
4. General Inspection and Measurement of Vital Signs
5. Ethnic, Cultural, and Spiritual Considerations
6. Pain Assessment
7. Mental Health and Abusive Behavior Assessment
8. Nutritional Assessment
Unit II: Health Assessment of the Adult
9. Skin, Hair, and Nails
10. Head, Eyes, Ears, Nose, and Throat
11. Lungs and Respiratory System
12. Heart and Peripheral Vascular System
13. Abdomen and Gastrointestinal System
14. Musculoskeletal System
15. Neurologic System
16. Breasts and Axillae
17. Reproductive System and the Perineum
Unit III: Health Assessment Across the Life Span
18. Developmental Assessment Throughout the Life Span
19. Assessment of the Infant, Child, and Adolescent
20. Assessment of the Pregnant Patient
21. Assessment of the Older Adult
Unit IV: Synthesis and Application of Health Assessment
22. Conducting a Head-to-Toe Examination
23. Documenting the Head-to-Toe Health Assessment
24. Adapting Health Assessment
Chapter 01: Introduction to Health Assessment
,MULTIPLE CHOICE
1. A
patient**comes**to**the**emergency**department**and**tells**the**triage**nurse**that**heis**“havi
ng**a**heart**attack.” ** What**is**the**nurse’s**top**priority**at**this**time?
a. Determine **the**patient’s**personal**data**and**i
nsurance**coverage.
b. Ask**the**patient**to**take**a**seat**in**the**waitin
g**room**until**his**name**is**called.
c. Request **that** a** nurse** collect** data** for
acomprehensive* * history.
d. Ask** a** nurse**to** start**a**focused**assessment
of**this**patient**now.
ANSWER: D
The**nurse**needs**to**begin**an**assessment**as**soon**as**possible**that**is**focused**on**this**patient
’s**cardiovascular **system.**The**type**of**health**assessment**performed **by**the**nurse**is**also**d
riven**by**patient**need.**Personal**data**and**insurance**information**will**be**obtained,**but**in*
*this** situation, ** these ** data ** can ** wait** until** after ** the** patient ** is** assessed. ** Based ** also ** on ** Ma
slow’s**hierarchy**of**needs,**physiologic**needs**take**precedence.** Rather **than**asking**the**p
atient**to**wait,**the**nurse**needs**to**begin**data**collection,**such**as**vital**signs,**immediately**t
o**determine **the**patient’s**health**status.**Complications**can**be**prevented **if**an**immediate **
assessment**is** made**to**analyze **the**patient’s**symptoms.** A**comprehensive **history**is**not*
*indicated ** in ** this** situation ** at** this** time. ** Some ** subjective ** data ** will ** be ** collected, ** such ** as** a
llergies**and**medical**history**related**to**cardiovascular**disease.** Eyes,**ears,**or**a**complete
** musculoskeletal ** or ** mental ** health **assessment ** is** not** a ** priority**at** this**time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management
of**Care:Establishing* * Priorities
2. Which** situation**illustrates**a** screening**assessment?
a. A**patient**visits**an**obstetric**clinic**for**the**fir
st
time**and**the**nurse**conducts**a**detailedhistor
y**and**physical**examination.
b. A**hospital**sponsors**a**health**fair**at**a
localmall**and**provides**cholesterol**and**bl
ood**pressure**checks**to**mall**patrons.
c. The**nurse**in**an**urgent**care**center**checks
the**vital**signs**of**a**patient**who**is**complai
ning**of**leg**pain.
, d. A**patient** newly**diagnosed **with
diabetesmellitus**comes**to**test**his**fasting**blo
od**glucose**level.
ANSWER:**B
A**health**fair **at**a**local**mall**that**provides**cholesterol**and**blood **pressure **checks**is**an**e
xample**of**a**screening **assessment**focused **on**disease **detection.**A**detailed **history**and
**physical** examination **conducted ** during **a** first-
time**visit**to**an**obstetric**clinic**is**an**exampleof**a**comprehensive **assessment.**Assessing **
a**patient**complaining **of**leg**pain**in**the**triage**area**of**an**urgent**care**center**is**an**exampl
e**of**a**problem-
based/focused **assessment.**A**patient’s**return**appointment**1**month**after**today’s**offic
e**visit**to**report**fasting**blood**glucose **levels**is**an**example**of**an**episodic**or**follow-
up**assessment.
DIF:* * Cognitive**Level:**Understand REF:**Box**1-
3**|**p.**3**TOP:**Nursing**Process:**Assessment
MSC:**NCLEX**Patient**Needs:** Health**Promotion**and**Maintenance:** Health**Screening
3. For* * which**person**is** a* * screening**assessment* * indicated?
a. The**person**who**had**abdominal**surgery
yesterday
b. The**person**who**is**unaware**of**his**high**
serum**glucose**levels
c. The**person**who**is**being**admitted **to**a
long-term**care**facility
d. The**person**who**is**beginning**rehabilitation
after**a**knee**replacement
ANSWER:**B
A**screening**assessment**is**performed**for**the**purpose**of**disease **detection.**In**this**case**thi
s**person**may**have**diabetes**mellitus.**A**shift**assessment**is**most**appropriate **for**the**per
son**who**is**recovering**in**the**hospital**from**surgery.**A**comprehensive **assessment**is**perfo
rmed**during**admission**to**a**facility**to**obtain**a**detailed**history**and**complete**physical**
examination.**An**episodic**or**follow-
up**assessment**is**performed **after **knee**replacement**to**evaluate**the**outcome**of**the**pro
cedure.
DIF:* * Cognitive**Level:**Understand REF:**Box**1-
3**|**p.**3**TOP:**Nursing**Process:**Assessment
MSC:**NCLEX**Patient**Needs:**Safe**and**Effective**Care**Environment:**Management**of**Care:Establis
hing* * Priorities
4. For** which**person**is**a* * shift** assessment** indicated?
a. The**person**who**had**abdominal**surgery
yesterday
b. The**person**who**is**unaware**of**his**high
serum* * glucose* * levels
c. The**person**who**is**being**admitted **to**a
long-term**care**facility
d. The**person**who**is**beginning**rehabilitation
after**a**knee**replacement
ANSWER:**A
A**shift**assessment**is**most**appropriate **for**the**person **who**is**recovering **in**the**hospital**fro
m**surgery.**A**screening **assessment**is**performed**for**the**purpose **of**disease **detection,**i
n**this**case**diabetes**mellitus.**A**comprehensive **assessment**is**performed **during **admission
**to ** a
