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