,Chapter 01: Introduction to Health Assessment
d d d d d
Wilson: Health Assessment for Nursing Practice, 7th Edition
d d d d d d d
MULTIPLEdCHOICE
1. Adpatientdcomesdtodthedemergencyddepartmentdanddtellsdthedtriagednursedthatdhedisd“havingdadh
eartdattack.”dWhatdisdthednurse’sdtopdprioritydatdthisdtime?
a. Determinedthedpatient’sdpersonalddatadanddinsurancedcoverage.
b. Askdthedpatientdtodtakedadseatdindthedwaitingdroomduntildhisdnamedisdcalled.
c. Requestdthatdadnursedcollectddatadfordadcomprehensivedhistory.
d. Askdadnursedtodstartdadfocuseddassessmentdofdthisdpatientdnow.
ANS:d D
Thednursedneedsdtodbegindandassessmentdasdsoondasdpossibledthatdisdfocuseddondthisdpatient’sdcard
iovasculardsystem.dThedtypedofdhealthdassessmentdperformeddbydthednursedisdalsoddrivendbydpatie
ntdneed.dPersonalddatadanddinsurancedinformationdwilldbedobtained,dbutdindthisdsituation,dthesedda
tadcandwaitduntildafterdthedpatientdisdassessed.dBaseddalsodondMaslow’sdhierarchydofdneeds,dphysi
ologicdneedsdtakedprecedence.dRatherdthandaskingdthedpatientdtodwait,dthednursedneedsdtodbegindd
atadcollection,dsuchdasdvitaldsigns,dimmediatelydtoddeterminedthedpatient’sdhealthdstatus.dComplic
ationsdcandbedpreventeddifdandimmediatedassessmentdisdmadedtodanalyzedthedpatient’sdsymptoms.d
Adcomprehensivedhistorydisdnotdindicateddindthisdsituationdatdthisdtime.dSomedsubjectiveddatadwill
dbedcollected,dsuchdasdallergiesdanddmedicaldhistorydrelateddtodcardiovascularddisease.dEyes,dears,
dordadcompletedmusculoskeletaldordmentaldhealthdassessmentdisdnotdadprioritydatdthisdtime.
DIF: CognitivedLevel:dApply REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
2. Whichdsituationdillustratesdadscreeningdassessment?
a. Adpatientdvisitsdandobstetricdclinicdfordthedfirstdtimedanddthednursedconductsdadd
etaileddhistorydanddphysicaldexamination.
b. Adhospitaldsponsorsdadhealthdfairdatdadlocaldmalldanddprovidesdcholesteroldanddblooddp
ressuredchecksdtodmalldpatrons.
c. Thednursedindandurgentdcaredcenterdchecksdthedvitaldsignsdofdadpatientdwhodis
complainingdofdlegdpain.
d. Adpatientdnewlyddiagnoseddwithddiabetesdmellitusdcomesdtodtestdhisdfastingdbloodd
glucosedlevel.
ANS:d B
, Adhealthdfairdatdadlocaldmalldthatdprovidesdcholesteroldanddblooddpressuredchecksdisdandexampledo
fdadscreeningdassessmentdfocuseddonddiseaseddetection.dAddetaileddhistorydanddphysicaldexamina
tiondconducteddduringdadfirst-
timedvisitdtodandobstetricdclinicdisdandexampledofdadcomprehensivedassessment.dAssessingdadpatie
ntdcomplainingdofdlegdpaindindthedtriagedareadofdandurgentdcaredcenterdisdandexampledofdadproblem-
based/focuseddassessment.dAdpatient’sdreturndappointmentd1dmonthdafterdtoday’sdofficedvisitdtodr
eportdfastingdblooddglucosedlevelsdisdandexampledofdandepisodicdordfollow-updassessment.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dHealthdPromotiondanddMaintenance:dHealthdScreening
3. Fordwhichdpersondisdadscreeningdassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d B
Adscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection.dIndthisdcasedthisdpers
ondmaydhaveddiabetesdmellitus.dAdshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrec
overingdindthedhospitaldfromdsurgery.dAdcomprehensivedassessmentdisdperformeddduringdadmissi
ondtodadfacilitydtodobtaindaddetaileddhistorydanddcompletedphysicaldexamination.dAndepisodicdordf
ollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
4. Fordwhichdpersondisdadshiftdassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d A
Adshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrecoveringdindthedhospitaldfromdsur
gery.dAdscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection,dindthisdcaseddiab
etesdmellitus.dAdcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobtai
ndaddetaileddhistorydanddcompletedphysicaldexamination.dAndepisodicdordfollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d4dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
, 5. Fordwhichdpersondisdadcomprehensivedassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d C
Adcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobtaindaddetaileddhis
torydanddcompletedphysicaldexamination.dAdshiftdassessmentdisdmostdappropriatedfordthedpersond
whodisdrecoveringdindthedhospitaldfromdsurgery.dAdscreeningdassessmentdisdperformeddfordthedpu
rposedofddiseaseddetection,dindthisdcaseddiabetesdmellitus.dAndepisodicdordfollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
6. Fordwhichdpersondisdandepisodicdordfollow-updassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d D
Andepisodicdordfollow-
updassessmentdisdperformeddafterdthedkneedreplacementdtodevaluatedthedoutcomedofdthedprocedur
e.dAdshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrecoveringdindthedhospitaldfromds
urgery.dAdscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection,dindthisdcaseddi
abetesdmellitus.dAdcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobta
indaddetaileddhistorydanddcompletedphysicaldexamination.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
7. Whichdisdandexampledofddatadadnursedcollectsdduringdadphysicaldexamination?
a. Thedpatient’sdlackdofdhairdanddshinydskindoverdbothdshins
b. Thedpatient’sdstateddconcerndaboutdlackdofdmoneydfordprescriptions
c. Thedpatient’sdcomplaintsdofdtinglingdsensationsdindthedfeet
d. Thedpatient’sdmother’sdstatementsdthatdthedpatientdisdverydnervousdlately
ANS:d A
d d d d d
Wilson: Health Assessment for Nursing Practice, 7th Edition
d d d d d d d
MULTIPLEdCHOICE
1. Adpatientdcomesdtodthedemergencyddepartmentdanddtellsdthedtriagednursedthatdhedisd“havingdadh
eartdattack.”dWhatdisdthednurse’sdtopdprioritydatdthisdtime?
a. Determinedthedpatient’sdpersonalddatadanddinsurancedcoverage.
b. Askdthedpatientdtodtakedadseatdindthedwaitingdroomduntildhisdnamedisdcalled.
c. Requestdthatdadnursedcollectddatadfordadcomprehensivedhistory.
d. Askdadnursedtodstartdadfocuseddassessmentdofdthisdpatientdnow.
ANS:d D
Thednursedneedsdtodbegindandassessmentdasdsoondasdpossibledthatdisdfocuseddondthisdpatient’sdcard
iovasculardsystem.dThedtypedofdhealthdassessmentdperformeddbydthednursedisdalsoddrivendbydpatie
ntdneed.dPersonalddatadanddinsurancedinformationdwilldbedobtained,dbutdindthisdsituation,dthesedda
tadcandwaitduntildafterdthedpatientdisdassessed.dBaseddalsodondMaslow’sdhierarchydofdneeds,dphysi
ologicdneedsdtakedprecedence.dRatherdthandaskingdthedpatientdtodwait,dthednursedneedsdtodbegindd
atadcollection,dsuchdasdvitaldsigns,dimmediatelydtoddeterminedthedpatient’sdhealthdstatus.dComplic
ationsdcandbedpreventeddifdandimmediatedassessmentdisdmadedtodanalyzedthedpatient’sdsymptoms.d
Adcomprehensivedhistorydisdnotdindicateddindthisdsituationdatdthisdtime.dSomedsubjectiveddatadwill
dbedcollected,dsuchdasdallergiesdanddmedicaldhistorydrelateddtodcardiovascularddisease.dEyes,dears,
dordadcompletedmusculoskeletaldordmentaldhealthdassessmentdisdnotdadprioritydatdthisdtime.
DIF: CognitivedLevel:dApply REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
2. Whichdsituationdillustratesdadscreeningdassessment?
a. Adpatientdvisitsdandobstetricdclinicdfordthedfirstdtimedanddthednursedconductsdadd
etaileddhistorydanddphysicaldexamination.
b. Adhospitaldsponsorsdadhealthdfairdatdadlocaldmalldanddprovidesdcholesteroldanddblooddp
ressuredchecksdtodmalldpatrons.
c. Thednursedindandurgentdcaredcenterdchecksdthedvitaldsignsdofdadpatientdwhodis
complainingdofdlegdpain.
d. Adpatientdnewlyddiagnoseddwithddiabetesdmellitusdcomesdtodtestdhisdfastingdbloodd
glucosedlevel.
ANS:d B
, Adhealthdfairdatdadlocaldmalldthatdprovidesdcholesteroldanddblooddpressuredchecksdisdandexampledo
fdadscreeningdassessmentdfocuseddonddiseaseddetection.dAddetaileddhistorydanddphysicaldexamina
tiondconducteddduringdadfirst-
timedvisitdtodandobstetricdclinicdisdandexampledofdadcomprehensivedassessment.dAssessingdadpatie
ntdcomplainingdofdlegdpaindindthedtriagedareadofdandurgentdcaredcenterdisdandexampledofdadproblem-
based/focuseddassessment.dAdpatient’sdreturndappointmentd1dmonthdafterdtoday’sdofficedvisitdtodr
eportdfastingdblooddglucosedlevelsdisdandexampledofdandepisodicdordfollow-updassessment.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dHealthdPromotiondanddMaintenance:dHealthdScreening
3. Fordwhichdpersondisdadscreeningdassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d B
Adscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection.dIndthisdcasedthisdpers
ondmaydhaveddiabetesdmellitus.dAdshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrec
overingdindthedhospitaldfromdsurgery.dAdcomprehensivedassessmentdisdperformeddduringdadmissi
ondtodadfacilitydtodobtaindaddetaileddhistorydanddcompletedphysicaldexamination.dAndepisodicdordf
ollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
4. Fordwhichdpersondisdadshiftdassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d A
Adshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrecoveringdindthedhospitaldfromdsur
gery.dAdscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection,dindthisdcaseddiab
etesdmellitus.dAdcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobtai
ndaddetaileddhistorydanddcompletedphysicaldexamination.dAndepisodicdordfollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d4dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
, 5. Fordwhichdpersondisdadcomprehensivedassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d C
Adcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobtaindaddetaileddhis
torydanddcompletedphysicaldexamination.dAdshiftdassessmentdisdmostdappropriatedfordthedpersond
whodisdrecoveringdindthedhospitaldfromdsurgery.dAdscreeningdassessmentdisdperformeddfordthedpu
rposedofddiseaseddetection,dindthisdcaseddiabetesdmellitus.dAndepisodicdordfollow-
updassessmentdisdperformeddafterdkneedreplacementdtodevaluatedthedoutcomedofdthedprocedure.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
6. Fordwhichdpersondisdandepisodicdordfollow-updassessmentdindicated?
a. Thedpersondwhodhaddabdominaldsurgerydyesterday
b. Thedpersondwhodisdunawaredofdhisdhighdserumdglucosedlevels
c. Thedpersondwhodisdbeingdadmitteddtodadlong-termdcaredfacility
d. Thedpersondwhodisdbeginningdrehabilitationdafterdadkneedreplacement
ANS:d D
Andepisodicdordfollow-
updassessmentdisdperformeddafterdthedkneedreplacementdtodevaluatedthedoutcomedofdthedprocedur
e.dAdshiftdassessmentdisdmostdappropriatedfordthedpersondwhodisdrecoveringdindthedhospitaldfromds
urgery.dAdscreeningdassessmentdisdperformeddfordthedpurposedofddiseaseddetection,dindthisdcaseddi
abetesdmellitus.dAdcomprehensivedassessmentdisdperformeddduringdadmissiondtodadfacilitydtodobta
indaddetaileddhistorydanddcompletedphysicaldexamination.
DIF: CognitivedLevel:dUnderstand REF:dBoxd1-
3d|dp.d3dTOP:d NursingdProcess:dAssessment
MSC:d NCLEXdPatientdNeeds:dSafedanddEffectivedCaredEnvironment:dManagementdofdCare:dEstablishin
gdPriorities
7. Whichdisdandexampledofddatadadnursedcollectsdduringdadphysicaldexamination?
a. Thedpatient’sdlackdofdhairdanddshinydskindoverdbothdshins
b. Thedpatient’sdstateddconcerndaboutdlackdofdmoneydfordprescriptions
c. Thedpatient’sdcomplaintsdofdtinglingdsensationsdindthedfeet
d. Thedpatient’sdmother’sdstatementsdthatdthedpatientdisdverydnervousdlately
ANS:d A
