Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1101:11Introduction11to11Health11Assessment
MULTIPLE11CHOICE
1. A11patient11comes11to11the11emergency11department11and11tells11the11triage11 n
urse11that11 he11is11“having11a11heart11attack.”11What11is11the11nurse’s11top11priority11at11th
is11time?
a. Determine11the11patient’s11personal11data11a
nd11insurance11coverage.
b. Ask11the11patient11to11take11a11seat11in11the1
1waiting11room11until11 his11name11is11called.
c. Request11that11a11nurse11collect11data
11for11a11comprehensive11 history.
d. Ask11a11nurse11to11start11a11focused11ass
essment11of11this11patient11now.
ANSWER:11 D
The11nurse11needs11to11begin11an11assessment11as11soon11as11possible11that11is11focused11
on11this11patient’s11cardiovascular11system.11The11type11of11health11assessment11performed
11by11the11nurse11is11also11driven11by11patient11need.11Personal11data11and11insurance11info
rmation11will11be11obtained,11but11in11this11situation,11these11data11can11wait11until11after1
1the11patient11is11assessed.11Based11also11on11Maslow’s11hierarchy11of11needs,11physiolog
ic11needs11take11precedence.11Rather11than11asking11the11patient11to11wait,11the11nurse11ne
eds11to11begin11data11collection,11such11as11vital11signs,11immediately11to11determine11the11
patient’s11health11status.11Complications11can11be11prevented11if11an11immediate11assessm
ent11is11made11to11analyze11the11patient’s11symptoms.11A11comprehensive11history11is11no
t11indicated11in11this11situation11at11this11time.11Some11subjective11data11will11be11collecte
d,11such11as11allergies11and11medical11history11related11to11cardiovascular11disease.11Eyes,
11ears,11or11a11complete11musculoskeletal11or11mental11 health11assessment11is11not11a11pri
ority11at11this11time.
DIF:111111 Cognitive11Level:11Apply REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
2. Which11situation11illustrates11a11 screening11assessment?
a. A11patient11visits11an11obstetric11clinic11for
11the11first11time11and11the11nurse11conducts
11a11detailed11history11and11physical11examin
ation.
b. A11hospital11sponsors11a11health11fair11at1
1a11local11mall11and11provides11cholestero
l11and11blood11pressure11checks11to11mall
11patrons.
c. The11nurse11in11an11urgent11care11center1
1checks11the11vital11signs11of11a11patient11
who11is11complaining11of11leg11pain.
, d. A11patient11 newly11diagnosed11with11dia
betes11mellitus11comes11to11test11his11fast
ing11blood11glucose11level.
ANSWER:11B
A11health11fair11at11a11local11mall11that11provides11cholesterol11and11blood11pressure11che
cks11is11an11example11of11a11screening11assessment11focused11on11disease11detection.11A11
detailed11history11and11physical11examination11conducted11during11a11first-
time11visit11to11an11obstetric11clinic11is11an11example11of11a11comprehensive11assessment.11
Assessing11a11patient11complaining11of11leg11pain11in11the11triage11area11of11an11urgent11c
are11center11is11an11example11of11a11problem-
based/focused11assessment.11A11patient’s11return11appointment11111month11after11today’s1
1office11visit11to11report11fasting11blood11glucose11levels11is11an11example11of11an11episodi
c11or11follow-up11assessment.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Health11Promotion11and11Maintenance:11Health11Screening
3. For11which11person11is11a11screening11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitte
d11to11a11long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11B
A11screening11assessment11is11performed11for11the11purpose11of11disease11detection.11In1
1this11case11this11person11may11have11diabetes11mellitus.11A11shift11assessment11is11most1
1appropriate11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A
11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtai
n11a11detailed11history11and11complete11physical11examination.11An11episodic11or11follo
w-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of1
1the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
4. For11which11person11is11a11shift11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitted11to1
1a
long-term11care11facility
d. The11person11who11is11beginning11rehabilit
ation11after11a11knee11replacement
ANSWER:11 A
A11shift11assessment11is11most11appropriate11for11the11person11who11is11recovering11in11th
e11hospital11from11surgery.11A11screening11assessment11is11performed11for11the11purpose11o
f11disease11detection,11in11this11case11diabetes11mellitus.11 A11comprehensive11assessment11
is11performed11during11admission11to11a
, facility11to11obtain11a11detailed11history11and11complete11physical11examination.11An11e
pisodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11o
f11the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11411TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
5. For11which11person11is11a11comprehensive11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitte
d11to11a11long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11C
A11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a
detailed11history11and11complete11physical11examination.11A11shift11assessment11is11most1
1appropriate11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A1
1screening11assessment11is11performed11for11the11purpose11of11disease11detection,11in11thi
s11case11diabetes11mellitus.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of
11the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
6. For11which11person11is11an11episodic11or11follow-up11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitted11to11
a
long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11 D
An11episodic11or11follow-
up11assessment11is11performed11after11the11knee11replacement11to11evaluate11the11outcom
e11of11the11procedure.11A11shift11assessment11is11most11appropriate11for11the11person11wh
o11is11recovering11in11the11hospital11from11surgery.11A11screening11assessment11is11perfor
med11for11the11purpose11of11disease11detection,11in11this11case11diabetes11mellitus.11A11com
prehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a1
1detailed11history11and11complete11physical11examination.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1101:11Introduction11to11Health11Assessment
MULTIPLE11CHOICE
1. A11patient11comes11to11the11emergency11department11and11tells11the11triage11 n
urse11that11 he11is11“having11a11heart11attack.”11What11is11the11nurse’s11top11priority11at11th
is11time?
a. Determine11the11patient’s11personal11data11a
nd11insurance11coverage.
b. Ask11the11patient11to11take11a11seat11in11the1
1waiting11room11until11 his11name11is11called.
c. Request11that11a11nurse11collect11data
11for11a11comprehensive11 history.
d. Ask11a11nurse11to11start11a11focused11ass
essment11of11this11patient11now.
ANSWER:11 D
The11nurse11needs11to11begin11an11assessment11as11soon11as11possible11that11is11focused11
on11this11patient’s11cardiovascular11system.11The11type11of11health11assessment11performed
11by11the11nurse11is11also11driven11by11patient11need.11Personal11data11and11insurance11info
rmation11will11be11obtained,11but11in11this11situation,11these11data11can11wait11until11after1
1the11patient11is11assessed.11Based11also11on11Maslow’s11hierarchy11of11needs,11physiolog
ic11needs11take11precedence.11Rather11than11asking11the11patient11to11wait,11the11nurse11ne
eds11to11begin11data11collection,11such11as11vital11signs,11immediately11to11determine11the11
patient’s11health11status.11Complications11can11be11prevented11if11an11immediate11assessm
ent11is11made11to11analyze11the11patient’s11symptoms.11A11comprehensive11history11is11no
t11indicated11in11this11situation11at11this11time.11Some11subjective11data11will11be11collecte
d,11such11as11allergies11and11medical11history11related11to11cardiovascular11disease.11Eyes,
11ears,11or11a11complete11musculoskeletal11or11mental11 health11assessment11is11not11a11pri
ority11at11this11time.
DIF:111111 Cognitive11Level:11Apply REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
2. Which11situation11illustrates11a11 screening11assessment?
a. A11patient11visits11an11obstetric11clinic11for
11the11first11time11and11the11nurse11conducts
11a11detailed11history11and11physical11examin
ation.
b. A11hospital11sponsors11a11health11fair11at1
1a11local11mall11and11provides11cholestero
l11and11blood11pressure11checks11to11mall
11patrons.
c. The11nurse11in11an11urgent11care11center1
1checks11the11vital11signs11of11a11patient11
who11is11complaining11of11leg11pain.
, d. A11patient11 newly11diagnosed11with11dia
betes11mellitus11comes11to11test11his11fast
ing11blood11glucose11level.
ANSWER:11B
A11health11fair11at11a11local11mall11that11provides11cholesterol11and11blood11pressure11che
cks11is11an11example11of11a11screening11assessment11focused11on11disease11detection.11A11
detailed11history11and11physical11examination11conducted11during11a11first-
time11visit11to11an11obstetric11clinic11is11an11example11of11a11comprehensive11assessment.11
Assessing11a11patient11complaining11of11leg11pain11in11the11triage11area11of11an11urgent11c
are11center11is11an11example11of11a11problem-
based/focused11assessment.11A11patient’s11return11appointment11111month11after11today’s1
1office11visit11to11report11fasting11blood11glucose11levels11is11an11example11of11an11episodi
c11or11follow-up11assessment.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Health11Promotion11and11Maintenance:11Health11Screening
3. For11which11person11is11a11screening11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitte
d11to11a11long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11B
A11screening11assessment11is11performed11for11the11purpose11of11disease11detection.11In1
1this11case11this11person11may11have11diabetes11mellitus.11A11shift11assessment11is11most1
1appropriate11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A
11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtai
n11a11detailed11history11and11complete11physical11examination.11An11episodic11or11follo
w-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of1
1the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
4. For11which11person11is11a11shift11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitted11to1
1a
long-term11care11facility
d. The11person11who11is11beginning11rehabilit
ation11after11a11knee11replacement
ANSWER:11 A
A11shift11assessment11is11most11appropriate11for11the11person11who11is11recovering11in11th
e11hospital11from11surgery.11A11screening11assessment11is11performed11for11the11purpose11o
f11disease11detection,11in11this11case11diabetes11mellitus.11 A11comprehensive11assessment11
is11performed11during11admission11to11a
, facility11to11obtain11a11detailed11history11and11complete11physical11examination.11An11e
pisodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11o
f11the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11411TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
5. For11which11person11is11a11comprehensive11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitte
d11to11a11long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11C
A11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a
detailed11history11and11complete11physical11examination.11A11shift11assessment11is11most1
1appropriate11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A1
1screening11assessment11is11performed11for11the11purpose11of11disease11detection,11in11thi
s11case11diabetes11mellitus.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of
11the11procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11C
are:11Establishing11Priorities
6. For11which11person11is11an11episodic11or11follow-up11assessment11indicated?
a. The11person11who11had11abdominal11su
rgery11yesterday
b. The11person11who11is11unaware11of11h
is11high11serum11glucose11levels
c. The11person11who11is11being11admitted11to11
a
long-term11care11facility
d. The11person11who11is11beginning11rehabilita
tion11after11a11knee11replacement
ANSWER:11 D
An11episodic11or11follow-
up11assessment11is11performed11after11the11knee11replacement11to11evaluate11the11outcom
e11of11the11procedure.11A11shift11assessment11is11most11appropriate11for11the11person11wh
o11is11recovering11in11the11hospital11from11surgery.11A11screening11assessment11is11perfor
med11for11the11purpose11of11disease11detection,11in11this11case11diabetes11mellitus.11A11com
prehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a1
1detailed11history11and11complete11physical11examination.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.11311TOP:11Nursing11Process:11Assessment
