Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,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
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.
ANSWER: 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 | p. 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.
ANSWER: 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 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person may have diabetes mellitus. A shift assessment is most appropriate for the person
who is recovering in the hospital from surgery. A comprehensive assessment is performed
during admission 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:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery. A screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. A comprehensive assessment is performed during admission 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. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For iwhich iperson iis ia icomprehensive iassessment iindicated?
a. The iperson iwho ihad iabdominal
isurgeryiyesterday
b. The iperson iwho iis iunaware iof ihis
ihighiserum iglucose ilevels
c. The iperson iwho iis ibeing iadmitted ito
iailong-term icare ifacility
d. The iperson iwho iis ibeginning
irehabilitationiafter ia iknee ireplacement
ANSWER: iC
A icomprehensive iassessment iis iperformed iduring iadmission ito ia ifacility ito iobtain ia
detailed ihistory iand icomplete iphysical iexamination. iA ishift iassessment iis imost
iappropriateifor ithe iperson iwho iis irecovering iin ithe ihospital ifrom isurgery. iA iscreening
iassessment iis iperformed ifor ithe ipurpose iof idisease idetection, iin ithis icase idiabetes
imellitus. iAn iepisodic ior ifollow-up iassessment iis iperformed iafter iknee ireplacement ito
ievaluate ithe ioutcome iof ithe iprocedure.
DIF: i i i Cognitive iLevel: iUnderstand REF: iBox i1-3 i| ip.
i3iTOP: iNursing iProcess: iAssessment
MSC: iNCLEX iPatient iNeeds: iSafe iand iEffective iCare iEnvironment: iManagement iof
iCare:iEstablishing iPriorities
6. For iwhich iperson iis ian iepisodic ior ifollow-up iassessment iindicated?
a. The iperson iwho ihad iabdominal
isurgeryiyesterday
b. The iperson iwho iis iunaware iof ihis
ihighiserum iglucose ilevels
c. The iperson iwho iis ibeing iadmitted ito ia
long-term icare ifacility
d. The iperson iwho iis ibeginning
irehabilitationiafter ia iknee ireplacement
ANSWER: i D
An iepisodic ior ifollow-up iassessment iis iperformed iafter ithe iknee ireplacement ito
ievaluate ithe ioutcome iof ithe iprocedure. iA ishift iassessment iis imost iappropriate ifor ithe
iperson iwho iisirecovering iin ithe ihospital ifrom isurgery. iA iscreening iassessment iis
iperformed ifor ithe ipurpose iof idisease idetection, iin ithis icase idiabetes imellitus. iA
icomprehensive iassessment iis iperformed iduring iadmission ito ia ifacility ito iobtain ia
idetailed ihistory iand icomplete iphysicaliexamination.
DIF: i i i Cognitive iLevel: iUnderstand REF: iBox i1-3 i| ip.
i3iTOP: iNursing iProcess: iAssessment
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,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
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.
ANSWER: 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 | p. 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.
ANSWER: 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 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person may have diabetes mellitus. A shift assessment is most appropriate for the person
who is recovering in the hospital from surgery. A comprehensive assessment is performed
during admission 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:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery. A screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. A comprehensive assessment is performed during admission 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. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For iwhich iperson iis ia icomprehensive iassessment iindicated?
a. The iperson iwho ihad iabdominal
isurgeryiyesterday
b. The iperson iwho iis iunaware iof ihis
ihighiserum iglucose ilevels
c. The iperson iwho iis ibeing iadmitted ito
iailong-term icare ifacility
d. The iperson iwho iis ibeginning
irehabilitationiafter ia iknee ireplacement
ANSWER: iC
A icomprehensive iassessment iis iperformed iduring iadmission ito ia ifacility ito iobtain ia
detailed ihistory iand icomplete iphysical iexamination. iA ishift iassessment iis imost
iappropriateifor ithe iperson iwho iis irecovering iin ithe ihospital ifrom isurgery. iA iscreening
iassessment iis iperformed ifor ithe ipurpose iof idisease idetection, iin ithis icase idiabetes
imellitus. iAn iepisodic ior ifollow-up iassessment iis iperformed iafter iknee ireplacement ito
ievaluate ithe ioutcome iof ithe iprocedure.
DIF: i i i Cognitive iLevel: iUnderstand REF: iBox i1-3 i| ip.
i3iTOP: iNursing iProcess: iAssessment
MSC: iNCLEX iPatient iNeeds: iSafe iand iEffective iCare iEnvironment: iManagement iof
iCare:iEstablishing iPriorities
6. For iwhich iperson iis ian iepisodic ior ifollow-up iassessment iindicated?
a. The iperson iwho ihad iabdominal
isurgeryiyesterday
b. The iperson iwho iis iunaware iof ihis
ihighiserum iglucose ilevels
c. The iperson iwho iis ibeing iadmitted ito ia
long-term icare ifacility
d. The iperson iwho iis ibeginning
irehabilitationiafter ia iknee ireplacement
ANSWER: i D
An iepisodic ior ifollow-up iassessment iis iperformed iafter ithe iknee ireplacement ito
ievaluate ithe ioutcome iof ithe iprocedure. iA ishift iassessment iis imost iappropriate ifor ithe
iperson iwho iisirecovering iin ithe ihospital ifrom isurgery. iA iscreening iassessment iis
iperformed ifor ithe ipurpose iof idisease idetection, iin ithis icase idiabetes imellitus. iA
icomprehensive iassessment iis iperformed iduring iadmission ito ia ifacility ito iobtain ia
idetailed ihistory iand icomplete iphysicaliexamination.
DIF: i i i Cognitive iLevel: iUnderstand REF: iBox i1-3 i| ip.
i3iTOP: iNursing iProcess: iAssessment
