Chapter
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, 01: Introduction to Health Assessment
ju ju ju ju ju
MULTIPLE CHOICE ju
1. A patient comes to the emergency department and tells the triage nurse that
ju ju ju ju ju ju ju ju ju ju ju ju
he is “having a heart attack.” What is the nurse’s top priority at this time?
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
a. Determine the patient’s personal data and ju ju ju ju ju
insurance coverage. ju ju
b. Ask the patient to take a seat in the ju ju ju ju ju ju ju ju
waiting room until his name is called. ju ju ju ju ju ju ju
c. Request that a nurse collect data for a ju ju ju ju ju ju ju
comprehensive history. ju ju
d. Ask a nurse to start a focused assessment ju ju ju ju ju ju ju
of this patient now. ju ju ju ju
ANS: D ju
The nurse needs to begin an assessment as soon as possible that is focused on this
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
patient’s cardiovascular system. The type of health assessment performed by the nurse
ju ju ju ju ju ju ju ju ju ju ju ju
is also driven by patient need. Personal data and insurance information will be
ju ju ju ju ju ju ju ju ju ju ju ju ju
obtained, but in this situation, these data can wait until after the patient is assessed.
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
Based also on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather
ju ju ju ju ju ju ju ju ju ju ju ju
than asking the patient to wait, the nurse needs to begin data collection, such as vital
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
signs, immediately to determine the patient’s health status. Complications can be
ju ju ju ju ju ju ju ju ju ju ju
prevented if an immediate assessment is made to analyze the patient’s symptoms. A
ju ju ju ju ju ju ju ju ju ju ju ju ju
comprehensive history is not indicated in this situation at this time. Some subjective
ju ju ju ju ju ju ju ju ju ju ju ju ju
data will be collected, such as allergies and medical history related to cardiovascular
ju ju ju ju ju ju ju ju ju ju ju ju ju
disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
priority at this time.
ju ju ju ju
DIF: Cognitive Level: Apply REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
2. Which situation illustrates a screening assessment?
ju ju ju ju ju
a. A patient visits an obstetric clinic for the ju ju ju ju ju ju ju
first time and the nurse conducts a ju ju ju ju ju ju ju
detailed history and physical ju ju ju ju
examination. ju
b. A hospital sponsors a health fair at a local ju ju ju ju ju ju ju ju
mall and provides cholesterol and blood ju ju ju ju ju ju
pressure checks to mall patrons. ju ju ju ju ju
c. The nurse in an urgent care center checks ju ju ju ju ju ju ju
the vital signs of a patient who is ju ju ju ju ju ju ju ju
complaining of leg pain. ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
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d. A patient newly diagnosed with diabetes
ju ju ju ju ju
mellitus comes to test his fasting blood
ju ju ju ju ju ju ju
glucose level.
ju ju
ANS: B ju
A health fair at a local mall that provides cholesterol and blood pressure checks is an
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
example of a screening assessment focused on disease detection. A detailed history and
ju ju ju ju ju ju ju ju ju ju ju ju ju
physical examination conducted during a first-time visit to an obstetric clinic is an
ju ju ju ju ju ju ju ju ju ju ju ju ju
example of a comprehensive assessment. Assessing a patient complaining of leg pain in
ju ju ju ju ju ju ju ju ju ju ju ju ju
the triage area of an urgent care center is an example of a problem-based/focused
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
assessment. A patient’s return appointment 1 month after today’s office visit to report
ju ju ju ju ju ju ju ju ju ju ju ju ju
fasting blood glucose levels is an example of an episodic or follow-up assessment.
ju ju ju ju ju ju ju ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
ju ju ju ju ju ju ju ju ju
3. For which person is a screening assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high ju ju ju ju ju ju ju
serum glucose levels ju ju ju
c. The person who is being admitted to a ju ju ju ju ju ju ju
long-term care facility ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: B ju
A screening assessment is performed for the purpose of disease detection. In this case
ju ju ju ju ju ju ju ju ju ju ju ju ju
this person may have diabetes mellitus. A shift assessment is most appropriate for the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
person who is recovering in the hospital from surgery. A comprehensive assessment is
ju ju ju ju ju ju ju ju ju ju ju ju ju
performed during admission to a facility to obtain a detailed history and complete
ju ju ju ju ju ju ju ju ju ju ju ju ju
physical examination. An episodic or follow-up assessment is performed after knee
ju ju ju ju ju ju ju ju ju ju ju
replacement to evaluate the outcome of the procedure.
ju ju ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
4. For which person is a shift assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high ju ju ju ju ju ju ju
serum glucose levels ju ju ju
c. The person who is being admitted to ju ju ju ju ju ju
a long-term care facility ju ju ju ju
d. The person who is beginning rehabilitation ju ju ju ju ju
after a knee replacement ju ju ju ju
ANS: A ju
A shift assessment is most appropriate for the person who is recovering in the hospital
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
from surgery. A screening assessment is performed for the purpose of disease
ju ju ju ju ju ju ju ju ju ju ju ju
detection, in this case diabetes mellitus. A comprehensive assessment is performed
ju ju ju ju ju ju ju ju ju ju ju
during admission to a
ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
https://www.coursehero.com/file/34584368/chapter-1pdf/
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facility to obtain a detailed history and complete physical examination. An episodic
ju ju ju ju ju ju ju ju ju ju ju
or follow-up assessment is performed after knee replacement to evaluate the
ju ju ju ju ju ju ju ju ju ju ju
outcome of the procedure.
ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
4 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
5. For which person is a comprehensive assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high
ju ju ju ju ju ju ju
serum glucose levels
ju ju ju
c. The person who is being admitted to a
ju ju ju ju ju ju ju
long-term care facility
ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: C ju
A comprehensive assessment is performed during admission to a facility to obtain a
ju ju ju ju ju ju ju ju ju ju ju ju
detailed history and complete physical examination. A shift assessment is most
ju ju ju ju ju ju ju ju ju ju
appropriate for the person who is recovering in the hospital from surgery. A screening
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
assessment is performed for the purpose of disease detection, in this case diabetes
ju ju ju ju ju ju ju ju ju ju ju ju ju
mellitus. An episodic or follow-up assessment is performed after knee replacement to
ju ju ju ju ju ju ju ju ju ju ju ju
evaluate the outcome of the procedure.
ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
6. For which person is an episodic or follow-up assessment indicated?
ju ju ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high
ju ju ju ju ju ju ju
serum glucose levels
ju ju ju
c. The person who is being admitted to a
ju ju ju ju ju ju ju
long-term care facility
ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: D ju
An episodic or follow-up assessment is performed after the knee replacement to
ju ju ju ju ju ju ju ju ju ju ju
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
person who is recovering in the hospital from surgery. A screening assessment is
ju ju ju ju ju ju ju ju ju ju ju ju ju
performed for the purpose of disease detection, in this case diabetes mellitus. A
ju ju ju ju ju ju ju ju ju ju ju ju ju
comprehensive assessment is performed during admission to a facility to obtain a
ju ju ju ju ju ju ju ju ju ju ju ju
detailed history and complete physical examination.
ju ju ju ju ju ju
DIF: Cognitive Level: Understand ju ju REF: Box 1-3 | p. ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
https://www.coursehero.com/file/34584368/chapter-1pdf/
Downloaded by: cmedrano14 |
Distribution of this document is illegal
Downloaded by: cmedrano14 |
Distribution of this document is illegal
, 01: Introduction to Health Assessment
ju ju ju ju ju
MULTIPLE CHOICE ju
1. A patient comes to the emergency department and tells the triage nurse that
ju ju ju ju ju ju ju ju ju ju ju ju
he is “having a heart attack.” What is the nurse’s top priority at this time?
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
a. Determine the patient’s personal data and ju ju ju ju ju
insurance coverage. ju ju
b. Ask the patient to take a seat in the ju ju ju ju ju ju ju ju
waiting room until his name is called. ju ju ju ju ju ju ju
c. Request that a nurse collect data for a ju ju ju ju ju ju ju
comprehensive history. ju ju
d. Ask a nurse to start a focused assessment ju ju ju ju ju ju ju
of this patient now. ju ju ju ju
ANS: D ju
The nurse needs to begin an assessment as soon as possible that is focused on this
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
patient’s cardiovascular system. The type of health assessment performed by the nurse
ju ju ju ju ju ju ju ju ju ju ju ju
is also driven by patient need. Personal data and insurance information will be
ju ju ju ju ju ju ju ju ju ju ju ju ju
obtained, but in this situation, these data can wait until after the patient is assessed.
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
Based also on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather
ju ju ju ju ju ju ju ju ju ju ju ju
than asking the patient to wait, the nurse needs to begin data collection, such as vital
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
signs, immediately to determine the patient’s health status. Complications can be
ju ju ju ju ju ju ju ju ju ju ju
prevented if an immediate assessment is made to analyze the patient’s symptoms. A
ju ju ju ju ju ju ju ju ju ju ju ju ju
comprehensive history is not indicated in this situation at this time. Some subjective
ju ju ju ju ju ju ju ju ju ju ju ju ju
data will be collected, such as allergies and medical history related to cardiovascular
ju ju ju ju ju ju ju ju ju ju ju ju ju
disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
priority at this time.
ju ju ju ju
DIF: Cognitive Level: Apply REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
2. Which situation illustrates a screening assessment?
ju ju ju ju ju
a. A patient visits an obstetric clinic for the ju ju ju ju ju ju ju
first time and the nurse conducts a ju ju ju ju ju ju ju
detailed history and physical ju ju ju ju
examination. ju
b. A hospital sponsors a health fair at a local ju ju ju ju ju ju ju ju
mall and provides cholesterol and blood ju ju ju ju ju ju
pressure checks to mall patrons. ju ju ju ju ju
c. The nurse in an urgent care center checks ju ju ju ju ju ju ju
the vital signs of a patient who is ju ju ju ju ju ju ju ju
complaining of leg pain. ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
https://www.coursehero.com/file/34584368/chapter-1pdf/
Downloaded by: cmedrano14 |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study
d. A patient newly diagnosed with diabetes
ju ju ju ju ju
mellitus comes to test his fasting blood
ju ju ju ju ju ju ju
glucose level.
ju ju
ANS: B ju
A health fair at a local mall that provides cholesterol and blood pressure checks is an
ju ju ju ju ju ju ju ju ju ju ju ju ju ju ju
example of a screening assessment focused on disease detection. A detailed history and
ju ju ju ju ju ju ju ju ju ju ju ju ju
physical examination conducted during a first-time visit to an obstetric clinic is an
ju ju ju ju ju ju ju ju ju ju ju ju ju
example of a comprehensive assessment. Assessing a patient complaining of leg pain in
ju ju ju ju ju ju ju ju ju ju ju ju ju
the triage area of an urgent care center is an example of a problem-based/focused
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
assessment. A patient’s return appointment 1 month after today’s office visit to report
ju ju ju ju ju ju ju ju ju ju ju ju ju
fasting blood glucose levels is an example of an episodic or follow-up assessment.
ju ju ju ju ju ju ju ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
ju ju ju ju ju ju ju ju ju
3. For which person is a screening assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high ju ju ju ju ju ju ju
serum glucose levels ju ju ju
c. The person who is being admitted to a ju ju ju ju ju ju ju
long-term care facility ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: B ju
A screening assessment is performed for the purpose of disease detection. In this case
ju ju ju ju ju ju ju ju ju ju ju ju ju
this person may have diabetes mellitus. A shift assessment is most appropriate for the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
person who is recovering in the hospital from surgery. A comprehensive assessment is
ju ju ju ju ju ju ju ju ju ju ju ju ju
performed during admission to a facility to obtain a detailed history and complete
ju ju ju ju ju ju ju ju ju ju ju ju ju
physical examination. An episodic or follow-up assessment is performed after knee
ju ju ju ju ju ju ju ju ju ju ju
replacement to evaluate the outcome of the procedure.
ju ju ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
4. For which person is a shift assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high ju ju ju ju ju ju ju
serum glucose levels ju ju ju
c. The person who is being admitted to ju ju ju ju ju ju
a long-term care facility ju ju ju ju
d. The person who is beginning rehabilitation ju ju ju ju ju
after a knee replacement ju ju ju ju
ANS: A ju
A shift assessment is most appropriate for the person who is recovering in the hospital
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
from surgery. A screening assessment is performed for the purpose of disease
ju ju ju ju ju ju ju ju ju ju ju ju
detection, in this case diabetes mellitus. A comprehensive assessment is performed
ju ju ju ju ju ju ju ju ju ju ju
during admission to a
ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
https://www.coursehero.com/file/34584368/chapter-1pdf/
Downloaded by: cmedrano14 |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study
facility to obtain a detailed history and complete physical examination. An episodic
ju ju ju ju ju ju ju ju ju ju ju
or follow-up assessment is performed after knee replacement to evaluate the
ju ju ju ju ju ju ju ju ju ju ju
outcome of the procedure.
ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
4 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
5. For which person is a comprehensive assessment indicated?
ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high
ju ju ju ju ju ju ju
serum glucose levels
ju ju ju
c. The person who is being admitted to a
ju ju ju ju ju ju ju
long-term care facility
ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: C ju
A comprehensive assessment is performed during admission to a facility to obtain a
ju ju ju ju ju ju ju ju ju ju ju ju
detailed history and complete physical examination. A shift assessment is most
ju ju ju ju ju ju ju ju ju ju
appropriate for the person who is recovering in the hospital from surgery. A screening
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
assessment is performed for the purpose of disease detection, in this case diabetes
ju ju ju ju ju ju ju ju ju ju ju ju ju
mellitus. An episodic or follow-up assessment is performed after knee replacement to
ju ju ju ju ju ju ju ju ju ju ju ju
evaluate the outcome of the procedure.
ju ju ju ju ju ju
DIF: Cognitive Level: Understand REF: Box 1-3 | p. ju ju ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
ju ju ju ju ju ju ju ju ju ju ju
Establishing Priorities
ju ju
6. For which person is an episodic or follow-up assessment indicated?
ju ju ju ju ju ju ju ju ju
a. The person who had abdominal surgery ju ju ju ju ju
yesterday ju
b. The person who is unaware of his high
ju ju ju ju ju ju ju
serum glucose levels
ju ju ju
c. The person who is being admitted to a
ju ju ju ju ju ju ju
long-term care facility
ju ju ju
d. The person who is beginning rehabilitation
ju ju ju ju ju
after a knee replacement
ju ju ju ju
ANS: D ju
An episodic or follow-up assessment is performed after the knee replacement to
ju ju ju ju ju ju ju ju ju ju ju
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
ju ju ju ju ju ju ju ju ju ju ju ju ju ju
person who is recovering in the hospital from surgery. A screening assessment is
ju ju ju ju ju ju ju ju ju ju ju ju ju
performed for the purpose of disease detection, in this case diabetes mellitus. A
ju ju ju ju ju ju ju ju ju ju ju ju ju
comprehensive assessment is performed during admission to a facility to obtain a
ju ju ju ju ju ju ju ju ju ju ju ju
detailed history and complete physical examination.
ju ju ju ju ju ju
DIF: Cognitive Level: Understand ju ju REF: Box 1-3 | p. ju ju ju
3 TOP: Nursing Process: Assessment
ju ju ju ju ju
This j u study j u source j u was j u downloaded j u by j u 100000838401522 j u from j u CourseHero.com j u on j u 03-03-2022 j u 08:46:13 j u GMT j u -06:00
https://www.coursehero.com/file/34584368/chapter-1pdf/
Downloaded by: cmedrano14 |
Distribution of this document is illegal
