Chapter 01: Introduction to Health Assessment
x& x& x& x& x&
,Wilson: Health Assessment for Nursing Practice, 8th Edition
x& x& x& x& x& x& x&
MULTIPLE CHOICE x&
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
a heart attack.‖ What is the nurse‘s top priority at this time?
x& x& x& x& x& x& x& x& x& x& x&
a. Determine the patient‘s personal data and insurance coverage. x& x& x& x& x& x& x&
b. Ask the patient to take a seat in the waiting room until his name is called.
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
c. Request that a nurse collect data for a comprehensive history.
x& x& x& x& x& x& x& x& x&
d. Ask a nurse to start a focused assessment of this patient now.
x& x& x& x& x& x& x& x& x& x& x&
ANS: D x &
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
cardiovascular system. The type of health assessment performed by the nurse is also driven
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
by patient need. Personal data and insurance information will be obtained, but in this situati
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
on, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
&of needs, physiologic needs take precedence. Rather than asking the patient to wait, the nur
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
se needs to begin data collection, such as vital signs, immediately to determine the patient‘s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
&health status. Complications can be prevented if an immediate assessment is made to analy
x& x& x& x& x& x& x& x& x& x& x& x& x&
ze the patient‘s symptoms. A comprehensive history is not indicated in this situation at this
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
time. Some subjective data will be collected, such as allergies and medical history related to
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessm
x& x& x& x& x& x& x& x& x& x& x& x&
ent is not a priority at this time.
x& x& x& x& x& x& x&
DIF:Cognitive Level: Apply REF: Box 1- x& x& x & x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities x&
2. Which situation illustrates a screening assessment?
x& x& x& x& x&
a. A patient visits an obstetric clinic for the first time and the nurse conducts
x& x& x& x& x& x& x& x& x& x& x& x& x& x
a detailed history and physical examination.
& x& x& x& x& x&
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
od pressure checks to mall patrons.
x& x& x& x& x&
c. The nurse in an urgent care center checks the vital signs of a patient who
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
is complaining of leg pain.
& x& x& x& x&
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
x& x& x& x& x& x& x& x& x& x& x& x&
d glucose level. x& x&
ANS: B x &
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
ple of a screening assessment focused on disease detection. A detailed history and physical
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
examination conducted during a first- x& x& x& x&
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
atient complaining of leg pain in the triage area of an urgent care center is an example of a
x& x& x& x& x& x& x& x& x& x & x& x& x& x& x& x& x& x& x
&problem-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
x& x& x& x& x& x& x& x& x& x& x& x&
to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Understand x& x& REF: Box 1-3 x& x&
, TOP:Nursing Process: Assessment x& x&
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x& x& x& x& x& x& x& x&
3. For which person is a screening assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: B x&
A screening assessment is performed for the purpose of disease detection. In this case this p
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
erson may have diabetes mellitus. A shift assessment is most appropriate for the person wh
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
o is recovering in the hospital from surgery. A comprehensive assessment is performed duri
x& x& x& x& x& x& x& x& x& x& x& x& x&
ng admission to a facility to obtain a detailed history and complete physical examination. A
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
n episodic or follow-
x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedure
x& x& x& x& x& x& x& x& x& x& x& x& x&
.
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
x& x& x& x& x& x& x& x& x& x& x&
hing Priorities x&
4. For which person is a shift assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: A x&
A shift assessment is most appropriate for the person who is recovering in the hospital from
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
surgery. A screening assessment is performed for the purpose of disease detection, in this cas
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
x& x& x& x& x& x& x& x& x& x& x& x& x
&to obtain a detailed history and complete physical examination. An episodic or follow-
x& x& x& x& x& x& x& x& x& x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedure
x& x& x& x& x& x& x& x& x& x& x& x& x&
.
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
5. For which person is a comprehensive assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: C x&
A comprehensive assessment is performed during admission to a facility to obtain a detailed
x& x& x& x& x& x& x& x& x& x& x& x& x&
history and complete physical examination. A shift assessment is most appropriate for the
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
person who is recovering in the hospital from surgery. A screening assessment is performe
x& x& x& x& x& x& x& x& x& x& x& x& x&
d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedur
x& x& x& x& x& x& x& x& x& x& x& x& x&
e.
, DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
6. For which person is an episodic or follow-up assessment indicated?
x& x& x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: D x&
An episodic or follow-
x& x& x&
up assessment is performed after the knee replacement to evaluate the outcome of the proc
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
edure. A shift assessment is most appropriate for the person who is recovering in the hospit
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
al from surgery. A screening assessment is performed for the purpose of disease detection, i
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
n this case diabetes mellitus. A comprehensive assessment is performed during admission to
x& x& x& x& x& x& x& x& x& x& x& x&
a facility to obtain a detailed history and complete physical examination.
x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
7. Which is an example of data a nurse collects during a physical examination?
x& x& x& x& x& x& x& x& x& x& x& x&
a. The patient‘s lack of hair and shiny skin over both shins
x& x& x& x& x& x& x& x& x& x&
b. The patient‘s stated concern about lack of money for prescriptions
x& x& x& x& x& x& x& x& x&
c. The patient‘s complaints of tingling sensations in the feet
x& x& x& x& x& x& x& x&
d. The patient‘s mother‘s statements that the patient is very nervous lately
x& x& x& x& x& x& x& x& x& x&
ANS: A x&
The lack of hair and shiny skin over both shins are objective data or signs that are part of t
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
he physical examination. A patient‘s concerns about lack of money are subjective data and
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
are part of the health history. A patient‘s complaints of tingling sensations in the feet are s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
ubjective data and are part of the health history. A patient‘s family statements are considere
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
d secondary data, are subjective data, and are part of the health history.
x& x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Apply REF: Box 1- x& x& x & x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
x& x& x& x& x& x& x& x& x& x& x&
Assessments
8. The nurse documents which information in the patient‘s history?
x& x& x& x& x& x& x& x&
a. The patient‘s skin feels warm to the touch.
x& x& x& x& x& x& x&
b. The patient is scratching his arm.
x& x& x& x& x&
c. The patient‘s temperature is 100 F.
x& x& x& x& x&
d. The patient complains of itching.
x& x& x& x&
ANS: D x&
x& x& x& x& x&
,Wilson: Health Assessment for Nursing Practice, 8th Edition
x& x& x& x& x& x& x&
MULTIPLE CHOICE x&
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
a heart attack.‖ What is the nurse‘s top priority at this time?
x& x& x& x& x& x& x& x& x& x& x&
a. Determine the patient‘s personal data and insurance coverage. x& x& x& x& x& x& x&
b. Ask the patient to take a seat in the waiting room until his name is called.
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
c. Request that a nurse collect data for a comprehensive history.
x& x& x& x& x& x& x& x& x&
d. Ask a nurse to start a focused assessment of this patient now.
x& x& x& x& x& x& x& x& x& x& x&
ANS: D x &
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
cardiovascular system. The type of health assessment performed by the nurse is also driven
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
by patient need. Personal data and insurance information will be obtained, but in this situati
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
on, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
&of needs, physiologic needs take precedence. Rather than asking the patient to wait, the nur
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
se needs to begin data collection, such as vital signs, immediately to determine the patient‘s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
&health status. Complications can be prevented if an immediate assessment is made to analy
x& x& x& x& x& x& x& x& x& x& x& x& x&
ze the patient‘s symptoms. A comprehensive history is not indicated in this situation at this
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
time. Some subjective data will be collected, such as allergies and medical history related to
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessm
x& x& x& x& x& x& x& x& x& x& x& x&
ent is not a priority at this time.
x& x& x& x& x& x& x&
DIF:Cognitive Level: Apply REF: Box 1- x& x& x & x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities x&
2. Which situation illustrates a screening assessment?
x& x& x& x& x&
a. A patient visits an obstetric clinic for the first time and the nurse conducts
x& x& x& x& x& x& x& x& x& x& x& x& x& x
a detailed history and physical examination.
& x& x& x& x& x&
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
od pressure checks to mall patrons.
x& x& x& x& x&
c. The nurse in an urgent care center checks the vital signs of a patient who
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x
is complaining of leg pain.
& x& x& x& x&
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
x& x& x& x& x& x& x& x& x& x& x& x&
d glucose level. x& x&
ANS: B x &
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
ple of a screening assessment focused on disease detection. A detailed history and physical
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
examination conducted during a first- x& x& x& x&
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
atient complaining of leg pain in the triage area of an urgent care center is an example of a
x& x& x& x& x& x& x& x& x& x & x& x& x& x& x& x& x& x& x
&problem-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
x& x& x& x& x& x& x& x& x& x& x& x&
to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Understand x& x& REF: Box 1-3 x& x&
, TOP:Nursing Process: Assessment x& x&
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x& x& x& x& x& x& x& x&
3. For which person is a screening assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: B x&
A screening assessment is performed for the purpose of disease detection. In this case this p
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
erson may have diabetes mellitus. A shift assessment is most appropriate for the person wh
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
o is recovering in the hospital from surgery. A comprehensive assessment is performed duri
x& x& x& x& x& x& x& x& x& x& x& x& x&
ng admission to a facility to obtain a detailed history and complete physical examination. A
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
n episodic or follow-
x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedure
x& x& x& x& x& x& x& x& x& x& x& x& x&
.
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
x& x& x& x& x& x& x& x& x& x& x&
hing Priorities x&
4. For which person is a shift assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: A x&
A shift assessment is most appropriate for the person who is recovering in the hospital from
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
surgery. A screening assessment is performed for the purpose of disease detection, in this cas
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
x& x& x& x& x& x& x& x& x& x& x& x& x
&to obtain a detailed history and complete physical examination. An episodic or follow-
x& x& x& x& x& x& x& x& x& x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedure
x& x& x& x& x& x& x& x& x& x& x& x& x&
.
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
5. For which person is a comprehensive assessment indicated?
x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: C x&
A comprehensive assessment is performed during admission to a facility to obtain a detailed
x& x& x& x& x& x& x& x& x& x& x& x& x&
history and complete physical examination. A shift assessment is most appropriate for the
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
person who is recovering in the hospital from surgery. A screening assessment is performe
x& x& x& x& x& x& x& x& x& x& x& x& x&
d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
up assessment is performed after knee replacement to evaluate the outcome of the procedur
x& x& x& x& x& x& x& x& x& x& x& x& x&
e.
, DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
6. For which person is an episodic or follow-up assessment indicated?
x& x& x& x& x& x& x& x& x&
a. The person who had abdominal surgery yesterday
x& x& x& x& x& x&
b. The person who is unaware of his high serum glucose levels
x& x& x& x& x& x& x& x& x& x&
c. The person who is being admitted to a long-term care facility
x& x& x& x& x& x& x& x& x& x&
d. The person who is beginning rehabilitation after a knee replacement
x& x& x& x& x& x& x& x& x&
ANS: D x&
An episodic or follow-
x& x& x&
up assessment is performed after the knee replacement to evaluate the outcome of the proc
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
edure. A shift assessment is most appropriate for the person who is recovering in the hospit
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
al from surgery. A screening assessment is performed for the purpose of disease detection, i
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
n this case diabetes mellitus. A comprehensive assessment is performed during admission to
x& x& x& x& x& x& x& x& x& x& x& x&
a facility to obtain a detailed history and complete physical examination.
x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Understand REF: Box 1- x& x& x& x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
x& x& x& x& x& x& x& x& x& x& x&
ing Priorities
x&
7. Which is an example of data a nurse collects during a physical examination?
x& x& x& x& x& x& x& x& x& x& x& x&
a. The patient‘s lack of hair and shiny skin over both shins
x& x& x& x& x& x& x& x& x& x&
b. The patient‘s stated concern about lack of money for prescriptions
x& x& x& x& x& x& x& x& x&
c. The patient‘s complaints of tingling sensations in the feet
x& x& x& x& x& x& x& x&
d. The patient‘s mother‘s statements that the patient is very nervous lately
x& x& x& x& x& x& x& x& x& x&
ANS: A x&
The lack of hair and shiny skin over both shins are objective data or signs that are part of t
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
he physical examination. A patient‘s concerns about lack of money are subjective data and
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
are part of the health history. A patient‘s complaints of tingling sensations in the feet are s
x& x& x& x& x& x& x& x& x& x& x& x& x& x& x& x&
ubjective data and are part of the health history. A patient‘s family statements are considere
x& x& x& x& x& x& x& x& x& x& x& x& x& x&
d secondary data, are subjective data, and are part of the health history.
x& x& x& x& x& x& x& x& x& x& x& x&
DIF:Cognitive Level: Apply REF: Box 1- x& x& x & x&
3 TOP:Nursing Process: Assessment
x& x& x&
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
x& x& x& x& x& x& x& x& x& x& x&
Assessments
8. The nurse documents which information in the patient‘s history?
x& x& x& x& x& x& x& x&
a. The patient‘s skin feels warm to the touch.
x& x& x& x& x& x& x&
b. The patient is scratching his arm.
x& x& x& x& x&
c. The patient‘s temperature is 100 F.
x& x& x& x& x&
d. The patient complains of itching.
x& x& x& x&
ANS: D x&
