v v v v v
v Nursing Practice 7th Edition by Wilson
v v v v v
v Chapter 1 - 24 v v v
,Chapter v01: vIntroduction vto vHealth vAssessment
MULTIPLE vCHOICE
1. A vpatient vcomes vto vthe vemergency vdepartment vand vtells vthe vtriage v nurse
vthat v hevis v“having va v heart vattack.” vWhat vis vthe v nurse’s vtop vpriority vat vthis vtime?
a. Determine vthe vpatient’s vpersonal vdata vand
vinsurance vcoverage.
b. Ask vthe vpatient vto vtake va vseat vin vthe
vwaitingvroom vuntil v his vname vis vcalled.
c. Request vthat va vnurse vcollect vdata
vfor vavcomprehensive v history.
d. Ask va vnurse vto vstart va vfocused
vassessmentvof vthis vpatient vnow.
ANSWER: v D
The vnurse vneeds vto vbegin van vassessment vas vsoon vas vpossible vthat vis vfocused von vthis
vpatient’sv cardiovascular vsystem. vThe vtype vof vhealth vassessment vperformed vby vthe vnurse
vis valso vdrivenv by vpatient vneed. vPersonal vdata vand vinsurance vinformation vwill vbe
vobtained, vbut vin vthis vsituation, vthese vdata vcan vwait vuntil vafter vthe vpatient vis vassessed.
vBased valso von vMaslow’s vhierarchy vof vneeds, vphysiologic vneeds vtake vprecedence.
vRather vthan vasking vthe vpatient vto vwait, vthe vnurse vneeds vto vbegin vdata vcollection, vsuch
vas vvital vsigns, vimmediately vto vdeterminevthe vpatient’s vhealth vstatus. vComplications vcan
vbe vprevented vif van vimmediate vassessment vis vmade vto vanalyze vthe vpatient’s vsymptoms.
vA vcomprehensive vhistory vis vnot vindicated vin vthis v situation vat vthis vtime. vSome
vsubjective vdata vwill vbe vcollected, vsuch vas vallergies vand vmedical vhistory vrelated vto
vcardiovascular vdisease. vEyes, vears, vor va vcomplete v musculoskeletal vor vmental v health
vassessment vis vnot va vpriority vat vthis vtime.
DIF: v v v Cognitive vLevel: vApply REF: vBox v1-3 v| vp.
v3vTOP: vNursing vProcess: v Assessment
MSC: vNCLEX vPatient vNeeds: vSafe vand vEffective vCare vEnvironment: vManagement vof vCare:
vEstablishing vPriorities
2. Which vsituation villustrates va v screening vassessment?
a. A vpatient vvisits van vobstetric vclinic vfor vthe
vfirst vtime vand vthe vnurse vconducts va
vdetailedvhistory vand vphysical vexamination.
b. A vhospital v sponsors va vhealth vfair vat va
vlocalvmall vand vprovides vcholesterol vand
vblood vpressure vchecks vto vmall vpatrons.
c. The vnurse vin van vurgent vcare vcenter
vchecksvthe vvital vsigns vof va vpatient vwho
vis vcomplaining vof vleg vpain.
, d. A vpatient v newly vdiagnosed vwith
vdiabetesvmellitus vcomes vto vtest vhis
vfasting vblood vglucose vlevel.
ANSWER: vB
A vhealth vfair vat va vlocal vmall vthat vprovides vcholesterol vand vblood vpressure vchecks vis
van vexample vof va vscreening vassessment vfocused von vdisease vdetection. vA vdetailed
vhistory vand vphysical vexamination vconducted vduring va vfirst-time v visit vto van vobstetric
vclinic vis van vexamplev of va vcomprehensive vassessment. vAssessing va vpatient vcomplaining
vof vleg vpain vin vthe vtriage varea vof van vurgent vcare vcenter vis van vexample vof va vproblem-
based/focused vassessment. vA vpatient’s vreturn vappointment v1 vmonth vafter vtoday’s voffice
vvisit vto vreport vfasting vblood vglucose vlevels vis van vexample vof van vepisodic vor v follow-up
vassessment.
DIF: v v v Cognitive vLevel: vUnderstand REF: vBox v1-3 v| vp.
v3vTOP: vNursing vProcess: v Assessment
MSC: vNCLEX vPatient v Needs: v Health vPromotion vand vMaintenance: vHealth vScreening
3. For vwhich vperson vis va v screening vassessment vindicated?
a. The vperson vwho vhad vabdominal
vsurgeryvyesterday
b. The vperson vwho vis vunaware vof vhis
vhighvserum vglucose vlevels
c. The vperson vwho vis vbeing vadmitted
vto vavlong-term vcare vfacility
d. The vperson vwho vis vbeginning
vrehabilitationvafter va vknee vreplacement
ANSWER: vB
A vscreening vassessment vis vperformed vfor vthe vpurpose vof vdisease vdetection. vIn vthis
vcase vthisvperson vmay vhave vdiabetes vmellitus. vA vshift vassessment vis vmost vappropriate
vfor vthe vperson vwho vis vrecovering vin vthe vhospital vfrom vsurgery. vA vcomprehensive
vassessment vis vperformedv during vadmission vto va vfacility vto vobtain va vdetailed vhistory
vand vcomplete vphysical vexamination. vAn vepisodic vor vfollow-up vassessment vis
vperformed vafter vknee vreplacement vtovevaluate vthe voutcome vof vthe vprocedure.
DIF: v v v Cognitive vLevel: vUnderstand REF: vBox v1-3 v| vp.
v3vTOP: vNursing vProcess: v Assessment
MSC: vNCLEX vPatient vNeeds: vSafe vand vEffective vCare vEnvironment: vManagement vof vCare:
vEstablishing vPriorities
4. For vwhich vperson vis va v shift vassessment vindicated?
a. The vperson vwho vhad vabdominal
vsurgeryvyesterday
b. The vperson vwho vis vunaware vof vhis
vhighvserum vglucose vlevels
c. The vperson vwho vis vbeing vadmitted vto va
long-term vcare vfacility
d. The vperson vwho vis vbeginning
vrehabilitationvafter va vknee vreplacement
ANSWER: v A
A vshift vassessment vis vmost vappropriate vfor vthe vperson vwho vis vrecovering vin vthe
vhospital vfromv surgery. vA vscreening vassessment vis vperformed vfor vthe vpurpose vof vdisease
vdetection, vin vthis vcase vdiabetes vmellitus. v A vcomprehensive vassessment vis vperformed
vduring vadmission vto va
, facility vto vobtain va vdetailed vhistory vand vcomplete vphysical vexamination. vAn vepisodic
vor vfollow-up vassessment vis vperformed vafter vknee vreplacement vto vevaluate vthe
voutcome vof vthev procedure.
DIF: v v v Cognitive vLevel: vUnderstand REF: vBox v1-3 v| vp.
v4vTOP: vNursing vProcess: v Assessment
MSC: vNCLEX vPatient vNeeds: vSafe vand vEffective vCare vEnvironment: vManagement vof vCare:
vEstablishing vPriorities
5. For vwhich vperson vis va vcomprehensive vassessment v indicated?
a. The vperson vwho v had vabdominal
vsurgeryvyesterday
b. The vperson vwho vis vunaware vof vhis
vhighvserum vglucose vlevels
c. The vperson vwho vis vbeing vadmitted
vto vavlong-term vcare vfacility
d. The vperson vwho vis vbeginning
vrehabilitationvafter va vknee vreplacement
ANSWER: vC
A vcomprehensive vassessment vis vperformed vduring vadmission vto va vfacility vto vobtain va
detailed vhistory vand vcomplete vphysical vexamination. vA vshift vassessment vis vmost
vappropriatevfor vthe vperson vwho vis vrecovering vin vthe vhospital vfrom vsurgery. vA
vscreening vassessment vis vperformed vfor vthe vpurpose vof vdisease vdetection, vin vthis vcase
vdiabetes vmellitus. vAn vepisodic vor vfollow-up vassessment vis vperformed vafter vknee
vreplacement vto vevaluate vthe voutcome vof vthe vprocedure.
DIF: v v v Cognitive vLevel: vUnderstand REF: vBox v1-3 v| vp.
v3vTOP: vNursing vProcess: v Assessment
MSC: vNCLEX vPatient vNeeds: vSafe vand vEffective vCare vEnvironment: vManagement vof vCare:
vEstablishing vPriorities
6. For vwhich vperson vis van vepisodic vor vfollow-up vassessment vindicated?
a. The vperson vwho vhad vabdominal
vsurgeryvyesterday
b. The vperson vwho vis vunaware vof vhis
vhighvserum vglucose vlevels
c. The vperson vwho v is vbeing vadmitted vto va
long-term vcare vfacility
d. The vperson vwho vis vbeginning
vrehabilitationvafter va vknee vreplacement
ANSWER: v D
An vepisodic vor vfollow-up vassessment vis vperformed vafter vthe vknee vreplacement vto
vevaluate vthe voutcome vof vthe vprocedure. vA vshift vassessment vis vmost vappropriate vfor
vthe vperson vwho visvrecovering vin vthe vhospital vfrom vsurgery. vA vscreening vassessment vis
vperformed vfor vthe vpurpose vof vdisease vdetection, vin vthis vcase vdiabetes vmellitus. vA
vcomprehensive vassessment vis vperformed vduring vadmission vto va vfacility vto vobtain va
vdetailed vhistory vand vcomplete vphysicalvexamination.
DIF: v v v Cognitive vLevel: vUnderstand REF: vBox v1-3 v| vp.
v3vTOP: vNursing vProcess: v Assessment