,Chapter 01: Introduction to Health Assessment
Wilson: Health Assessment for Nursing Practice, 7th 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
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
, TOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bHealth bPromotion band bMaintenance: bHealth bScreening
3. For bwhich bperson bis ba bscreening bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bB
A bscreening bassessment bis bperformed bfor bthe bpurpose bof bdisease bdetection. bIn bthis bcase bthis
bperson bmay bhave bdiabetes bmellitus. bA bshift bassessment bis bmost bappropriate bfor bthe bperson
bwho bis brecovering bin bthe bhospital bfrom bsurgery. bA bcomprehensive bassessment bis bperformed
bduring badmission bto ba bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical
bexamination. bAn bepisodic bor bfollow-up bassessment bis bperformed bafter bknee breplacement bto
bevaluate bthe boutcome bof bthe bprocedure.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
4. For bwhich bperson bis ba bshift bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bA
A bshift bassessment bis bmost bappropriate bfor bthe bperson bwho bis brecovering bin bthe bhospital bfrom
bsurgery. bA bscreening bassessment bis bperformed bfor bthe bpurpose bof bdisease bdetection, bin bthis
bcase bdiabetes bmellitus. bA bcomprehensive bassessment bis bperformed bduring badmission bto ba
bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical bexamination. bAn bepisodic bor
bfollow-up bassessment bis bperformed bafter bknee breplacement bto bevaluate bthe boutcome bof bthe
bprocedure.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
5. For bwhich bperson bis ba bcomprehensive bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bC
A bcomprehensive bassessment bis bperformed bduring badmission bto ba bfacility bto bobtain ba bdetailed
bhistory band bcomplete bphysical bexamination. bA bshift bassessment bis bmost bappropriate bfor bthe
bperson bwho bis brecovering bin bthe bhospital bfrom bsurgery. bA bscreening bassessment bis
bperformed bfor bthe bpurpose bof bdisease bdetection, bin bthis bcase bdiabetes bmellitus. bAn bepisodic
bor bfollow-up bassessment bis bperformed bafter bknee breplacement bto bevaluate bthe boutcome bof
bthe bprocedure.
, DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
6. For bwhich bperson bis ban bepisodic bor bfollow-up bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bD
An bepisodic bor bfollow-up bassessment bis bperformed bafter bthe bknee breplacement bto bevaluate
bthe boutcome bof bthe bprocedure. bA bshift bassessment bis bmost bappropriate bfor bthe bperson bwho bis
brecovering bin bthe bhospital bfrom bsurgery. bA bscreening bassessment bis bperformed bfor bthe
bpurpose bof bdisease bdetection, bin bthis bcase bdiabetes bmellitus. bA bcomprehensive bassessment bis
bperformed bduring badmission bto ba bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical
bexamination.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
7. Which bis ban bexample bof bdata ba bnurse bcollects bduring ba bphysical bexamination?
a. The bpatient‘s black bof bhair band bshiny bskin bover bboth bshins
b. The bpatient‘s bstated bconcern babout black bof bmoney bfor bprescriptions
c. The bpatient‘s bcomplaints bof btingling bsensations bin bthe bfeet
d. The bpatient‘s bmother‘s bstatements bthat bthe bpatient bis bvery bnervous blately
ANS: bA
The black bof bhair band bshiny bskin bover bboth bshins bare bobjective bdata bor bsigns bthat bare bpart bof
bthe bphysical bexamination. bA bpatient‘s bconcerns babout black bof bmoney bare bsubjective bdata
band bare bpart bof bthe bhealth bhistory. bA bpatient‘s bcomplaints bof btingling bsensations bin bthe bfeet
bare bsubjective bdata band bare bpart bof bthe bhealth bhistory. bA bpatient‘s bfamily bstatements bare
bconsidered bsecondary bdata, bare bsubjective bdata, band bare bpart bof bthe bhealth bhistory.
DIF:Cognitive bLevel: bApply b REF: Box b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bPhysiological bIntegrity: bReduction bof bRisk bPotential: bSystem bSpecific
bAssessments
8. The bnurse bdocuments bwhich binformation bin bthe bpatient‘s bhistory?
a. The bpatient‘s bskin bfeels bwarm bto bthe btouch.
b. The bpatient bis bscratching bhis barm.
c. The bpatient‘s btemperature bis b100 bF.
d. The bpatient bcomplains bof bitching.
ANS: bD
Wilson: Health Assessment for Nursing Practice, 7th 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
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
, TOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bHealth bPromotion band bMaintenance: bHealth bScreening
3. For bwhich bperson bis ba bscreening bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bB
A bscreening bassessment bis bperformed bfor bthe bpurpose bof bdisease bdetection. bIn bthis bcase bthis
bperson bmay bhave bdiabetes bmellitus. bA bshift bassessment bis bmost bappropriate bfor bthe bperson
bwho bis brecovering bin bthe bhospital bfrom bsurgery. bA bcomprehensive bassessment bis bperformed
bduring badmission bto ba bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical
bexamination. bAn bepisodic bor bfollow-up bassessment bis bperformed bafter bknee breplacement bto
bevaluate bthe boutcome bof bthe bprocedure.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
4. For bwhich bperson bis ba bshift bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bA
A bshift bassessment bis bmost bappropriate bfor bthe bperson bwho bis brecovering bin bthe bhospital bfrom
bsurgery. bA bscreening bassessment bis bperformed bfor bthe bpurpose bof bdisease bdetection, bin bthis
bcase bdiabetes bmellitus. bA bcomprehensive bassessment bis bperformed bduring badmission bto ba
bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical bexamination. bAn bepisodic bor
bfollow-up bassessment bis bperformed bafter bknee breplacement bto bevaluate bthe boutcome bof bthe
bprocedure.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
5. For bwhich bperson bis ba bcomprehensive bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bC
A bcomprehensive bassessment bis bperformed bduring badmission bto ba bfacility bto bobtain ba bdetailed
bhistory band bcomplete bphysical bexamination. bA bshift bassessment bis bmost bappropriate bfor bthe
bperson bwho bis brecovering bin bthe bhospital bfrom bsurgery. bA bscreening bassessment bis
bperformed bfor bthe bpurpose bof bdisease bdetection, bin bthis bcase bdiabetes bmellitus. bAn bepisodic
bor bfollow-up bassessment bis bperformed bafter bknee breplacement bto bevaluate bthe boutcome bof
bthe bprocedure.
, DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
6. For bwhich bperson bis ban bepisodic bor bfollow-up bassessment bindicated?
a. The bperson bwho bhad babdominal bsurgery byesterday
b. The bperson bwho bis bunaware bof bhis bhigh bserum bglucose blevels
c. The bperson bwho bis bbeing badmitted bto ba blong-term bcare bfacility
d. The bperson bwho bis bbeginning brehabilitation bafter ba bknee breplacement
ANS: bD
An bepisodic bor bfollow-up bassessment bis bperformed bafter bthe bknee breplacement bto bevaluate
bthe boutcome bof bthe bprocedure. bA bshift bassessment bis bmost bappropriate bfor bthe bperson bwho bis
brecovering bin bthe bhospital bfrom bsurgery. bA bscreening bassessment bis bperformed bfor bthe
bpurpose bof bdisease bdetection, bin bthis bcase bdiabetes bmellitus. bA bcomprehensive bassessment bis
bperformed bduring badmission bto ba bfacility bto bobtain ba bdetailed bhistory band bcomplete bphysical
bexamination.
DIF:Cognitive bLevel: bUnderstand REF: bBox b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bSafe band bEffective bCare bEnvironment: bManagement bof bCare:
bEstablishing bPriorities
7. Which bis ban bexample bof bdata ba bnurse bcollects bduring ba bphysical bexamination?
a. The bpatient‘s black bof bhair band bshiny bskin bover bboth bshins
b. The bpatient‘s bstated bconcern babout black bof bmoney bfor bprescriptions
c. The bpatient‘s bcomplaints bof btingling bsensations bin bthe bfeet
d. The bpatient‘s bmother‘s bstatements bthat bthe bpatient bis bvery bnervous blately
ANS: bA
The black bof bhair band bshiny bskin bover bboth bshins bare bobjective bdata bor bsigns bthat bare bpart bof
bthe bphysical bexamination. bA bpatient‘s bconcerns babout black bof bmoney bare bsubjective bdata
band bare bpart bof bthe bhealth bhistory. bA bpatient‘s bcomplaints bof btingling bsensations bin bthe bfeet
bare bsubjective bdata band bare bpart bof bthe bhealth bhistory. bA bpatient‘s bfamily bstatements bare
bconsidered bsecondary bdata, bare bsubjective bdata, band bare bpart bof bthe bhealth bhistory.
DIF:Cognitive bLevel: bApply b REF: Box b1-3
bTOP:Nursing bProcess: bAssessment
MSC:NCLEX bPatient bNeeds: bPhysiological bIntegrity: bReduction bof bRisk bPotential: bSystem bSpecific
bAssessments
8. The bnurse bdocuments bwhich binformation bin bthe bpatient‘s bhistory?
a. The bpatient‘s bskin bfeels bwarm bto bthe btouch.
b. The bpatient bis bscratching bhis barm.
c. The bpatient‘s btemperature bis b100 bF.
d. The bpatient bcomplains bof bitching.
ANS: bD
