Chapter 01: Introduction to Health Assessment
L L L L L
MULTIPLE CHOICE : L L
1. A patient comes to the emergency department and tells the
L L L L L L L L L
triage nurse that heis “having a heart attack.” What is the nurse’s top
L L L L L L L L L L L L L
priority at this time?
L L L L
a. Determine the patient’s personal data and L L L L L
insurance coverage.
L L
b. Ask the patient to take a seat in the waiting
L L L L L L L L L
room until his name is called.
L L L L L L
c. Request that a nurse collect data for a L L L L L L L
comprehensive history.
L L
d. Ask a nurse to start a focused assessment
L L L L L L L
of this patient now.
L L L L
ANS: D L
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
L L L L L L L L L L L L L L L L
cardiovascular system. The type of health assessment performed by the nurse is also driven
L L L L L L L L L L L L L L
by patient need. Personal data and insurance information will be obtained, but in this
L L L L L L L L L L L L L L
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
L L L L L L L L L L L L L L L
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
L L L L L L L L L L L L L
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
L L L L L L L L L L L L L L L
the patient’s health status. Complications can be prevented if an immediate assessment is
L L L L L L L L L L L L L
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
L L L L L L L L L L L L L L
situation at this time. Some subjective data will be collected, such as allergies and medical
L L L L L L L L L L L L L L L
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
L L L L L L L L L L L L
mental health assessment is not a priority at this time.
L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
2. Which situation illustrates a screening assessment?
L L L L L
a. A patient visits an obstetric clinic for the L L L L L L L
first time and the nurse conducts a detailed L L L L L L L L
history and physical examination. L L L L
b. A hospital sponsors a health fair at a local L L L L L L L L
mall and provides cholesterol and blood L L L L L L
pressure checks to mall patrons. L L L L L
c. The nurse in an urgent care center checks L L L L L L L
the vital signs of a patient who is L L L L L L L L
complaining of leg pain. L L L L
, d. A patient newly diagnosed with diabetes
L L L L L
mellitus comes to test his fasting blood
L L L L L L L
glucose level.
L L
ANS: B L
A health fair at a local mall that provides cholesterol and blood pressure checks is an
L L L L L L L L L L L L L L L
example of a screening assessment focused on disease detection. A detailed history and
L L L L L L L L L L L L L
physical examination conducted during a first-time visit to an obstetric clinic is an example
L L L L L L L L L L L L L L
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
L L L L L L L L L L L L L L
area of an urgent care center is an example of a problem-based/focused assessment. A
L L L L L L L L L L L L L L
patient’s return appointment 1 month after today’s office visit to report fasting blood
L L L L L L L L L L L L L
glucose levels is an example of an episodic or follow-up assessment.
L L L L L L L L L L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
L L L L L L L L L
3. For which person is a screening assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: B L
A screening assessment is performed for the purpose of disease detection. In this case this
L L L L L L L L L L L L L L
person may have diabetes mellitus. A shift assessment is most appropriate for the person
L L L L L L L L L L L L L L
who is recovering in the hospital from surgery. A comprehensive assessment is performed
L L L L L L L L L L L L L
during admission to a facility to obtain a detailed history and complete physical
L L L L L L L L L L L L L
examination. An episodic or follow-up assessment is performed after knee replacement to
L L L L L L L L L L L L
evaluate the outcome of the procedure.
L L L L L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
4. For which person is a shift assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: A L
A shift assessment is most appropriate for the person who is recovering in the hospital from
L L L L L L L L L L L L L L L
surgery. A screening assessment is performed for the purpose of disease detection, in this
L L L L L L L L L L L L L L
case diabetes mellitus. A comprehensive assessment is performed during admission to a
L L L L L L L L L L L L
,facility to obtain a detailed history and complete physical examination. An episodic or
L L L L L L L L L L L L
follow-up assessment is performed after knee replacement to evaluate the outcome of the
L L L L L L L L L L L L L
procedure.
L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 4 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
5. For which person is a comprehensive assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: C L
A comprehensive assessment is performed during admission to a facility to obtain a
L L L L L L L L L L L L
detailed history and complete physical examination. A shift assessment is most appropriate
L L L L L L L L L L L
for the person who is recovering in the hospital from surgery. A screening assessment is
L L L L L L L L L L L L L L L
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
L L L L L L L L L L L L L L
or follow-up assessment is performed after knee replacement to evaluate the outcome of
L L L L L L L L L L L L L
the procedure.
L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
6. For which person is an episodic or follow-up assessment indicated?
L L L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: D L
An episodic or follow-up assessment is performed after the knee replacement to evaluate
L L L L L L L L L L L L
the outcome of the procedure. A shift assessment is most appropriate for the person who is
L L L L L L L L L L L L L L L L
recovering in the hospital from surgery. A screening assessment is performed for the
L L L L L L L L L L L L L
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
L L L L L L L L L L L L L
performed during admission to a facility to obtain a detailed history and complete physical
L L L L L L L L L L L L L L
examination.
L
DIF: Cognitive Level: Understand
L L L REF: Box 1-3 | p. 3 L L L L L
TOP: Nursing Process: Assessment
L L L L
, MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
7. Which is an example of data a nurse collects during a physical L L L L L L L L L L L
examination?
L
a. The patient’s lack of hair and shiny skin L L L L L L L
over both shins L L L
b. The patient’s stated concern about lack of
L L L L L L
money for prescriptions
L L L
c. The patient’s complaints of tingling
L L L L
sensations in the feet
L L L L
d. The patient’s mother’s statements that the
L L L L L
patient is very nervous lately
L L L L L
ANS: A L
The lack of hair and shiny skin over both shins are objective data or signs that are part of the
L L L L L L L L L L L L L L L L L L L
physical examination. A patient’s concerns about lack of money are subjective data and are
L L L L L L L L L L L L L L
part of the health history. A patient’s complaints of tingling sensations in the feet are
L L L L L L L L L L L L L L L
subjective data and are part of the health history. A patient’s family statements are
L L L L L L L L L L L L L L
considered secondary data, are subjective data, and are part of the health history.
L L L L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
L L L L L L L L L L
Specific Assessments
L L
8. The nurse documents which information in the patient’s history?
L L L L L L L L
a. The patient’s skin feels warm to the touch. L L L L L L L
b. The patient is scratching his arm.
L L L L L
c. The patient’s temperature is 100° F.
L L L L L
d. The patient complains of itching.
L L L L
ANS: D L
A patient’s complaint of itching is subjective information, which means it is a symptom
L L L L L L L L L L L L L
and is documented in the history. The patient’s warm skin is objective information
L L L L L L L L L L L L L
gathered by the nurse through palpation, is also a sign, and is documented in the physical
L L L L L L L L L L L L L L L L
examination. The patient’s scratching is objective information gathered by the nurse
L L L L L L L L L L L
through observation, is also a sign, and is documented in the physical examination. The
L L L L L L L L L L L L L L
patient’s elevated temperature is objective information gathered by the nurse through
L L L L L L L L L L L
measurement, is also a sign, and is documented in the physical examination.
L L L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: p. 1 | p. 2 and Box 1-2 L L L L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
9. Which patient information does the nurse document in the patient’s physical
L L L L L L L L L L
assessment?
L
a. Slurred speech L
b. Immunizations
c. Smoking habit L
d. Allergies
L L L L L
MULTIPLE CHOICE : L L
1. A patient comes to the emergency department and tells the
L L L L L L L L L
triage nurse that heis “having a heart attack.” What is the nurse’s top
L L L L L L L L L L L L L
priority at this time?
L L L L
a. Determine the patient’s personal data and L L L L L
insurance coverage.
L L
b. Ask the patient to take a seat in the waiting
L L L L L L L L L
room until his name is called.
L L L L L L
c. Request that a nurse collect data for a L L L L L L L
comprehensive history.
L L
d. Ask a nurse to start a focused assessment
L L L L L L L
of this patient now.
L L L L
ANS: D L
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
L L L L L L L L L L L L L L L L
cardiovascular system. The type of health assessment performed by the nurse is also driven
L L L L L L L L L L L L L L
by patient need. Personal data and insurance information will be obtained, but in this
L L L L L L L L L L L L L L
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
L L L L L L L L L L L L L L L
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
L L L L L L L L L L L L L
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
L L L L L L L L L L L L L L L
the patient’s health status. Complications can be prevented if an immediate assessment is
L L L L L L L L L L L L L
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
L L L L L L L L L L L L L L
situation at this time. Some subjective data will be collected, such as allergies and medical
L L L L L L L L L L L L L L L
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
L L L L L L L L L L L L
mental health assessment is not a priority at this time.
L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
2. Which situation illustrates a screening assessment?
L L L L L
a. A patient visits an obstetric clinic for the L L L L L L L
first time and the nurse conducts a detailed L L L L L L L L
history and physical examination. L L L L
b. A hospital sponsors a health fair at a local L L L L L L L L
mall and provides cholesterol and blood L L L L L L
pressure checks to mall patrons. L L L L L
c. The nurse in an urgent care center checks L L L L L L L
the vital signs of a patient who is L L L L L L L L
complaining of leg pain. L L L L
, d. A patient newly diagnosed with diabetes
L L L L L
mellitus comes to test his fasting blood
L L L L L L L
glucose level.
L L
ANS: B L
A health fair at a local mall that provides cholesterol and blood pressure checks is an
L L L L L L L L L L L L L L L
example of a screening assessment focused on disease detection. A detailed history and
L L L L L L L L L L L L L
physical examination conducted during a first-time visit to an obstetric clinic is an example
L L L L L L L L L L L L L L
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
L L L L L L L L L L L L L L
area of an urgent care center is an example of a problem-based/focused assessment. A
L L L L L L L L L L L L L L
patient’s return appointment 1 month after today’s office visit to report fasting blood
L L L L L L L L L L L L L
glucose levels is an example of an episodic or follow-up assessment.
L L L L L L L L L L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
L L L L L L L L L
3. For which person is a screening assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: B L
A screening assessment is performed for the purpose of disease detection. In this case this
L L L L L L L L L L L L L L
person may have diabetes mellitus. A shift assessment is most appropriate for the person
L L L L L L L L L L L L L L
who is recovering in the hospital from surgery. A comprehensive assessment is performed
L L L L L L L L L L L L L
during admission to a facility to obtain a detailed history and complete physical
L L L L L L L L L L L L L
examination. An episodic or follow-up assessment is performed after knee replacement to
L L L L L L L L L L L L
evaluate the outcome of the procedure.
L L L L L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
4. For which person is a shift assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: A L
A shift assessment is most appropriate for the person who is recovering in the hospital from
L L L L L L L L L L L L L L L
surgery. A screening assessment is performed for the purpose of disease detection, in this
L L L L L L L L L L L L L L
case diabetes mellitus. A comprehensive assessment is performed during admission to a
L L L L L L L L L L L L
,facility to obtain a detailed history and complete physical examination. An episodic or
L L L L L L L L L L L L
follow-up assessment is performed after knee replacement to evaluate the outcome of the
L L L L L L L L L L L L L
procedure.
L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 4 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
5. For which person is a comprehensive assessment indicated?
L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: C L
A comprehensive assessment is performed during admission to a facility to obtain a
L L L L L L L L L L L L
detailed history and complete physical examination. A shift assessment is most appropriate
L L L L L L L L L L L
for the person who is recovering in the hospital from surgery. A screening assessment is
L L L L L L L L L L L L L L L
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
L L L L L L L L L L L L L L
or follow-up assessment is performed after knee replacement to evaluate the outcome of
L L L L L L L L L L L L L
the procedure.
L L
DIF: Cognitive Level: Understand
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
6. For which person is an episodic or follow-up assessment indicated?
L L L L L L L L L
a. The person who had abdominal surgery L L L L L
yesterday L
b. The person who is unaware of his high L L L L L L L
serum glucose levels L L L
c. The person who is being admitted to a L L L L L L L
long-term care facility L L L
d. The person who is beginning rehabilitation L L L L L
after a knee replacement L L L L
ANS: D L
An episodic or follow-up assessment is performed after the knee replacement to evaluate
L L L L L L L L L L L L
the outcome of the procedure. A shift assessment is most appropriate for the person who is
L L L L L L L L L L L L L L L L
recovering in the hospital from surgery. A screening assessment is performed for the
L L L L L L L L L L L L L
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
L L L L L L L L L L L L L
performed during admission to a facility to obtain a detailed history and complete physical
L L L L L L L L L L L L L L
examination.
L
DIF: Cognitive Level: Understand
L L L REF: Box 1-3 | p. 3 L L L L L
TOP: Nursing Process: Assessment
L L L L
, MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
7. Which is an example of data a nurse collects during a physical L L L L L L L L L L L
examination?
L
a. The patient’s lack of hair and shiny skin L L L L L L L
over both shins L L L
b. The patient’s stated concern about lack of
L L L L L L
money for prescriptions
L L L
c. The patient’s complaints of tingling
L L L L
sensations in the feet
L L L L
d. The patient’s mother’s statements that the
L L L L L
patient is very nervous lately
L L L L L
ANS: A L
The lack of hair and shiny skin over both shins are objective data or signs that are part of the
L L L L L L L L L L L L L L L L L L L
physical examination. A patient’s concerns about lack of money are subjective data and are
L L L L L L L L L L L L L L
part of the health history. A patient’s complaints of tingling sensations in the feet are
L L L L L L L L L L L L L L L
subjective data and are part of the health history. A patient’s family statements are
L L L L L L L L L L L L L L
considered secondary data, are subjective data, and are part of the health history.
L L L L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: Box 1-3 | p. 3 L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
L L L L L L L L L L
Specific Assessments
L L
8. The nurse documents which information in the patient’s history?
L L L L L L L L
a. The patient’s skin feels warm to the touch. L L L L L L L
b. The patient is scratching his arm.
L L L L L
c. The patient’s temperature is 100° F.
L L L L L
d. The patient complains of itching.
L L L L
ANS: D L
A patient’s complaint of itching is subjective information, which means it is a symptom
L L L L L L L L L L L L L
and is documented in the history. The patient’s warm skin is objective information
L L L L L L L L L L L L L
gathered by the nurse through palpation, is also a sign, and is documented in the physical
L L L L L L L L L L L L L L L L
examination. The patient’s scratching is objective information gathered by the nurse
L L L L L L L L L L L
through observation, is also a sign, and is documented in the physical examination. The
L L L L L L L L L L L L L L
patient’s elevated temperature is objective information gathered by the nurse through
L L L L L L L L L L L
measurement, is also a sign, and is documented in the physical examination.
L L L L L L L L L L L L
DIF: Cognitive Level: Apply
L REF: p. 1 | p. 2 and Box 1-2 L L L L L L L L L L
TOP: Nursing Process: Assessment
L L L L
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
L L L L L L L L L L L
Establishing Priorities
L L
9. Which patient information does the nurse document in the patient’s physical
L L L L L L L L L L
assessment?
L
a. Slurred speech L
b. Immunizations
c. Smoking habit L
d. Allergies
