Test Bank for Health Assessment for
mm mm mm mm mm
mm Nursing Practice 7th Edition by Wilson
mm mm mm mm mm
mm Chapter 1 - 24mm mm mm
,Chapter 01: Introduction to Health Assessment
mm mm mm mm mm
MULTIPLE CHOICE mm
1. A patient comes to the emergency department and tells the triage nurse
mm mm mm mm mm mm mm mm mm mm mm
that heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
mm mm m mm mm mm mm mm mm mm mm mm mm mm mm mm
a. Determine the patient‘s personal data mm mm mm mm
andinsurance coverage. mm m mm
b. Ask the patient to take a seat in the
mm mm mm mm mm mm mm mm
waitingroom until his name is called.
mm m mm mm mm mm mm
c. Request that a nurse collect data mm mm mm mm mm
for acomprehensive history.
mm mm m mm
d. Ask a nurse to start a focused
mm mm mm mm mm mm
assessmentof this patient now.
mm m mm mm mm
ANSWER: D mm
The nurse needs to begin an assessment as soon as possible that is focused on this
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
patient‘scardiovascular system. The type of health assessment performed by the
mm m mm mm mm mm mm mm mm mm mm
nurse is also drivenby patient need. Personal data and insurance information will be
mm mm mm mm m mm mm mm mm mm mm mm mm mm
obtained, but in this situation, these data can wait until after the patient is
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take
mm mm mm mm mm mm mm mm mm mm mm
precedence. Rather than asking the patient to wait, the nurse needs to begin data
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
collection, such as vital signs, immediately to determinethe patient‘s health status.
mm mm mm mm mm mm mm mm m mm mm mm
Complications can be prevented if an immediate assessment is made to analyze the
mm mm mm mm mm mm mm mm mm mm mm mm mm
patient‘s symptoms. A comprehensive history is not indicated in this situation at
mm mm mm mm mm mm mm mm mm mm mm mm
this time. Some subjective data will be collected, such as allergies and medical
mm mm mm mm mm mm mm mm mm mm mm mm mm
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
mm mm mm mm mm mm mm mm mm mm mm
or mental health assessment is not a priority at this time.
mm mm mm mm mm mm mm mm mm mm mm
DIF: Cognitive Level: Apply
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
2. Which situation illustrates a screening assessment?
mm mm mm mm mm
a. A patient visits an obstetric clinic for mm mm mm mm mm mm
the first time and the nurse conducts a mm mm mm mm mm mm mm mm
detailedhistory and physical examination. mm m mm mm mm
b. A hospital sponsors a health fair at a mm mm mm mm mm mm mm
localmall and provides cholesterol mm m mm mm mm
and blood pressure checks to mall mm mm mm mm mm mm
patrons. mm
c. The nurse in an urgent care center mm mm mm mm mm mm
checksthe vital signs of a patient mm m mm mm mm mm mm
who is complaining of leg pain. mm mm mm mm mm mm
, d. A patient newly diagnosed with
mm mm mm mm
diabetesmellitus comes to test his
mm m mm mm mm mm
fasting blood glucose level.
mm mm mm mm
ANSWER: B mm
A health fair at a local mall that provides cholesterol and blood pressure checks is
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
an example of a screening assessment focused on disease detection. A detailed
mm mm mm mm mm mm mm mm mm mm mm mm
history and physical examination conducted during a first-time visit to an obstetric
mm mm mm mm mm mm mm mm mm mm mm mm
clinic is an exampleof a comprehensive assessment. Assessing a patient complaining
mm mm mm mm m mm mm mm mm mm mm mm
of leg pain in the triage area of an urgent care center is an example of a problem-
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
based/focused assessment. A patient‘s return appointment 1 month after today‘s
mm mm mm mm mm mm mm mm mm
office visit to report fasting blood glucose levels is an example of an episodic or
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
follow-up assessment.
mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
mm mm mm mm mm mm mm mm mm
3. For which person is a screening assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted mm mm mm mm mm
to along-term care facility mm mm m mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: B mm
A screening assessment is performed for the purpose of disease detection. In this
mm mm mm mm mm mm mm mm mm mm mm mm
case thisperson may have diabetes mellitus. A shift assessment is most appropriate
mm mm m mm mm mm mm mm mm mm mm mm mm
for the person who is recovering in the hospital from surgery. A comprehensive
mm mm mm mm mm mm mm mm mm mm mm mm mm
assessment is performedduring admission to a facility to obtain a detailed history
mm mm mm m mm mm mm mm mm mm mm mm mm
and complete physical examination. An episodic or follow-up assessment is
mm mm mm mm mm mm mm mm mm mm
performed after knee replacement toevaluate the outcome of the procedure.
mm mm mm mm mm m mm mm mm mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
4. For which person is a shift assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted to a mm mm mm mm mm mm mm
long-term care facility mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: A mm
A shift assessment is most appropriate for the person who is recovering in the
mm mm mm mm mm mm mm mm mm mm mm mm mm
hospital fromsurgery. A screening assessment is performed for the purpose of
mm mm m mm mm mm mm mm mm mm mm mm
disease detection, in this case diabetes mellitus. A comprehensive assessment is
mm mm mm mm mm mm mm mm mm mm mm
performed during admission to a
mm mm mm mm mm
, facility to obtain a detailed history and complete physical examination. An
mm mm mm mm mm mm mm mm mm mm
episodic or follow-up assessment is performed after knee replacement to evaluate
mm mm mm mm mm mm mm mm mm mm mm
the outcome of theprocedure.
mm mm mm mm m
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 4TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
5. For which person is a comprehensive assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted mm mm mm mm mm
to along-term care facility mm mm m mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: C mm
A comprehensive assessment is performed during admission to a facility to obtain a
mm mm mm mm mm mm mm mm mm mm mm mm
detailed history and complete physical examination. A shift assessment is most
mm mm mm mm mm mm mm mm mm mm
appropriatefor the person who is recovering in the hospital from surgery. A
mm m mm mm mm mm mm mm mm mm mm mm mm
screening assessment is performed for the purpose of disease detection, in this
mm mm mm mm mm mm mm mm mm mm mm mm
case diabetes mellitus. An episodic or follow-up assessment is performed after
mm mm mm mm mm mm mm mm mm mm mm
knee replacement to evaluate the outcome of the procedure.
mm mm mm mm mm mm mm mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
6. For which person is an episodic or follow-up assessment indicated?
mm mm mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted to a mm mm mm mm mm mm mm
long-term care facility mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: D mm
An episodic or follow-up assessment is performed after the knee replacement to
mm mm mm mm mm mm mm mm mm mm mm
evaluate the outcome of the procedure. A shift assessment is most appropriate for
mm mm mm mm mm mm mm mm mm mm mm mm mm
the person who isrecovering in the hospital from surgery. A screening assessment
mm mm mm mm m mm mm mm mm mm mm mm mm
is performed for the purpose of disease detection, in this case diabetes mellitus. A
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
comprehensive assessment is performed during admission to a facility to obtain a
mm mm mm mm mm mm mm mm mm mm mm mm
detailed history and complete physicalexamination.
mm mm mm mm mm m
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
mm mm mm mm mm
mm Nursing Practice 7th Edition by Wilson
mm mm mm mm mm
mm Chapter 1 - 24mm mm mm
,Chapter 01: Introduction to Health Assessment
mm mm mm mm mm
MULTIPLE CHOICE mm
1. A patient comes to the emergency department and tells the triage nurse
mm mm mm mm mm mm mm mm mm mm mm
that heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
mm mm m mm mm mm mm mm mm mm mm mm mm mm mm mm
a. Determine the patient‘s personal data mm mm mm mm
andinsurance coverage. mm m mm
b. Ask the patient to take a seat in the
mm mm mm mm mm mm mm mm
waitingroom until his name is called.
mm m mm mm mm mm mm
c. Request that a nurse collect data mm mm mm mm mm
for acomprehensive history.
mm mm m mm
d. Ask a nurse to start a focused
mm mm mm mm mm mm
assessmentof this patient now.
mm m mm mm mm
ANSWER: D mm
The nurse needs to begin an assessment as soon as possible that is focused on this
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
patient‘scardiovascular system. The type of health assessment performed by the
mm m mm mm mm mm mm mm mm mm mm
nurse is also drivenby patient need. Personal data and insurance information will be
mm mm mm mm m mm mm mm mm mm mm mm mm mm
obtained, but in this situation, these data can wait until after the patient is
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take
mm mm mm mm mm mm mm mm mm mm mm
precedence. Rather than asking the patient to wait, the nurse needs to begin data
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
collection, such as vital signs, immediately to determinethe patient‘s health status.
mm mm mm mm mm mm mm mm m mm mm mm
Complications can be prevented if an immediate assessment is made to analyze the
mm mm mm mm mm mm mm mm mm mm mm mm mm
patient‘s symptoms. A comprehensive history is not indicated in this situation at
mm mm mm mm mm mm mm mm mm mm mm mm
this time. Some subjective data will be collected, such as allergies and medical
mm mm mm mm mm mm mm mm mm mm mm mm mm
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
mm mm mm mm mm mm mm mm mm mm mm
or mental health assessment is not a priority at this time.
mm mm mm mm mm mm mm mm mm mm mm
DIF: Cognitive Level: Apply
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
2. Which situation illustrates a screening assessment?
mm mm mm mm mm
a. A patient visits an obstetric clinic for mm mm mm mm mm mm
the first time and the nurse conducts a mm mm mm mm mm mm mm mm
detailedhistory and physical examination. mm m mm mm mm
b. A hospital sponsors a health fair at a mm mm mm mm mm mm mm
localmall and provides cholesterol mm m mm mm mm
and blood pressure checks to mall mm mm mm mm mm mm
patrons. mm
c. The nurse in an urgent care center mm mm mm mm mm mm
checksthe vital signs of a patient mm m mm mm mm mm mm
who is complaining of leg pain. mm mm mm mm mm mm
, d. A patient newly diagnosed with
mm mm mm mm
diabetesmellitus comes to test his
mm m mm mm mm mm
fasting blood glucose level.
mm mm mm mm
ANSWER: B mm
A health fair at a local mall that provides cholesterol and blood pressure checks is
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
an example of a screening assessment focused on disease detection. A detailed
mm mm mm mm mm mm mm mm mm mm mm mm
history and physical examination conducted during a first-time visit to an obstetric
mm mm mm mm mm mm mm mm mm mm mm mm
clinic is an exampleof a comprehensive assessment. Assessing a patient complaining
mm mm mm mm m mm mm mm mm mm mm mm
of leg pain in the triage area of an urgent care center is an example of a problem-
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
based/focused assessment. A patient‘s return appointment 1 month after today‘s
mm mm mm mm mm mm mm mm mm
office visit to report fasting blood glucose levels is an example of an episodic or
mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm
follow-up assessment.
mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
mm mm mm mm mm mm mm mm mm
3. For which person is a screening assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted mm mm mm mm mm
to along-term care facility mm mm m mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: B mm
A screening assessment is performed for the purpose of disease detection. In this
mm mm mm mm mm mm mm mm mm mm mm mm
case thisperson may have diabetes mellitus. A shift assessment is most appropriate
mm mm m mm mm mm mm mm mm mm mm mm mm
for the person who is recovering in the hospital from surgery. A comprehensive
mm mm mm mm mm mm mm mm mm mm mm mm mm
assessment is performedduring admission to a facility to obtain a detailed history
mm mm mm m mm mm mm mm mm mm mm mm mm
and complete physical examination. An episodic or follow-up assessment is
mm mm mm mm mm mm mm mm mm mm
performed after knee replacement toevaluate the outcome of the procedure.
mm mm mm mm mm m mm mm mm mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
4. For which person is a shift assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted to a mm mm mm mm mm mm mm
long-term care facility mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: A mm
A shift assessment is most appropriate for the person who is recovering in the
mm mm mm mm mm mm mm mm mm mm mm mm mm
hospital fromsurgery. A screening assessment is performed for the purpose of
mm mm m mm mm mm mm mm mm mm mm mm
disease detection, in this case diabetes mellitus. A comprehensive assessment is
mm mm mm mm mm mm mm mm mm mm mm
performed during admission to a
mm mm mm mm mm
, facility to obtain a detailed history and complete physical examination. An
mm mm mm mm mm mm mm mm mm mm
episodic or follow-up assessment is performed after knee replacement to evaluate
mm mm mm mm mm mm mm mm mm mm mm
the outcome of theprocedure.
mm mm mm mm m
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 4TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
5. For which person is a comprehensive assessment indicated?
mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted mm mm mm mm mm
to along-term care facility mm mm m mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: C mm
A comprehensive assessment is performed during admission to a facility to obtain a
mm mm mm mm mm mm mm mm mm mm mm mm
detailed history and complete physical examination. A shift assessment is most
mm mm mm mm mm mm mm mm mm mm
appropriatefor the person who is recovering in the hospital from surgery. A
mm m mm mm mm mm mm mm mm mm mm mm mm
screening assessment is performed for the purpose of disease detection, in this
mm mm mm mm mm mm mm mm mm mm mm mm
case diabetes mellitus. An episodic or follow-up assessment is performed after
mm mm mm mm mm mm mm mm mm mm mm
knee replacement to evaluate the outcome of the procedure.
mm mm mm mm mm mm mm mm mm
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
mm mm mm mm mm mm mm mm mm mm
Care:Establishing Priorities
mm m mm
6. For which person is an episodic or follow-up assessment indicated?
mm mm mm mm mm mm mm mm mm
a. The person who had abdominal mm mm mm mm
surgeryyesterday mm m
b. The person who is unaware of his mm mm mm mm mm mm
highserum glucose levels mm m mm mm
c. The person who is being admitted to a mm mm mm mm mm mm mm
long-term care facility mm mm
d. The person who is beginning mm mm mm mm
rehabilitationafter a knee replacement mm m mm mm mm
ANSWER: D mm
An episodic or follow-up assessment is performed after the knee replacement to
mm mm mm mm mm mm mm mm mm mm mm
evaluate the outcome of the procedure. A shift assessment is most appropriate for
mm mm mm mm mm mm mm mm mm mm mm mm mm
the person who isrecovering in the hospital from surgery. A screening assessment
mm mm mm mm m mm mm mm mm mm mm mm mm
is performed for the purpose of disease detection, in this case diabetes mellitus. A
mm mm mm mm mm mm mm mm mm mm mm mm mm mm
comprehensive assessment is performed during admission to a facility to obtain a
mm mm mm mm mm mm mm mm mm mm mm mm
detailed history and complete physicalexamination.
mm mm mm mm mm m
DIF: Cognitive Level: Understand
mm mm m m REF: Box 1-3 | mm mm mm mm mm
p. 3TOP: Nursing Process: Assessment
mm mm m mm mm mm