, , , , , ,
rsing Practice 7th Edition by Wilson Chap
, , , , , ,
ter 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,ins
urance,coverage.
b. Ask,the,patient,to,take,a,seat,in,the,waiting,r
oom,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,drive
n,by,patient,need.,Personal,data,and,insurance,information,will,be,obtained,,but,in,this,situ
ation,,these,data,can,wait,until,after,the,patient,is,assessed.,Based,also,on,Maslow’s,hierar
chy,of,needs,,physiologic,needs,take,precedence.,Rather,than,asking,the,patient,to,wait,,th
e,nurse,needs,to,begin,data,collection,,such,as,vital,signs,,immediately,to,determine,the,pat
ient’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,r
elated,to,cardiovascular,disease.,Eyes,,ears,,or,a,complete,musculoskeletal,or,mental, healt
h,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:,Establis
hing,Priorities
2. Which,situation,illustrates,a, screening,assessment?
a. A,patient,visits,an,obstetric,clinic,for,the,fir
st,time,and,the,nurse,conducts,a,detailed,hist
ory,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,compla
ining,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,exam
ple,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,p
atient,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,visi
t,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,a
fter,a,knee,replacement
ANSWER:,B
A,screening,assessment,is,performed,for,the,purpose,of,disease,detection.,In,this,case,thi
s,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,performe
d,during,admission,to,a,facility,to,obtain,a,detailed,history,and,complete,physical,examin
ation.,An,episodic,or,follow-
up,assessment,is,performed,after,knee,replacement,to,evaluate,the,outcome,of,the,procedu
re.
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:,Establis
hing,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,fro
m,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,f
ollow-
up,assessment,is,performed,after,knee,replacement,to,evaluate,the,outcome,of,the,proced
ure.
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:,Establis
hing,Priorities
5. For,which,person,is,a,comprehensive,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,a
fter,a,knee,replacement
ANSWER:,C
A,comprehensive,assessment,is,performed,during,admission,to,a,facility,to,obtain,a
detailed,history,and,complete,physical,examination.,A,shift,assessment,is,most,appropriat
e,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.,An,episodic
,or,follow-
up,assessment,is,performed,after,knee,replacement,to,evaluate,the,outcome,of,the,proced
ure.
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:,Establis
hing,Priorities
6. For,which,person,is,an,episodic,or,follow-up,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,a
fter,a,knee,replacement
ANSWER:, D
An,episodic,or,follow-
up,assessment,is,performed,after,the,knee,replacement,to,evaluate,the,outcome,of,the,pro
cedure.,A,shift,assessment,is,most,appropriate,for,the,person,who,is,recovering,in,the,hosp
ital,from,surgery.,A,screening,assessment,is,performed,for,the,purpose,of,disease,detectio
n,,in,this,case,diabetes,mellitus.,A,comprehensive,assessment,is,performed,during,admissi
on,to,a,facility,to,obtain,a,detailed,history,and,complete,physical,examination.
DIF:,,, Cognitive,Level:,Understand REF:,Box,1-
3,|,p.,3,TOP:,Nursing,Process:,Assessment