Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1101:11Introduction11to11Health11Assessment
MULTIPLE11CHOICE
1. A11patient11comes11to11the11emergency11department11and11tells11the11triage11 nurse1
1that11 he1is11“having11a11 heart11attack.”11What11is11the11nurse’s11top11priority11at11this11time?
a. Determine11the11patient’s11personal11data11and1
insurance11coverage.
b. Ask11the11patient11to11take11a11seat11in11the11wa
iting1room11until11 his11name11is11called.
c. Request11that11a11nurse11collect11data11f
or11a1comprehensive11history.
d. Ask11a11nurse11to11start11a11focused11assess
ment1of11this11patient11now.
ANSWER:11 D
The11nurse11needs11to11begin11an11assessment11as11soon11as11possible11that11is11focused11on11thi
s11patient’s1cardiovascular11system.11The11type11of11health11assessment11performed11by11the11n
urse11is11also11driven1by11patient11need.11Personal11data11and11insurance11information11will11be1
1obtained,11but11in11this11situation,11these11data11can11wait11until11after11the11patient11is11assesse
d.11Based11also11on11Maslow’s11hierarchy11of11needs,11physiologic11needs11take11precedence.11
Rather11than11asking11the11patient11to11wait,11the11nurse11needs11to11begin11data11collection,11su
ch11as11vital11signs,11immediately11to11determine1the11patient’s11health11status.11Complications
11can11be11prevented11if11an11immediate11assessment11is11made11to11analyze11the11patient’s11sy
mptoms.11A11comprehensive11history11is11not11indicated11in11this11situation11at11this11time.11So
me11subjective11data11will11be11collected,11such11as11allergies11and11medical11history11related11t
o11cardiovascular11disease.11Eyes,11ears,11or11a11complete11musculoskeletal11or11mental11 healt
h11assessment11is11not11a11priority11at11this11time.
DIF:111111 Cognitive11Level:11Apply REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
2. Which11situation11illustrates11a11 screening11assessment?
a. A11patient11visits11an11obstetric11clinic11for11th
e11first11time11and11the11nurse11conducts11a11det
ailed1history11and11physical11examination.
b. A11hospital11sponsors11a11health11fair11at11a11
local1mall11and11provides11cholesterol11and
11blood11pressure11checks11to11mall11patron
s.
c. The11nurse11in11an11urgent11care11center11ch
ecks1the11vital11signs11of11a11patient11who11i
s11complaining11of11leg11pain.
, d. A11patient11 newly11diagnosed11with11diab
etes1mellitus11comes11to11test11his11fasting1
1blood11glucose11level.
ANSWER:11B
A11health11fair11at11a11local11mall11that11provides11cholesterol11and11blood11pressure11checks11is
11an11example11of11a11screening11assessment11focused11on11disease11detection.11A11detailed11hi
story11and11physical11examination11conducted11during11a11first-
time11visit11to11an11obstetric11clinic11is11an11example1of11a11comprehensive11assessment.11Asses
sing11a11patient11complaining11of11leg11pain11in11the11triage11area11of11an11urgent11care11center11
is11an11example11of11a11problem-
based/focused11assessment.11A11patient’s11return11appointment11111month11after11today’s11offi
ce11visit11to11report11fasting11blood11glucose11levels11is11an11example11of11an11episodic11or11follo
w-up11assessment.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11 Needs:11 Health11Promotion11and11Maintenance:11Health11Screening
3. For11which11person11is11a11screening11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11
to11a1long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11B
A11screening11assessment11is11performed11for11the11purpose11of11disease11detection.11In11this1
1case11this1person11may11have11diabetes11mellitus.11A11shift11assessment11is11most11appropriat
e11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A11comprehensive
11assessment11is11performed1during11admission11to11a11facility11to11obtain11a11detailed11history
11and11complete11physical11examination.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to1evaluate11the11outcome11of11the11
procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
4. For11which11person11is11a11shift11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11to11a
long-term11care11facility
d. The11person11who11is11beginning11rehabilitat
ion1after11a11knee11replacement
ANSWER:11 A
A11shift11assessment11is11most11appropriate11for11the11person11who11is11recovering11in11the11hos
pital11from1surgery.11A11screening11assessment11is11performed11for11the11purpose11of11disease11
detection,11in11this11case11diabetes11mellitus.11 A11comprehensive11assessment11is11performed11d
uring11admission11to11a
, facility11to11obtain11a11detailed11history11and11complete11physical11examination.11An11episo
dic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of11the1
procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1141TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
5. For11which11person11is11a11comprehensive11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11
to11a1long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11C
A11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a
detailed11history11and11complete11physical11examination.11A11shift11assessment11is11most11app
ropriate1for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A11screening
11assessment11is11performed11for11the11purpose11of11disease11detection,11in11this11case11diabete
s11mellitus.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of11the1
1procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
6. For11which11person11is11an11episodic11or11follow-up11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11to11a
long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11 D
An11episodic11or11follow-
up11assessment11is11performed11after11the11knee11replacement11to11evaluate11the11outcome11of1
1the11procedure.11A11shift11assessment11is11most11appropriate11for11the11person11who11is1recove
ring11in11the11hospital11from11surgery.11A11screening11assessment11is11performed11for11the11pur
pose11of11disease11detection,11in11this11case11diabetes11mellitus.11A11comprehensive11assessmen
t11is11performed11during11admission11to11a11facility11to11obtain11a11detailed11history11and11com
plete11physical1examination.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1101:11Introduction11to11Health11Assessment
MULTIPLE11CHOICE
1. A11patient11comes11to11the11emergency11department11and11tells11the11triage11 nurse1
1that11 he1is11“having11a11 heart11attack.”11What11is11the11nurse’s11top11priority11at11this11time?
a. Determine11the11patient’s11personal11data11and1
insurance11coverage.
b. Ask11the11patient11to11take11a11seat11in11the11wa
iting1room11until11 his11name11is11called.
c. Request11that11a11nurse11collect11data11f
or11a1comprehensive11history.
d. Ask11a11nurse11to11start11a11focused11assess
ment1of11this11patient11now.
ANSWER:11 D
The11nurse11needs11to11begin11an11assessment11as11soon11as11possible11that11is11focused11on11thi
s11patient’s1cardiovascular11system.11The11type11of11health11assessment11performed11by11the11n
urse11is11also11driven1by11patient11need.11Personal11data11and11insurance11information11will11be1
1obtained,11but11in11this11situation,11these11data11can11wait11until11after11the11patient11is11assesse
d.11Based11also11on11Maslow’s11hierarchy11of11needs,11physiologic11needs11take11precedence.11
Rather11than11asking11the11patient11to11wait,11the11nurse11needs11to11begin11data11collection,11su
ch11as11vital11signs,11immediately11to11determine1the11patient’s11health11status.11Complications
11can11be11prevented11if11an11immediate11assessment11is11made11to11analyze11the11patient’s11sy
mptoms.11A11comprehensive11history11is11not11indicated11in11this11situation11at11this11time.11So
me11subjective11data11will11be11collected,11such11as11allergies11and11medical11history11related11t
o11cardiovascular11disease.11Eyes,11ears,11or11a11complete11musculoskeletal11or11mental11 healt
h11assessment11is11not11a11priority11at11this11time.
DIF:111111 Cognitive11Level:11Apply REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
2. Which11situation11illustrates11a11 screening11assessment?
a. A11patient11visits11an11obstetric11clinic11for11th
e11first11time11and11the11nurse11conducts11a11det
ailed1history11and11physical11examination.
b. A11hospital11sponsors11a11health11fair11at11a11
local1mall11and11provides11cholesterol11and
11blood11pressure11checks11to11mall11patron
s.
c. The11nurse11in11an11urgent11care11center11ch
ecks1the11vital11signs11of11a11patient11who11i
s11complaining11of11leg11pain.
, d. A11patient11 newly11diagnosed11with11diab
etes1mellitus11comes11to11test11his11fasting1
1blood11glucose11level.
ANSWER:11B
A11health11fair11at11a11local11mall11that11provides11cholesterol11and11blood11pressure11checks11is
11an11example11of11a11screening11assessment11focused11on11disease11detection.11A11detailed11hi
story11and11physical11examination11conducted11during11a11first-
time11visit11to11an11obstetric11clinic11is11an11example1of11a11comprehensive11assessment.11Asses
sing11a11patient11complaining11of11leg11pain11in11the11triage11area11of11an11urgent11care11center11
is11an11example11of11a11problem-
based/focused11assessment.11A11patient’s11return11appointment11111month11after11today’s11offi
ce11visit11to11report11fasting11blood11glucose11levels11is11an11example11of11an11episodic11or11follo
w-up11assessment.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11 Needs:11 Health11Promotion11and11Maintenance:11Health11Screening
3. For11which11person11is11a11screening11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11
to11a1long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11B
A11screening11assessment11is11performed11for11the11purpose11of11disease11detection.11In11this1
1case11this1person11may11have11diabetes11mellitus.11A11shift11assessment11is11most11appropriat
e11for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A11comprehensive
11assessment11is11performed1during11admission11to11a11facility11to11obtain11a11detailed11history
11and11complete11physical11examination.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to1evaluate11the11outcome11of11the11
procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
4. For11which11person11is11a11shift11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11to11a
long-term11care11facility
d. The11person11who11is11beginning11rehabilitat
ion1after11a11knee11replacement
ANSWER:11 A
A11shift11assessment11is11most11appropriate11for11the11person11who11is11recovering11in11the11hos
pital11from1surgery.11A11screening11assessment11is11performed11for11the11purpose11of11disease11
detection,11in11this11case11diabetes11mellitus.11 A11comprehensive11assessment11is11performed11d
uring11admission11to11a
, facility11to11obtain11a11detailed11history11and11complete11physical11examination.11An11episo
dic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of11the1
procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1141TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
5. For11which11person11is11a11comprehensive11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11
to11a1long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11C
A11comprehensive11assessment11is11performed11during11admission11to11a11facility11to11obtain11a
detailed11history11and11complete11physical11examination.11A11shift11assessment11is11most11app
ropriate1for11the11person11who11is11recovering11in11the11hospital11from11surgery.11A11screening
11assessment11is11performed11for11the11purpose11of11disease11detection,11in11this11case11diabete
s11mellitus.11An11episodic11or11follow-
up11assessment11is11performed11after11knee11replacement11to11evaluate11the11outcome11of11the1
1procedure.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
MSC:11NCLEX11Patient11Needs:11Safe11and11Effective11Care11Environment:11Management11of11Care:1E
stablishing11Priorities
6. For11which11person11is11an11episodic11or11follow-up11assessment11indicated?
a. The11person11who11had11abdominal11surg
ery1yesterday
b. The11person11who11is11unaware11of11his11
high1serum11glucose11levels
c. The11person11who11is11being11admitted11to11a
long-term11care11facility
d. The11person11who11is11beginning11rehabilitati
on1after11a11knee11replacement
ANSWER:11 D
An11episodic11or11follow-
up11assessment11is11performed11after11the11knee11replacement11to11evaluate11the11outcome11of1
1the11procedure.11A11shift11assessment11is11most11appropriate11for11the11person11who11is1recove
ring11in11the11hospital11from11surgery.11A11screening11assessment11is11performed11for11the11pur
pose11of11disease11detection,11in11this11case11diabetes11mellitus.11A11comprehensive11assessmen
t11is11performed11during11admission11to11a11facility11to11obtain11a11detailed11history11and11com
plete11physical1examination.
DIF:111111 Cognitive11Level:11Understand REF:11Box111-
311|11p.1131TOP:11Nursing11Process:11Assessment
