Test Bank for Health Assessment for
n n n n n
Nursing Practice 7th Edition by Wilson
n n n n n n
Chapter 1 - 24
n n n n
,Chapter 01: Introduction to Health Assessment n n n n n
MULTIPLE CHOICE n
1. Apatient comesto the emergencydepartment and tells the triage nurse that heis
n n n n n n n n n n n n n n
“havinga heart attack.” What isthe nurse’stop priorityat this time?
n n n n n n n n n n n n n
a. Determine the patient’s personal data and n n n n n
insurance coverage. n n
b. Ask the patient to take a seat in the waiting
n n n n n n n n n
room until his name is called.
n n n n n n
c. Request that a nurse collect data for a n n n n n n n
comprehensive history.
n n
d. Ask a nurse to start a focused assessmentof
n n n n n n n n
thispatient now.
n n n
ANSWER: D n
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
n n n n n n n n n n n n n n n n
cardiovascular system. The type of health assessment performed by the nurse is also drivenby
n n n n n n n n n n n n n n n
patient need. Personal data and insurance information will be obtained, but in this situation,
n n n n n n n n n n n n n n
these data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of
n n n n n n n n n n n n n n n n
needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
n n n n n n n n n n n n n n
needs to begin data collection, such as vital signs, immediately to determinethe patient’s health
n n n n n n n n n n n n n n n
status. Complications can be prevented if an immediate assessment is made to analyze the
n n n n n n n n n n n n n n
patient’s symptoms. A comprehensive history is not indicated in this situation at this time.
n n n n n n n n n n n n n n
Some subjective data will be collected, such as allergies and medical history related to
n n n n n n n n n n n n n n
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment
n n n n n n n n n n n n
is not a priorityat this time.
n n n n n n n
DIF: Cognitive Level: Apply
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
2. Which situation illustratesa screening assessment?
n n n n n
a. A patient visits an obstetric clinic for the first n n n n n n n n
time and the nurse conducts a detailedhistory n n n n n n n n
and physical examination. n n n
b. A hospital sponsorsa health fair at a local n n n n n n n n
mall and provides cholesterol and blood n n n n n n
pressure checks to mall patrons. n n n n n
c. The nurse in an urgent care center checks n n n n n n n
the vital signs of a patient who is n n n n n n n n
complainingof legpain. n n n n
, d. A patient newly diagnosed with diabetes
n n n n n
mellitus comes to test his fasting blood
n n n n n n n
glucose level.
n n
ANSWER: B n
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of
n n n n n n n n n n n n n n n n n
a screening assessment focused on disease detection. A detailed history and physical
n n n n n n n n n n n n
examination conducted during a first-time visit to an obstetric clinic is an exampleof a
n n n n n n n n n n n n n n n
comprehensive assessment. Assessing a patient complaining of leg pain in the triage area of an
n n n n n n n n n n n n n n n
urgent care center is an example of a problem-based/focused assessment. A patient’s return
n n n n n n n n n n n n n
appointment 1 month after today’s office visit to report fasting blood glucose levels is an
n n n n n n n n n n n n n n n
example of an episodic or follow-up assessment.
n n n n n n n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEXPatient Needs: HealthPromotion and Maintenance: Health Screening
n n n n n n n n n
3. For whichpersonis a screeningassessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh
n n n n n n n
serum glucose levels
n n n
c. The person who is being admitted to a
n n n n n n n
long-termcare facility
n n n
d. The person who is beginning rehabilitation
n n n n n
after a knee replacement
n n n n
ANSWER: B n
A screening assessment is performed for the purpose of disease detection. In this case this
n n n n n n n n n n n n n n
person may have diabetes mellitus. A shift assessment is most appropriate for the person who
n n n n n n n n n n n n n n n
is recovering in the hospital from surgery. A comprehensive assessment is performedduring
n n n n n n n n n n n n n
admission to a facility to obtain a detailed history and complete physical examination. An
n n n n n n n n n n n n n n
episodic or follow-up assessment is performed after knee replacement toevaluate the
n n n n n n n n n n n n
outcome of the procedure.
n n n n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
4. For whichperson isa shift assessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh n n n n n n n
serum glucose levels n n n
c. The person who isbeing admitted to a n n n n n n n
long-termcare facility n n
d. The person who isbeginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: A n
A shift assessment is most appropriate for the person who is recovering in the hospital from
n n n n n n n n n n n n n n n
surgery. A screening assessment is performed for the purpose of disease detection, in this case
n n n n n n n n n n n n n n n
diabetes mellitus. A comprehensive assessment isperformed duringadmission to a
n n n n n n n n n n n
, facility to obtain a detailed history and complete physical examination. An episodic or
n n n n n n n n n n n n
follow-up assessment isperformed after knee replacement to evaluate the outcome of the
n n n n n n n n n n n n n
procedure.
n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 4 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
5. For which personis a comprehensive assessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh n n n n n n n
serum glucose levels n n n
c. The person who is being admitted to a n n n n n n n
long-termcare facility n n n
d. The person who is beginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: C n
Acomprehensive assessment isperformed duringadmission to a facilityto obtain a
n n n n n n n n n n n n
detailed history and complete physical examination. A shift assessment is most appropriatefor
n n n n n n n n n n n n
the person who is recovering in the hospital from surgery. A screening assessment is
n n n n n n n n n n n n n n
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic or
n n n n n n n n n n n n n n n
follow-up assessment is performed after knee replacement to evaluate the outcome of the
n n n n n n n n n n n n n
procedure.
n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
6. For whichperson is anepisodic or follow-up assessment indicated?
n n n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who isunaware of his high n n n n n n n
serum glucose levels n n n
c. The person who isbeingadmitted to a n n n n n n n
long-termcare facility n n
d. The person who is beginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: D n
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
n n n n n n n n n n n n n
outcome of the procedure. A shift assessment is most appropriate for the person who is
n n n n n n n n n n n n n n n
recovering in the hospital from surgery. A screening assessment is performed for the purpose
n n n n n n n n n n n n n n
of disease detection, inthiscase diabetes mellitus. A comprehensive assessment is performed
n n n n n n n n n n n n n
during admission to a facility to obtain a detailed history and complete physicalexamination.
n n n n n n n n n n n n n n
DIF: Cognitive Level: Understand
nn n n n REF: Box 1-3 | p. 3 n n n n n
TOP: Nursing Process: Assessment
n n n n
n n n n n
Nursing Practice 7th Edition by Wilson
n n n n n n
Chapter 1 - 24
n n n n
,Chapter 01: Introduction to Health Assessment n n n n n
MULTIPLE CHOICE n
1. Apatient comesto the emergencydepartment and tells the triage nurse that heis
n n n n n n n n n n n n n n
“havinga heart attack.” What isthe nurse’stop priorityat this time?
n n n n n n n n n n n n n
a. Determine the patient’s personal data and n n n n n
insurance coverage. n n
b. Ask the patient to take a seat in the waiting
n n n n n n n n n
room until his name is called.
n n n n n n
c. Request that a nurse collect data for a n n n n n n n
comprehensive history.
n n
d. Ask a nurse to start a focused assessmentof
n n n n n n n n
thispatient now.
n n n
ANSWER: D n
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
n n n n n n n n n n n n n n n n
cardiovascular system. The type of health assessment performed by the nurse is also drivenby
n n n n n n n n n n n n n n n
patient need. Personal data and insurance information will be obtained, but in this situation,
n n n n n n n n n n n n n n
these data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of
n n n n n n n n n n n n n n n n
needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
n n n n n n n n n n n n n n
needs to begin data collection, such as vital signs, immediately to determinethe patient’s health
n n n n n n n n n n n n n n n
status. Complications can be prevented if an immediate assessment is made to analyze the
n n n n n n n n n n n n n n
patient’s symptoms. A comprehensive history is not indicated in this situation at this time.
n n n n n n n n n n n n n n
Some subjective data will be collected, such as allergies and medical history related to
n n n n n n n n n n n n n n
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment
n n n n n n n n n n n n
is not a priorityat this time.
n n n n n n n
DIF: Cognitive Level: Apply
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
2. Which situation illustratesa screening assessment?
n n n n n
a. A patient visits an obstetric clinic for the first n n n n n n n n
time and the nurse conducts a detailedhistory n n n n n n n n
and physical examination. n n n
b. A hospital sponsorsa health fair at a local n n n n n n n n
mall and provides cholesterol and blood n n n n n n
pressure checks to mall patrons. n n n n n
c. The nurse in an urgent care center checks n n n n n n n
the vital signs of a patient who is n n n n n n n n
complainingof legpain. n n n n
, d. A patient newly diagnosed with diabetes
n n n n n
mellitus comes to test his fasting blood
n n n n n n n
glucose level.
n n
ANSWER: B n
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of
n n n n n n n n n n n n n n n n n
a screening assessment focused on disease detection. A detailed history and physical
n n n n n n n n n n n n
examination conducted during a first-time visit to an obstetric clinic is an exampleof a
n n n n n n n n n n n n n n n
comprehensive assessment. Assessing a patient complaining of leg pain in the triage area of an
n n n n n n n n n n n n n n n
urgent care center is an example of a problem-based/focused assessment. A patient’s return
n n n n n n n n n n n n n
appointment 1 month after today’s office visit to report fasting blood glucose levels is an
n n n n n n n n n n n n n n n
example of an episodic or follow-up assessment.
n n n n n n n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEXPatient Needs: HealthPromotion and Maintenance: Health Screening
n n n n n n n n n
3. For whichpersonis a screeningassessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh
n n n n n n n
serum glucose levels
n n n
c. The person who is being admitted to a
n n n n n n n
long-termcare facility
n n n
d. The person who is beginning rehabilitation
n n n n n
after a knee replacement
n n n n
ANSWER: B n
A screening assessment is performed for the purpose of disease detection. In this case this
n n n n n n n n n n n n n n
person may have diabetes mellitus. A shift assessment is most appropriate for the person who
n n n n n n n n n n n n n n n
is recovering in the hospital from surgery. A comprehensive assessment is performedduring
n n n n n n n n n n n n n
admission to a facility to obtain a detailed history and complete physical examination. An
n n n n n n n n n n n n n n
episodic or follow-up assessment is performed after knee replacement toevaluate the
n n n n n n n n n n n n
outcome of the procedure.
n n n n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
4. For whichperson isa shift assessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh n n n n n n n
serum glucose levels n n n
c. The person who isbeing admitted to a n n n n n n n
long-termcare facility n n
d. The person who isbeginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: A n
A shift assessment is most appropriate for the person who is recovering in the hospital from
n n n n n n n n n n n n n n n
surgery. A screening assessment is performed for the purpose of disease detection, in this case
n n n n n n n n n n n n n n n
diabetes mellitus. A comprehensive assessment isperformed duringadmission to a
n n n n n n n n n n n
, facility to obtain a detailed history and complete physical examination. An episodic or
n n n n n n n n n n n n
follow-up assessment isperformed after knee replacement to evaluate the outcome of the
n n n n n n n n n n n n n
procedure.
n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 4 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
5. For which personis a comprehensive assessment indicated?
n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who is unaware of hishigh n n n n n n n
serum glucose levels n n n
c. The person who is being admitted to a n n n n n n n
long-termcare facility n n n
d. The person who is beginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: C n
Acomprehensive assessment isperformed duringadmission to a facilityto obtain a
n n n n n n n n n n n n
detailed history and complete physical examination. A shift assessment is most appropriatefor
n n n n n n n n n n n n
the person who is recovering in the hospital from surgery. A screening assessment is
n n n n n n n n n n n n n n
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic or
n n n n n n n n n n n n n n n
follow-up assessment is performed after knee replacement to evaluate the outcome of the
n n n n n n n n n n n n n
procedure.
n
DIF: Cognitive Level: Understand
nn n REF: Box 1-3 | p. 3 n n n n n n n
TOP: Nursing Process: Assessment
n n n n
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
n n n n n n n n n n n n
Priorities
n
6. For whichperson is anepisodic or follow-up assessment indicated?
n n n n n n n n n
a. The person who had abdominal surgery n n n n n
yesterday n
b. The person who isunaware of his high n n n n n n n
serum glucose levels n n n
c. The person who isbeingadmitted to a n n n n n n n
long-termcare facility n n
d. The person who is beginning rehabilitation n n n n n
after a knee replacement n n n n
ANSWER: D n
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
n n n n n n n n n n n n n
outcome of the procedure. A shift assessment is most appropriate for the person who is
n n n n n n n n n n n n n n n
recovering in the hospital from surgery. A screening assessment is performed for the purpose
n n n n n n n n n n n n n n
of disease detection, inthiscase diabetes mellitus. A comprehensive assessment is performed
n n n n n n n n n n n n n
during admission to a facility to obtain a detailed history and complete physicalexamination.
n n n n n n n n n n n n n n
DIF: Cognitive Level: Understand
nn n n n REF: Box 1-3 | p. 3 n n n n n
TOP: Nursing Process: Assessment
n n n n
