TablenofnContents
UnitnI.nFoundationsnfornHealthnAssessment
1. IntroductionntonHealthnAssessment
2. InterviewingnPatientsntonObtainnanHealthnHistory
3. TechniquesnandnEquipmentnfornPhysicalnAssessment
4. GeneralnInspectionnandnMeasurementnofnVitalnSigns
5. Ethnic,nCultural,nandnSpiritualnConsiderations
6. PainnAssessment
7. MentalnHealthnandnAbusivenBehaviornAssessment
8. NutritionalnAssessment
UnitnII.nHealthnAssessmentnofnthenAdult
9. Skin,nHair,nandnNails
10. Head,nEyes,nEars,nNose,nandnThroat
11. LungsnandnRespiratorynSystem
12. HeartnandnPeripheralnVascularnSystem
13. AbdomennandnGastrointestinalnSystem
,14. MusculoskeletalnSystem
15. NeurologicnSystem
16. BreastsnandnAxillae
17. ReproductivenSystemnandnthenPerineum
UnitnIII.nHealthnAssessmentnAcrossnthenLifenSpan
18. DevelopmentalnAssessmentnThroughoutnthenLifenSpan
19. AssessmentnofnthenInfant,nChild,nandnAdolescent
20. AssessmentnofnthenPregnantnPatient
21. AssessmentnofnthenOldernAdult
UnitnIV.nSynthesisnandnApplicationnofnHealthnAssessment
22. ConductingnanHead-to-ToenExamination
23. DocumentingnthenHead-to-ToenHealthnAssessment
24. AdaptingnHealthnAssessmentntonannIllnPatient
, Chapter 01: Introduction to Health Assessment
n n n n n
Wilson: Health Assessment for Nursing Practice, 6th Edition
n n n n n n n
MULTIPLEnCHOICE
1. Anpatientncomesntonthenemergencyndepartmentnandntellsnthentriagennursenthatnhenisn“havingnanh
eartnattack.”nWhatnisnthennurse’sntopnprioritynatnthisntime?
a. Determinenthenpatient’snpersonalndatanandninsurancencoverage.
b. Asknthenpatientntontakenanseatninnthenwaitingnroomnuntilnhisnnamenisncalled.
c. Requestnthatnannursencollectndatanfornancomprehensivenhistory.
d. Asknannursentonstartnanfocusednassessmentnofnthisnpatientnnow.
ANS:n D
Thennursenneedsntonbeginnannassessmentnasnsoonnasnpossiblenthatnisnfocusednonnthisnpatient’sncard
iovascularnsystem.nThentypenofnhealthnassessmentnperformednbynthennursenisnalsondrivennbynpatie
ntnneed.nPersonalndatanandninsuranceninformationnwillnbenobtained,nbutninnthisnsituation,nthesenda
tancannwaitnuntilnafternthenpatientnisnassessed.nBasednalsononnMaslow’snhierarchynofnneeds,nphysi
ologicnneedsntakenprecedence.nRathernthannaskingnthenpatientntonwait,nthennursenneedsntonbeginnd
atancollection,nsuchnasnvitalnsigns,nimmediatelyntondeterminenthenpatient’snhealthnstatus.nComplic
ationsncannbenpreventednifnannimmediatenassessmentnisnmadentonanalyzenthenpatient’snsymptoms.
nAncomprehensivenhistorynisnnotnindicatedninnthisnsituationnatnthisntime.nSomensubjectivendatanwil
lnbencollected,nsuchnasnallergiesnandnmedicalnhistorynrelatedntoncardiovascularndisease.nEyes,near
s,nornancompletenmusculoskeletalnornmentalnhealthnassessmentnisnnotnanprioritynatnthisntime.
DIF: CognitivenLevel:nApply REF:nBoxn1-
3n|np.n3nTOP:n NursingnProcess:nAssessment
MSC:n NCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishin
gnPriorities
2. Whichnsituationnillustratesnanscreeningnassessment?
a. Anpatientnvisitsnannobstetricnclinicnfornthenfirstntimenandnthennursenconductsnand
etailednhistorynandnphysicalnexamination.
b. Anhospitalnsponsorsnanhealthnfairnatnanlocalnmallnandnprovidesncholesterolnandnbloodnp
ressurenchecksntonmallnpatrons.
c. Thennurseninnannurgentncarencenternchecksnthenvitalnsignsnofnanpatientnwhonis
complainingnofnlegnpain.
d. Anpatientnnewlyndiagnosednwithndiabetesnmellitusncomesntontestnhisnfastingnbloodng
lucosenlevel.
ANS:n B