TEST BANK
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Health Assessment for Nursing Practice
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7th Edition by Wilson Chapter 1 - 24
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,TABLE OF CONTENTS hg hg hg
Unit I: Foundations for Health Assessment
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1. Introduction to Health Assessment
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2. Interviewing Patients to Obtain a Health History
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3. Techniques and Equipment for Physical Assessment
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4. General Inspection and Measurement of Vital Signs
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5. Ethnic, Cultural, and Spiritual Considerations
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6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
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8. Nutritional Assessment
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Unit II: Health Assessment of the Adult
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9. Skin, Hair, and Nails
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10. Head, Eyes, Ears, Nose, and Throat
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11. Lungs and Respiratory System
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12. Heart and Peripheral Vascular System
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13. Abdomen and Gastrointestinal System
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14. Musculoskeletal System
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15. Neurologic System
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16. Breasts and Axillae
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17. Reproductive System and the Perineum
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Unit III: Health Assessment Across the Life Span
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18. Developmental Assessment Throughout the Life Span
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19. Assessment of the Infant, Child, and Adolescent
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20. Assessment of the Pregnant Patient
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21. Assessment of the Older Adult
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Unit IV: Synthesis and Application of Health Assessment
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22. Conducting a Head-to-Toe Examination
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23. Documenting the Head-to-Toe Health Assessment
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24. Adapting Health Assessment
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Chapter 01: Introduction to Health Assessment
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,MULTIPLE CHOICE hg
1. A patient comes to the emergency department and tells the triage nurse that
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hg heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
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a. Determine the patient‘s personal data hg hg hg hg
andinsurance coverage. hg hg hg
b. Ask the patient to take a seat in the
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waitingroom until his name is called.
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c. Request that a nurse collect data for hg hg hg hg hg hg
acomprehensive history.
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d. Ask a nurse to start a focused
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assessmentof this patient now.
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ANSWER: D hg
The nurse needs to begin an assessment as soon as possible that is focused on this
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patient‘scardiovascular system. The type of health assessment performed by the nurse is
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also drivenby patient need. Personal data and insurance information will be obtained,
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but in this situation, these data can wait until after the patient is assessed. Based also on
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Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the
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patient to wait, the nurse needs to begin data collection, such as vital signs, immediately
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to determinethe patient‘s health status. Complications can be prevented if an immediate
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assessment is made to analyze the patient‘s symptoms. A comprehensive history is not
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indicated in this situation at this time. Some subjective data will be collected, such as
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allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete
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musculoskeletal or mental health assessment is not a priority at this time.
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DIF: Cognitive Level: Apply
hg hg h g REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
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Priorities
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2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the hg hg hg hg hg hg hg
first time and the nurse conducts a hg hg hg hg hg hg hg
detailedhistory and physical examination. hg hg hg hg hg
b. A hospital sponsors a health fair at a
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localmall and provides cholesterol and
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blood pressure checks to mall patrons.
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c. The nurse in an urgent care center
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checksthe vital signs of a patient who is
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complaining of leg pain.
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, d. A patient newly diagnosed with
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diabetesmellitus comes to test his
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fasting blood glucose level.
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ANSWER: B hg
A health fair at a local mall that provides cholesterol and blood pressure checks is an
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example of a screening assessment focused on disease detection. A detailed history and
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physical examination conducted during a first-time visit to an obstetric clinic is an
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exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
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the triage area of an urgent care center is an example of a problem-based/focused
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assessment. A patient‘s return appointment 1 month after today‘s office visit to report
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fasting blood glucose levels is an example of an episodic or follow-up assessment.
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DIF: Cognitive Level: Understand
hg hg hg REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal hg hg hg hg
surgeryyesterday hg hg
b. The person who is unaware of his
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highserum glucose levels
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c. The person who is being admitted to
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along-term care facility
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d. The person who is beginning
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rehabilitationafter a knee replacement
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ANSWER: B hg
A screening assessment is performed for the purpose of disease detection. In this case
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thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
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person who is recovering in the hospital from surgery. A comprehensive assessment is
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performedduring admission to a facility to obtain a detailed history and complete
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physical examination. An episodic or follow-up assessment is performed after knee
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replacement toevaluate the outcome of the procedure.
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DIF: Cognitive Level: Understand
hg hg hg REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
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Priorities
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4. For which person is a shift assessment indicated?
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a. The person who had abdominal hg hg hg hg
surgeryyesterday hg hg
b. The person who is unaware of his hg hg hg hg hg hg
highserum glucose levels hg hg hg hg
c. The person who is being admitted to a hg hg hg hg hg hg hg
long-term care facility hg hg
d. The person who is beginning hg hg hg hg
rehabilitationafter a knee replacement hg hg hg hg hg
ANSWER: A hg
A shift assessment is most appropriate for the person who is recovering in the hospital
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fromsurgery. A screening assessment is performed for the purpose of disease detection, in
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this case diabetes mellitus. A comprehensive assessment is performed during admission to a
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hg
Health Assessment for Nursing Practice
hg hg hg hg hg
7th Edition by Wilson Chapter 1 - 24
hg hg hg hg hg hg hg
,TABLE OF CONTENTS hg hg hg
Unit I: Foundations for Health Assessment
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1. Introduction to Health Assessment
hg hg hg hg
2. Interviewing Patients to Obtain a Health History
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3. Techniques and Equipment for Physical Assessment
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4. General Inspection and Measurement of Vital Signs
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5. Ethnic, Cultural, and Spiritual Considerations
hg hg hg hg hg
6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
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8. Nutritional Assessment
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Unit II: Health Assessment of the Adult
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9. Skin, Hair, and Nails
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10. Head, Eyes, Ears, Nose, and Throat
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11. Lungs and Respiratory System
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12. Heart and Peripheral Vascular System
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13. Abdomen and Gastrointestinal System
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14. Musculoskeletal System
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15. Neurologic System
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16. Breasts and Axillae
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17. Reproductive System and the Perineum
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Unit III: Health Assessment Across the Life Span
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18. Developmental Assessment Throughout the Life Span
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19. Assessment of the Infant, Child, and Adolescent
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20. Assessment of the Pregnant Patient
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21. Assessment of the Older Adult
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Unit IV: Synthesis and Application of Health Assessment
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22. Conducting a Head-to-Toe Examination
hg hg hg hg
23. Documenting the Head-to-Toe Health Assessment
hg hg hg hg hg
24. Adapting Health Assessment
hg hg hg
Chapter 01: Introduction to Health Assessment
hg hg hg hg hg
,MULTIPLE CHOICE hg
1. A patient comes to the emergency department and tells the triage nurse that
hg hg hg hg hg hg hg hg hg hg hg hg
hg heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
hg hg hg hg hg hg hg hg hg hg hg hg hg hg
a. Determine the patient‘s personal data hg hg hg hg
andinsurance coverage. hg hg hg
b. Ask the patient to take a seat in the
hg hg hg hg hg hg hg hg
waitingroom until his name is called.
hg hg hg hg hg hg hg
c. Request that a nurse collect data for hg hg hg hg hg hg
acomprehensive history.
hg hg hg
d. Ask a nurse to start a focused
hg hg hg hg hg hg
assessmentof this patient now.
hg hg hg hg hg
ANSWER: D hg
The nurse needs to begin an assessment as soon as possible that is focused on this
hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg
patient‘scardiovascular system. The type of health assessment performed by the nurse is
hg hg hg hg hg hg hg hg hg hg hg hg hg
also drivenby patient need. Personal data and insurance information will be obtained,
hg hg hg hg hg hg hg hg hg hg hg hg hg
but in this situation, these data can wait until after the patient is assessed. Based also on
hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg
Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the
hg hg hg hg hg hg hg hg hg hg hg hg
patient to wait, the nurse needs to begin data collection, such as vital signs, immediately
hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg
to determinethe patient‘s health status. Complications can be prevented if an immediate
hg hg hg hg hg hg hg hg hg hg hg hg hg
assessment is made to analyze the patient‘s symptoms. A comprehensive history is not
hg hg hg hg hg hg hg hg hg hg hg hg hg
indicated in this situation at this time. Some subjective data will be collected, such as
hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg
allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete
hg hg hg hg hg hg hg hg hg hg hg hg hg
musculoskeletal or mental health assessment is not a priority at this time.
hg hg hg hg hg hg hg hg hg hg hg hg
DIF: Cognitive Level: Apply
hg hg h g REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
hg hg hg hg hg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
hg hg hg hg hg hg hg hg hg hg hg hg
Priorities
hg
2. Which situation illustrates a screening assessment?
hg hg hg hg hg
a. A patient visits an obstetric clinic for the hg hg hg hg hg hg hg
first time and the nurse conducts a hg hg hg hg hg hg hg
detailedhistory and physical examination. hg hg hg hg hg
b. A hospital sponsors a health fair at a
hg hg hg hg hg hg hg
localmall and provides cholesterol and
hg hg hg hg hg hg
blood pressure checks to mall patrons.
hg hg hg hg hg hg
c. The nurse in an urgent care center
hg hg hg hg hg hg
checksthe vital signs of a patient who is
hg hg hg hg hg hg hg hg hg
complaining of leg pain.
hg hg hg hg
, d. A patient newly diagnosed with
hg hg hg hg
diabetesmellitus comes to test his
hg hg hg hg hg hg
fasting blood glucose level.
hg hg hg hg
ANSWER: B hg
A health fair at a local mall that provides cholesterol and blood pressure checks is an
hg hg hg hg hg hg hg hg hg hg hg hg hg hg hg
example of a screening assessment focused on disease detection. A detailed history and
hg hg hg hg hg hg hg hg hg hg hg hg hg
physical examination conducted during a first-time visit to an obstetric clinic is an
hg hg hg hg hg hg hg hg hg hg hg hg hg
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
hg hg hg hg hg hg hg hg hg hg hg hg hg
the triage area of an urgent care center is an example of a problem-based/focused
hg hg hg hg hg hg hg hg hg hg hg hg hg hg
assessment. A patient‘s return appointment 1 month after today‘s office visit to report
hg hg hg hg hg hg hg hg hg hg hg hg hg
fasting blood glucose levels is an example of an episodic or follow-up assessment.
hg hg hg hg hg hg hg hg hg hg hg hg hg
DIF: Cognitive Level: Understand
hg hg hg REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
hg hg hg hg hg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
hg hg hg hg hg hg hg hg hg
3. For which person is a screening assessment indicated?
hg hg hg hg hg hg hg
a. The person who had abdominal hg hg hg hg
surgeryyesterday hg hg
b. The person who is unaware of his
hg hg hg hg hg hg
highserum glucose levels
hg hg hg hg
c. The person who is being admitted to
hg hg hg hg hg hg
along-term care facility
hg hg hg hg
d. The person who is beginning
hg hg hg hg
rehabilitationafter a knee replacement
hg hg hg hg hg
ANSWER: B hg
A screening assessment is performed for the purpose of disease detection. In this case
hg hg hg hg hg hg hg hg hg hg hg hg hg
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
hg hg hg hg hg hg hg hg hg hg hg hg hg hg
person who is recovering in the hospital from surgery. A comprehensive assessment is
hg hg hg hg hg hg hg hg hg hg hg hg hg
performedduring admission to a facility to obtain a detailed history and complete
hg hg hg hg hg hg hg hg hg hg hg hg hg
physical examination. An episodic or follow-up assessment is performed after knee
hg hg hg hg hg hg hg hg hg hg hg
replacement toevaluate the outcome of the procedure.
hg hg hg hg hg hg hg hg
DIF: Cognitive Level: Understand
hg hg hg REF: Box 1-3 | p. hg hg hg hg hg hg
3TOP: Nursing Process: Assessment
hg hg hg hg hg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
hg hg hg hg hg hg hg hg hg hg hg hg
Priorities
hg
4. For which person is a shift assessment indicated?
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a. The person who had abdominal hg hg hg hg
surgeryyesterday hg hg
b. The person who is unaware of his hg hg hg hg hg hg
highserum glucose levels hg hg hg hg
c. The person who is being admitted to a hg hg hg hg hg hg hg
long-term care facility hg hg
d. The person who is beginning hg hg hg hg
rehabilitationafter a knee replacement hg hg hg hg hg
ANSWER: A hg
A shift assessment is most appropriate for the person who is recovering in the hospital
hg hg hg hg hg hg hg hg hg hg hg hg hg hg
fromsurgery. A screening assessment is performed for the purpose of disease detection, in
hg hg hg hg hg hg hg hg hg hg hg hg hg hg
this case diabetes mellitus. A comprehensive assessment is performed during admission to a
hg hg hg hg hg hg hg hg hg hg hg hg hg
