Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment ey ey ey ey ey
MULTIPLE CHOICE ey
1. A patient comes to the emergency department and tells the triage nurse that h
ey ey ey ey ey ey ey ey ey ey ey ey ey
eis “having a heart attack.” What is the nurse’s top priority at this time?
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
a. Determine the patient’s personal data andins ey ey ey ey ey ey
urance coverage. ey
b. Ask the patient to take a seat in the waitingr
ey ey ey ey ey ey ey ey ey ey
oom until his name is called. ey ey ey ey ey
c. Request that a nurse collect data for ey ey ey ey ey ey ey
acomprehensive history.
ey ey
d. Ask a nurse to start a focused assessmen
ey ey ey ey ey ey ey
tof this patient now.
ey ey ey ey
ANSWER: D ey
The nurse needs to begin an assessment as soon as possible that is focused on this patient’
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
scardiovascular system. The type of health assessment performed by the nurse is also drive
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
nby patient need. Personal data and insurance information will be obtained, but in this situ
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ation, these data can wait until after the patient is assessed. Based also on Maslow’s hierar
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
chy of needs, physiologic needs take precedence. Rather than asking the patient to wait, th
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
e nurse needs to begin data collection, such as vital signs, immediately to determinethe pat
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ient’s health status. Complications can be prevented if an immediate assessment is made t
ey ey ey ey ey ey ey ey ey ey ey ey ey
o analyze the patient’s symptoms. A comprehensive history is not indicated in this situation
ey ey ey ey ey ey ey ey ey ey ey ey ey e
yat this time. Some subjective data will be collected, such as allergies and medical history re
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
lated to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health
ey ey ey ey ey ey ey ey ey ey ey ey ey
assessment is not a priority at this time. ey ey ey ey ey ey ey
DIF: Cognitive Level: Apply
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
2. Which situation illustrates a screening assessment?
ey ey ey ey ey
a. A patient visits an obstetric clinic for the firs ey ey ey ey ey ey ey ey
t time and the nurse conducts a detailedhisto ey ey ey ey ey ey ey ey
ry and physical examination. ey ey ey
b. A hospital sponsors a health fair at a local ey ey ey ey ey ey ey ey ey
mall and provides cholesterol and blood ey ey ey ey ey ey
pressure checks to mall patrons. ey ey ey ey
c. The nurse in an urgent care center checks ey ey ey ey ey ey ey ey
the vital signs of a patient who is compla ey ey ey ey ey ey ey ey
ining of leg pain. ey ey ey
, d. A patient newly diagnosed with diabetes
ey ey ey ey ey ey
mellitus comes to test his fasting blood ey ey ey ey ey ey ey
glucose level. ey
ANSWER: B ey
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ple of a screening assessment focused on disease detection. A detailed history and physical
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
examination conducted during a first- ey ey ey ey
time visit to an obstetric clinic is an exampleof a comprehensive assessment. Assessing a pa
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
tient complaining of leg pain in the triage area of an urgent care center is an example of a
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
problem-
based/focused assessment. A patient’s return appointment 1 month after today’s office visi
ey ey ey ey ey ey ey ey ey ey ey
t to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
ey ey ey ey ey ey ey ey ey
3. For which person is a screening assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: B ey
A screening assessment is performed for the purpose of disease detection. In this case this
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
person may have diabetes mellitus. A shift assessment is most appropriate for the person
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
who is recovering in the hospital from surgery. A comprehensive assessment is performedd
ey ey ey ey ey ey ey ey ey ey ey ey ey
uring admission to a facility to obtain a detailed history and complete physical examinatio
ey ey ey ey ey ey ey ey ey ey ey ey ey
n. An episodic or follow-
ey ey ey ey
up assessment is performed after knee replacement toevaluate the outcome of the proced
ey ey ey ey ey ey ey ey ey ey ey ey ey
ure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
4. For which person is a shift assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitation ey ey ey ey ey ey
after a knee replacement ey ey ey
ANSWER: A ey
A shift assessment is most appropriate for the person who is recovering in the hospital from
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
surgery. A screening assessment is performed for the purpose of disease detection, in this c
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ase diabetes mellitus. A comprehensive assessment is performed during admission to a
ey ey ey ey ey ey ey ey ey ey ey
, facility to obtain a detailed history and complete physical examination. An episodic or fol
ey ey ey ey ey ey ey ey ey ey ey ey ey
low-
up assessment is performed after knee replacement to evaluate the outcome of theproce
ey ey ey ey ey ey ey ey ey ey ey ey ey
dure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 4TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
5. For which person is a comprehensive assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: C ey
A comprehensive assessment is performed during admission to a facility to obtain a
ey ey ey ey ey ey ey ey ey ey ey ey
detailed history and complete physical examination. A shift assessment is most appropriate
ey ey ey ey ey ey ey ey ey ey ey ey
for the person who is recovering in the hospital from surgery. A screening assessment is pe
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
rformed for the purpose of disease detection, in this case diabetes mellitus. An episodic or
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
follow-
up assessment is performed after knee replacement to evaluate the outcome of the proce
ey ey ey ey ey ey ey ey ey ey ey ey ey
dure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
6. For which person is an episodic or follow-up assessment indicated?
ey ey ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: D ey
An episodic or follow-
ey ey ey
up assessment is performed after the knee replacement to evaluate the outcome of the pr
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ocedure. A shift assessment is most appropriate for the person who isrecovering in the hos
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
pital from surgery. A screening assessment is performed for the purpose of disease detectio
ey ey ey ey ey ey ey ey ey ey ey ey ey
n, in this case diabetes mellitus. A comprehensive assessment is performed during admissio
ey ey ey ey ey ey ey ey ey ey ey ey
n to a facility to obtain a detailed history and complete physicalexamination.
ey ey ey ey ey ey ey ey ey ey ey ey
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment ey ey ey ey ey
MULTIPLE CHOICE ey
1. A patient comes to the emergency department and tells the triage nurse that h
ey ey ey ey ey ey ey ey ey ey ey ey ey
eis “having a heart attack.” What is the nurse’s top priority at this time?
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
a. Determine the patient’s personal data andins ey ey ey ey ey ey
urance coverage. ey
b. Ask the patient to take a seat in the waitingr
ey ey ey ey ey ey ey ey ey ey
oom until his name is called. ey ey ey ey ey
c. Request that a nurse collect data for ey ey ey ey ey ey ey
acomprehensive history.
ey ey
d. Ask a nurse to start a focused assessmen
ey ey ey ey ey ey ey
tof this patient now.
ey ey ey ey
ANSWER: D ey
The nurse needs to begin an assessment as soon as possible that is focused on this patient’
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
scardiovascular system. The type of health assessment performed by the nurse is also drive
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
nby patient need. Personal data and insurance information will be obtained, but in this situ
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ation, these data can wait until after the patient is assessed. Based also on Maslow’s hierar
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
chy of needs, physiologic needs take precedence. Rather than asking the patient to wait, th
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
e nurse needs to begin data collection, such as vital signs, immediately to determinethe pat
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ient’s health status. Complications can be prevented if an immediate assessment is made t
ey ey ey ey ey ey ey ey ey ey ey ey ey
o analyze the patient’s symptoms. A comprehensive history is not indicated in this situation
ey ey ey ey ey ey ey ey ey ey ey ey ey e
yat this time. Some subjective data will be collected, such as allergies and medical history re
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
lated to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health
ey ey ey ey ey ey ey ey ey ey ey ey ey
assessment is not a priority at this time. ey ey ey ey ey ey ey
DIF: Cognitive Level: Apply
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
2. Which situation illustrates a screening assessment?
ey ey ey ey ey
a. A patient visits an obstetric clinic for the firs ey ey ey ey ey ey ey ey
t time and the nurse conducts a detailedhisto ey ey ey ey ey ey ey ey
ry and physical examination. ey ey ey
b. A hospital sponsors a health fair at a local ey ey ey ey ey ey ey ey ey
mall and provides cholesterol and blood ey ey ey ey ey ey
pressure checks to mall patrons. ey ey ey ey
c. The nurse in an urgent care center checks ey ey ey ey ey ey ey ey
the vital signs of a patient who is compla ey ey ey ey ey ey ey ey
ining of leg pain. ey ey ey
, d. A patient newly diagnosed with diabetes
ey ey ey ey ey ey
mellitus comes to test his fasting blood ey ey ey ey ey ey ey
glucose level. ey
ANSWER: B ey
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ple of a screening assessment focused on disease detection. A detailed history and physical
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
examination conducted during a first- ey ey ey ey
time visit to an obstetric clinic is an exampleof a comprehensive assessment. Assessing a pa
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
tient complaining of leg pain in the triage area of an urgent care center is an example of a
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
problem-
based/focused assessment. A patient’s return appointment 1 month after today’s office visi
ey ey ey ey ey ey ey ey ey ey ey
t to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
ey ey ey ey ey ey ey ey ey
3. For which person is a screening assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: B ey
A screening assessment is performed for the purpose of disease detection. In this case this
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
person may have diabetes mellitus. A shift assessment is most appropriate for the person
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
who is recovering in the hospital from surgery. A comprehensive assessment is performedd
ey ey ey ey ey ey ey ey ey ey ey ey ey
uring admission to a facility to obtain a detailed history and complete physical examinatio
ey ey ey ey ey ey ey ey ey ey ey ey ey
n. An episodic or follow-
ey ey ey ey
up assessment is performed after knee replacement toevaluate the outcome of the proced
ey ey ey ey ey ey ey ey ey ey ey ey ey
ure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
4. For which person is a shift assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitation ey ey ey ey ey ey
after a knee replacement ey ey ey
ANSWER: A ey
A shift assessment is most appropriate for the person who is recovering in the hospital from
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
surgery. A screening assessment is performed for the purpose of disease detection, in this c
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ase diabetes mellitus. A comprehensive assessment is performed during admission to a
ey ey ey ey ey ey ey ey ey ey ey
, facility to obtain a detailed history and complete physical examination. An episodic or fol
ey ey ey ey ey ey ey ey ey ey ey ey ey
low-
up assessment is performed after knee replacement to evaluate the outcome of theproce
ey ey ey ey ey ey ey ey ey ey ey ey ey
dure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 4TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
5. For which person is a comprehensive assessment indicated?
ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: C ey
A comprehensive assessment is performed during admission to a facility to obtain a
ey ey ey ey ey ey ey ey ey ey ey ey
detailed history and complete physical examination. A shift assessment is most appropriate
ey ey ey ey ey ey ey ey ey ey ey ey
for the person who is recovering in the hospital from surgery. A screening assessment is pe
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
rformed for the purpose of disease detection, in this case diabetes mellitus. An episodic or
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
follow-
up assessment is performed after knee replacement to evaluate the outcome of the proce
ey ey ey ey ey ey ey ey ey ey ey ey ey
dure.
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
ey ey ey ey ey ey ey ey ey ey ey ey ey
Priorities
6. For which person is an episodic or follow-up assessment indicated?
ey ey ey ey ey ey ey ey ey
a. The person who had abdominal surgery ey ey ey ey ey ey
yesterday
b. The person who is unaware of his highs ey ey ey ey ey ey ey ey
erum glucose levels ey ey
c. The person who is being admitted to a ey ey ey ey ey ey ey
long-term care facility ey ey
d. The person who is beginning rehabilitationaf ey ey ey ey ey ey
ter a knee replacement ey ey ey
ANSWER: D ey
An episodic or follow-
ey ey ey
up assessment is performed after the knee replacement to evaluate the outcome of the pr
ey ey ey ey ey ey ey ey ey ey ey ey ey ey
ocedure. A shift assessment is most appropriate for the person who isrecovering in the hos
ey ey ey ey ey ey ey ey ey ey ey ey ey ey ey
pital from surgery. A screening assessment is performed for the purpose of disease detectio
ey ey ey ey ey ey ey ey ey ey ey ey ey
n, in this case diabetes mellitus. A comprehensive assessment is performed during admissio
ey ey ey ey ey ey ey ey ey ey ey ey
n to a facility to obtain a detailed history and complete physicalexamination.
ey ey ey ey ey ey ey ey ey ey ey ey
DIF: Cognitive Level: Understand
eyeye y REF: Box 1- ey ey ey ey
3 | p. 3TOP: Nursing Process: Assessment
ey ey ey ey ey ey ey
