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WILSON- HEALTH ASSESSMENT FOR NURSING PRACTICE, 6TH EDITION

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WILSON- HEALTH ASSESSMENT FOR NURSING PRACTICE, 6TH EDITION Do you know where you are? assesses orientation. If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back? assesses calculation ability. What would you do if a fire started in your home? assesses judgment. What does this phrase “A rolling stone gathers no moss” mean? assesses abstract reasoning. For the nurse to assess mental status, the patient needs to demonstrate abilities such as calculation, judgment, and abstract reasoning. DIF: Cognitive Level: Apply REF: p. 69 | p. 70 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts 3. While conducting a health history, the nurse asks which questions to assess for risk factors associated with depression? (Select all that apply.) a. Has anyone in your family ever been diagnosed with depression? b. Have you noticed a change in how much energy you have? c. Do you have crying spells? d. Do your muscles seem tense? e. Do you feel that something bad is about to happen to you? f. Do you have difficulty making decisions? ANS: A, B, C, F These questions are related to risk factors for depression. Tense muscles are associated with stress and anxiety rather than depression. Feeling that something bad is about to happen relates to paranoia rather than depression. DIF: Cognitive Level: Apply REF: p. 68 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: NPsUycRhoSsIocNiaGl ITntBCy:OMMental Health Concepts Chapter 08: Nutritional Assessment Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. A patient with mild renal disease has been put on a 2200-calorie per day diet plan with the lowest recommended amount of protein. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of protein in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient the least amount of protein he can eat on his prescribed diet? a. 2200 calories 0.15 = 330/9 calories/gram = 36.6 g b. 2200 calories 0.10 = 220/4 calories/gram = 55 g c. 2200 calories 0.20 = 440/9 calories/gram = 48.8 g d. 2200 calories 0.12 = 264/4 calories/gram = 66 g ANS: D Proteins should account for 12% to 20% of total calories. Each gram of protein yields 4 calories. Twelve percent is the least recommended percentage for proteins, rather than 10%. DIF: Cognitive Level: Apply REF: p. 80 TOP: Nursing Process: Implementation MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration 2. A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of carbohydrates in the product. The nurse explainsU, hoSweNver,Tthat theOlabel is based on 2000 calories. Which is the appropriate formula to teach this patient of the maximum grams of carbohydrates she can eat on her prescribed diet? a. 1800 calories 0.45 = 810/4 calories/gram = 202.5 g b. 1800 calories 0.60 = 1080/4 calories/gram = 270 g c. 1800 calories 0.55 = 990/9 calories/gram = 110 g d. 1800 calories 0.50 = 900/9 calories/gram = 100 g ANS: B Carbohydrates should account for 55% to 60% of total calories. Carbohydrates should account for a maximum of 60% of total calories rather than 45%. Each gram of carbohydrates yields 4 calories rather than 9. Carbohydrates should account for a maximum of 60% of total calories, rather than 50%. DIF: Cognitive Level: Apply REF: p. 80 TOP: Nursing Process: Implementation MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration 3. A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric intake per day. What is the nurse’s most appropriate response to this patient’s comment? a. “That is admirable; how do you accomplish fat intake that low on a daily basis?” b. “Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat.

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WILSON: HEALTH ASSESSMENT
FOR NURSING PRACTICE, 6TH
EDITION ALL CHAPTERS
COVERED

,Chapter 01: Introduction to Health Assessment

Wilson: Health Assessment for Nursing Practice, 6th Edition

MULTIPLE CHOICE

1. A patient comes to the emergency department and tells the triage nurse that he is “having a
heart attack.” What is the nurse’s top priority at this time?

a. Determine the patient’s personal data and insurance coverage.

b. Ask the patient to take a seat in the waiting room until his name is called.

c. Request that a nurse collect data for a comprehensive history.

d. Ask a nurse to start a focused assessment of this patient now.

ANS: D

The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
cardiovascular system. The type of health assessment performed by the nurse is also driven by patient
need. Personal data and insurance information will be obtained, but in this situation, these data can
wait until after the patient is assessed. Based also on Maslow’s hierarchy of needs, physiologic needs
take precedence. Rather than asking the patient to wait, the nurse needs to begin data collection, such
as vital signs, immediately to determine the patient’s health status. Complications can be prevented if
an immediate assessment is made to analyze the patient’s symptoms. A comprehensive history is not
indicated in this situation at this time. Some subjective data will be collected, such as allergies and
medical history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental
health assessment is not a priority at this time.



DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3 TOP: Nursing Process: Assessment

MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
Priorities

,2. Which situation illustrates a screening assessment?

a. A patient visits an obstetric clinic for the first time and the nurse conducts a detailed history and
physical examination.

b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood

pressure checks to mall patrons.

c. The nurse in an urgent care center checks the vital signs of a patient who is complaining of leg
pain.

d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood

glucose level.

ANS: B



A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a
screening assessment focused on disease detection. A detailed history and physical examination
conducted during a first-time visit to an obstetric clinic is an example of a comprehensive assessment.
Assessing a patient complaining of leg pain in the triage area of an urgent care center is an example of a
problem-based/focused assessment. A patient’s return appointment 1 month after today’s office visit to
report fasting blood glucose levels is an example of an episodic or follow-up assessment.



DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3 TOP: Nursing Process: Assessment

MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening



3. For which person is a screening assessment indicated?

a. The person who had abdominal surgery yesterday

b. The person who is unaware of his high serum glucose levels

c. The person who is being admitted to a long-term care facility

d. The person who is beginning rehabilitation after a knee replacement

ANS: B

A screening assessment is performed for the purpose of disease detection. In this case this person may
have diabetes mellitus. A shift assessment is most appropriate for the person who is recovering in the
hospital from surgery. A comprehensive assessment is performed during admission to a facility to obtain
a detailed history and complete physical examination. An episodic or follow-up assessment is performed
after knee replacement to evaluate the outcome of the procedure.

, DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3 TOP: Nursing Process: Assessment

MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
Priorities



4. For which person is a shift assessment indicated?

a. The person who had abdominal surgery yesterday

b. The person who is unaware of his high serum glucose levels

c. The person who is being admitted to a long-term care facility

d. The person who is beginning rehabilitation after a knee replacement

ANS: A

A shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A
screening assessment is performed for the purpose of disease detection, in this case diabetes mellitus. A
comprehensive assessment is performed during admission to a facility to obtain a detailed history and
complete physical examination. An episodic or follow-up assessment is performed after knee
replacement to evaluate the outcome of the procedure.



DIF: Cognitive Level: Understand REF: Box 1-3 | p. 4 TOP: Nursing Process: Assessment

MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
Priorities



5. For which person is a comprehensive assessment indicated?

a. The person who had abdominal surgery yesterday

b. The person who is unaware of his high serum glucose levels

c. The person who is being admitted to a long-term care facility

d. The person who is beginning rehabilitation after a knee replacement

ANS: C

A comprehensive assessment is performed during admission to a facility to obtain a detailed history and
complete physical examination. A shift assessment is most appropriate for the person who is recovering
in the hospital from surgery. A screening assessment is performed for the purpose of disease detection,
in this case diabetes mellitus. An episodic or follow-up assessment is performed after knee replacement
to evaluate the outcome of the procedure.

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