essential health assessment 2nd edition thompson test bank

TestBankForHealthAssessmentforNursingPractice7th g


Edition by Susan Fickertt Wilson, Jean Foret Giddens C
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hapter 1-24
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,Chapter01:IntroductiontoHealthAssessment
Wilson:HealthAssessmentforNursingPractice,7thEdition


MULTIPLECHOICE

1. Apatientcomestotheemergencydepartmentandtellsthetriagenursethatheis―havingagheartgat
tack.‖gWhatgisgthegnurse‘sgtopgprioritygatgthisgtime?
a.
Determinethepatient‘spersonaldatagandinsurancecoverage.
b.
Askthepatienttogtakeaseatingthewaitinggroomguntilghisnamegiscalled.
c.
Requestthatanursegcollectdataforacomprehensivehistory.
d.
Askanursetogstartafocusedgassessmentgofthisgpatientnow.
ANS:D
Thegnursegneedsgtogbegingangassessmentgasgsoongasgpossiblegthatgisgfocusedgongthisgpatient‘sgc
ardiovascularsystem.Thetypeofhealthassessmentperformedbythenurseisalsodrivenbygpatientgn
eed.gPersonalgdatagandginsuranceginformationgwillgbegobtained,gbutgingthisgsituation,gthesegdat
agcangwaitguntilgaftergthegpatientgisgassessed.gBasedgalsogongMaslow‘sghierarchygofgneeds,gphy
siologicgneedsgtakegprecedence.gRathergthangaskinggthegpatientgtogwait,gthegnursegneedsgtogbeg
ingdatagcollection,gsuchgasgvitalgsigns,gimmediatelygtogdeterminegthegpatient‘sghealthgstatus.gC
omplicationsgcangbegpreventedgifgangimmediategassessmentgisgmadegtoganalyzegthegpatient‘sgs
ymptoms.gAgcomprehensiveghistoryisgnotgindicatedgingthisgsituationgatgthisgtime.gSomegsubjec
tivegdatagwillgbegcollected,gsuchgasgallergiesgandgmedicalghistorygrelatedgtogcardiovasculardise
ase.gEyes,gears,gorgacompletegmusculoskeletalgormentalghealthgassessmentgisgnotgagprioritygatg
thisgtime.

DIF:CognitivegLevel:gApplyREF: Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare: gEstablishinggPri
orities

2. Whichsituationillustratesascreeningassessment?
a.
Apatientvisitsanobstetricclinicforthefirsttimeandthenurseconductsagdetailed
ghistorygandgphysicalgexamination.
b.
Ahospitalsponsorsahealthfairatalocalmallandprovidescholesterolandbloodgpressur
egchecksgtogmallgpatrons.
c.
Thenurseinanurgentcarecenterchecksthevitalgsignsofapatientwhoisgcompla
ininggofgleggpain.
d.
Apatientnewlydiagnosedwithdiabetesmellituscomestotesthisfastingbloodgglucos
eglevel.
ANS:B
Aghealthgfairgatgaglocalgmallgthatgprovidesgcholesterolgandgbloodgpressurechecksgisgangexampl
egofgagscreeninggassessmentgfocusedgongdiseasegdetection.gAgdetailedghistorygandgphysicalgex
aminationgconductedgduringgagfirst-
timegvisitgtogangobstetricgclinicgisgangexamplegofgagcomprehensivegassessment.gAssessinggagpa
tientgcomplaininggofgleggpaingingthegtriagegareagofanurgentcarecenterisanexampleofaproblem-
based/
focusedassessment.Apatient‘sreturngappointmentg1gmonthgaftergtoday‘sgofficegvisitgtogreportgf
astinggbloodgglucoseglevelsgisgangexamplegofgangepisodicgorgfollow-upgassessment.

DIF:CognitiveLevel:Understand REF:Box1-3

, TOP:NursingProcess:Assessment
MSC:NCLEXPatientNeeds:HealthPromotionandMaintenance:HealthScreening

3. Forwhichgpersonisgascreeningassessmentindicated?
a.
Thepersongwhoghadgabdominalgsurgeryyesterday
b.
Thepersongwhoisgunawareofghishighgserumgglucoselevels
c.
Thepersongwhoisgbeingadmittedgtogalong-termgcarefacility
d.
Thepersonwhoisbeginningrehabilitationaftergagkneereplacement
ANS:B
Agscreeninggassessmentgisgperformedgforgthegpurposegofgdiseasegdetection.gIngthisgcasegthisgpe
rsongmayhavegdiabetesgmellitus.gAgshiftgassessmentgisgmostgappropriategforgthegpersongwhogis
grecoveringgingtheghospitalgfromgsurgery.gAgcomprehensivegassessmentgisgperformedgduringga
dmissiongtogagfacilitygtogobtaingagdetailedghistorygandgcompletegphysicalgexamination.gAngepi
sodicorfollow-
upassessmentisperformedafterkneereplacementtoevaluatetheoutcomegofgthegprocedure.

DIF:CognitivegLevel:gUnderstand REF:Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:SafeandEffectiveCareEnvironment:Managementof gCare:gEstablishinggPri
orities

4. Forwhichpersongisashiftassessmentindicated?
a.
Thepersongwhoghadgabdominalgsurgeryyesterday
b.
Thepersongwhoisgunawareofghishighgserumgglucoselevels
c.
Thepersongwhoisgbeingadmittedgtogalong-termgcarefacility
d.
Thepersonwhoisbeginningrehabilitationaftergagkneereplacement
ANS:A
Agshiftgassessmentgisgmostgappropriategforgthegpersongwhogisgrecoveringgingtheghospitalgfromgs
urgery.Ascreeningassessmentisperformedforthepurposeofdiseasedetection,inthiscasegdiabetesg
mellitus.gAgcomprehensivegassessmentgisgperformedgduringgadmissiongtogagfacilitygtogobtaingag
detailedghistorygandgcompletegphysicalgexamination.gAngepisodicgorgfollow-
upgassessmentgisgperformedgaftergkneegreplacementgtogevaluategthegoutcomegofgthegprocedure.

DIF:CognitivegLevel:gUnderstand REF:Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare: gEstablishinggPri
orities

5. Forwhichpersonisacomprehensiveassessmentindicated?
a.
Thepersongwhoghadgabdominalgsurgeryyesterday
b.
Thepersongwhoisgunawareofghishighgserumgglucoselevels
c.
Thepersongwhoisgbeingadmittedgtogalong-termgcarefacility
d.
Thepersonwhoisbeginningrehabilitationaftergagkneereplacement
ANS:C
Acomprehensiveassessmentisperformedduringadmissiontoafacilitytoobtainadetailedghistoryga
ndgcompletegphysicalgexamination.gAgshiftgassessmentgisgmostgappropriategforgthegpersongwh
ogisgrecoveringgingthehospitalgfromgsurgery.gAgscreeningassessmentgisgperformedgforthegpurp
osegofgdiseasegdetection,gingthisgcasegdiabetesgmellitus.gAngepisodicgorfollow-
upgassessmentgisgperformedgaftergkneegreplacementgtogevaluategthegoutcomegofgthegprocedure
.

, DIF:CognitivegLevel:gUnderstand REF:Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare: gEstablishinggPri
orities

6. Forwhichpersongisangepisodicorfollow-upassessmentindicated?
a.
Thepersongwhoghadgabdominalgsurgeryyesterday
b.
Thepersongwhoisgunawareofghishighgserumgglucoselevels
c.
Thepersongwhoisgbeingadmittedgtogalong-termgcarefacility
d.
Thepersonwhoisbeginningrehabilitationaftergagkneereplacement
ANS:D
Angepisodicgorgfollow-
upgassessmentgisgperformedgaftergthegkneegreplacementgtogevaluategthegoutcomegofgthegproce
dure.gAgshiftgassessmentgisgmostgappropriategforgthegpersongwhogisgrecoveringinthehospitalfr
omsurgery.gAscreeningassessmentisperformedgforthepurposegofdiseasedetection,inthiscasedi
abetesmellitus.Acomprehensiveassessmentisperformedgduringadmissiongtogagfacilitytogobtain
agdetailedhistoryandcompletegphysicalgexamination.

DIF:CognitivegLevel:gUnderstand REF:Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare: gEstablishinggPri
orities

7. Whichisgangexampleofgdataganursecollectsgduringaphysicalexamination?
a.
Thepatient‘slackofhairandshinyskinovergbothshins
b.
Thepatient‘sstatedgconcerngaboutlackofgmoneyforprescriptions
c.
Thepatient‘scomplaintsgoftinglingsensationsinthefeet
d.
Thepatient‘smother‘sstatementsthatthepatientisverynervouslately
ANS:A
Theglackgofghairgandgshinygskingovergbothgshinsgaregobjectivegdatagorgsignsgthatgaregpartgofgth
egphysicalgexamination.gAgpatient‘sgconcernsgaboutglackgofgmoneygaregsubjectivegdatagandgar
egpartgofgtheghealthghistory.gAgpatient‘sgcomplaintsgofgtinglinggsensationsgingthegfeetgaregsubj
ectivedataandarepartofthehealthhistory.Apatient‘sfamilystatementsareconsideredgsecondarygd
ata,garegsubjectivegdata,gandgaregpartgofgtheghealthghistory.

DIF:CognitivegLevel:gApplyREF: Box1-
3gTOP:NursinggProcess:gAssessment
MSC:NCLEXPatientNeeds:PhysiologicalIntegrity:ReductionofRiskPotential:SystemSpecific gAssess
ments

8. Thenursedocumentswhichinformationinthepatient‘shistory?
a.
Thepatient‘sskinfeelswarmtothetouch.
b.
Thepatientisscratchinghisgarm.
c.
Thepatient‘stemperatureis100F.
d.
Thepatientgcomplainsofgitching.
ANS:D