Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson

Test Bank for Health Assessment for Nursing Practice 7th Edition by Wilson`

,Chapter`01:`Introduction`to`Health`Assessment
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`ins
urance`coverage`
b` Ask`the`patient`to`take`a`seat`in`the`waiting`ro
om`until`his`name`is`called`
c` Request`that`a`nurse`collect`data`for`a`compre
hensive`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`c
ar
diovascular`system``The`type`of`health`assessment`performed`by`the`nurse`is`also`driven`by`p
a
tient`need``Personal`data`and`insurance`information`will`be`obtained,`but`in`this`situation,`the
s
e`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`
b
egin`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`
s
ymptoms``A`comprehensive`history`is`not`indicated`in`this`situation`at`this`time``Some`subjec
t
ive`data`will`be`collected,`such`as`allergies`and`medical`history`related`to`cardiovascular`dise
a
se``Eyes,`ears,`or`a`complete`musculoskeletal`or`mental`health`assessment`is`not`a`priority`at`t
h is`time`

DIF:` Cognitive`Level:`Apply REF:` Box`1-
3`|`p``3`TOP:`Nursing`Process:`Assessment
MSC:`NCLEX`Patient`Needs:`Safe`and`Effective`Care`Environment:`Management`of`Care:`Esta
bl ishing`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`ma
l
l`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`complaini
ng`of`leg`pain`
d` A`patient`newly`diagnosed`with`diabetes`mel
l itus`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`exami
nation`conducted`during`a`first-
time`visit`to`an`obstetric`clinic`is`an`example`of`a`comprehensive`assessment``Assessing`a`pati
ent`complaining`of`leg`pain`in`the`triage`area`of`an`urgent`care`center`is`an`example`of`a`probl
e m-
based/focused`assessment``A`patient‘s`return`appointment`1`month`after`today‘s`office`visit`t
o`report`fasting`blood`glucose`levels`is`an`example`of`an`episodic`or`follow-up`assessment`

DIF:` Cognitive`Level:`Understand REF:` Box`1-
3`|`p``3`TOP:`Nursing`Process:`Assessment
MSC:`NCLEX`Patient`Needs:`Health`Promotion`and`Maintenance:`Health`Screenin
g

3. For`which`person`is`a`screening`assessment`indicated?
a` The`person`who`had`abdominal`surgery`yeste
rday
b` The`person`who`is`unaware`of`his`high`seru
m`glucose`levels
c` The`person`who`is`being`admitted`to`a
`l ong-term`care`facility

d` The`person`who`is`beginning`rehabilitation`af
ter`a`knee`replacement
ANS:`B
A`screening`assessment`is`performed`for`the`purpose`of`disease`detection``In`this`case`this`per
s
on`may`have`diabetes`mellitus``A`shift`assessment`is`most`appropriate`for`the`person`who`is`re
covering`in`the`hospital`from`surgery``A`comprehensive`assessment`is`performed`during`admi
ssion`to`a`facility`to`obtain`a`detailed`history`and`complete`physical`examination``An`episodic`
or`follow-
up`assessment`is`performed`after`knee`replacement`to`evaluate`the`outcome`of`the`procedure`

DIF:` Cognitive`Level:`Understand REF:` Box`1-
3`|`p``3`TOP:`Nursing`Process:`Assessment
MSC:`NCLEX`Patient`Needs:`Safe`and`Effective`Care`Environment:`Management`of`Care:`Esta
bl ishing`Priorities

4. For`which`person`is`a`shift`assessment`indicated?

, a` The`person`who`had`abdominal`surgery`yeste
rday
b` The`person`who`is`unaware`of`his`high
serum`glucose`levels
c` The`person`who`is`being`admitted`to`a
`l ong-term`care`facility
d` The`person`who`is`beginning`rehabilitation`af
ter`a`knee`replacement
ANS:`A
A`shift`assessment`is`most`appropriate`for`the`person`who`is`recovering`in`the`hospital`from`s
u
rgery``A`screening`assessment`is`performed`for`the`purpose`of`disease`detection,`in`this`case`d
iabetes`mellitus``A`comprehensive`assessment`is`performed`during`admission`to`a