,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 7th Edition
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MULTIPLE CHOICE r1
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
heart attack.‖ What is the nurse‘s top priority at this time?
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a. Determine the patient‘s personal data and insurance coverage. r1 r1 r1 r1 r1 r1 r1
b. Ask the patient to take a seat in the waiting room until his name is called.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. Request that a nurse collect data for a comprehensive history.
r1 r1 r1 r1 r1 r1 r1 r1 r1
d. Ask a nurse to start a focused assessment of this patient now.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: D r 1
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s c
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ardiovascular system. The type of health assessment performed by the nurse is also driven by
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
patient need. Personal data and insurance information will be obtained, but in this situation, t
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
hese data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy of ne
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
eds, physiologic needs take precedence. Rather than asking the patient to wait, the nurse need
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s to begin data collection, such as vital signs, immediately to determine the patient‘s health st
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
atus. Complications can be prevented if an immediate assessment is made to analyze the pati
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ent‘s symptoms. A comprehensive history is not indicated in this situation at this time. Some
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
subjective data will be collected, such as allergies and medical history related to cardiovascul
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ar disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a pri
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ority at this time. r1 r1 r1
DIF:Cognitive Level: Apply REF: Box 1- r1 r1 r 1 r1
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
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ng Priorities
r1
2. Which situation illustrates a screening assessment?
r1 r1 r1 r1 r1
a. A patient visits an obstetric clinic for the first time and the nurse conducts
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
a detailed history and physical examination.
r1 r1 r1 r1 r1
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
pressure checks to mall patrons.
r1 r1 r1 r1 r1
c. The nurse in an urgent care center checks the vital signs of a patient who i
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
glucose level.
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ANS: B r 1
A health fair at a local mall that provides cholesterol and blood pressure checks is an exampl
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
e of a screening assessment focused on disease detection. A detailed history and physical exa
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
mination conducted during a first- r1 r1 r1 r1
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a pa
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
tient complaining of leg pain in the triage area of an urgent care center is an example of a pr
r1 r1 r1 r1 r1 r1 r1 r1 r1 r 1 r1 r1 r1 r1 r1 r1 r1 r1 r1
oblem-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit t
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
o report fasting blood glucose levels is an example of an episodic or follow-up assessment.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand r1 r1 REF: Box 1-3 r1 r1
, TOP:Nursing Process: Assessment r1 r1
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
r1 r1 r1 r1 r1 r1 r1 r1
3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: B r1
A screening assessment is performed for the purpose of disease detection. In this case this pe
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rson may have diabetes mellitus. A shift assessment is most appropriate for the person who is
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
recovering in the hospital from surgery. A comprehensive assessment is performed during a
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
dmission to a facility to obtain a detailed history and complete physical examination. An epis
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
odic or follow- r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
4. For which person is a shift assessment indicated?
r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: A r1
A shift assessment is most appropriate for the person who is recovering in the hospital from s
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
urgery. A screening assessment is performed for the purpose of disease detection, in this case
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
diabetes mellitus. A comprehensive assessment is performed during admission to a facility to
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
obtain a detailed history and complete physical examination. An episodic or follow-
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
5. For which person is a comprehensive assessment indicated?
r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: C r1
A comprehensive assessment is performed during admission to a facility to obtain a detailed
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
history and complete physical examination. A shift assessment is most appropriate for the pe
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rson who is recovering in the hospital from surgery. A screening assessment is performed fo
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
r the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
.
, DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
6. For which person is an episodic or follow-up assessment indicated?
r1 r1 r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: D r1
An episodic or follow-
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up assessment is performed after the knee replacement to evaluate the outcome of the proced
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ure. A shift assessment is most appropriate for the person who is recovering in the hospital f
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rom surgery. A screening assessment is performed for the purpose of disease detection, in thi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s case diabetes mellitus. A comprehensive assessment is performed during admission to a fac
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ility to obtain a detailed history and complete physical examination.
r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A r1
The lack of hair and shiny skin over both shins are objective data or signs that are part of th
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e physical examination. A patient‘s concerns about lack of money are subjective data and ar
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e part of the health history. A patient‘s complaints of tingling sensations in the feet are subje
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ctive data and are part of the health history. A patient‘s family statements are considered sec
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ondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- r1 r1 r 1 r1
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.r1 r1 r1 r1 r1
c. The patient‘s temperature is 100 F.
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d. The patient complains of itching. r1 r1 r1 r1
ANS: D r1
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Wilson: Health Assessment for Nursing Practice, 7th Edition
r1 r1 r1 r1 r1 r1 r1
MULTIPLE CHOICE r1
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
heart attack.‖ What is the nurse‘s top priority at this time?
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
a. Determine the patient‘s personal data and insurance coverage. r1 r1 r1 r1 r1 r1 r1
b. Ask the patient to take a seat in the waiting room until his name is called.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. Request that a nurse collect data for a comprehensive history.
r1 r1 r1 r1 r1 r1 r1 r1 r1
d. Ask a nurse to start a focused assessment of this patient now.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: D r 1
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s c
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ardiovascular system. The type of health assessment performed by the nurse is also driven by
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
patient need. Personal data and insurance information will be obtained, but in this situation, t
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
hese data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy of ne
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
eds, physiologic needs take precedence. Rather than asking the patient to wait, the nurse need
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s to begin data collection, such as vital signs, immediately to determine the patient‘s health st
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
atus. Complications can be prevented if an immediate assessment is made to analyze the pati
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ent‘s symptoms. A comprehensive history is not indicated in this situation at this time. Some
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
subjective data will be collected, such as allergies and medical history related to cardiovascul
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ar disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a pri
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ority at this time. r1 r1 r1
DIF:Cognitive Level: Apply REF: Box 1- r1 r1 r 1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
2. Which situation illustrates a screening assessment?
r1 r1 r1 r1 r1
a. A patient visits an obstetric clinic for the first time and the nurse conducts
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
a detailed history and physical examination.
r1 r1 r1 r1 r1
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
pressure checks to mall patrons.
r1 r1 r1 r1 r1
c. The nurse in an urgent care center checks the vital signs of a patient who i
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s complaining of leg pain.
r1 r1 r1 r1
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
glucose level.
r1 r1
ANS: B r 1
A health fair at a local mall that provides cholesterol and blood pressure checks is an exampl
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
e of a screening assessment focused on disease detection. A detailed history and physical exa
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
mination conducted during a first- r1 r1 r1 r1
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a pa
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
tient complaining of leg pain in the triage area of an urgent care center is an example of a pr
r1 r1 r1 r1 r1 r1 r1 r1 r1 r 1 r1 r1 r1 r1 r1 r1 r1 r1 r1
oblem-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit t
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
o report fasting blood glucose levels is an example of an episodic or follow-up assessment.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand r1 r1 REF: Box 1-3 r1 r1
, TOP:Nursing Process: Assessment r1 r1
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
r1 r1 r1 r1 r1 r1 r1 r1
3. For which person is a screening assessment indicated?
r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: B r1
A screening assessment is performed for the purpose of disease detection. In this case this pe
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rson may have diabetes mellitus. A shift assessment is most appropriate for the person who is
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
recovering in the hospital from surgery. A comprehensive assessment is performed during a
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
dmission to a facility to obtain a detailed history and complete physical examination. An epis
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
odic or follow- r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
4. For which person is a shift assessment indicated?
r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: A r1
A shift assessment is most appropriate for the person who is recovering in the hospital from s
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
urgery. A screening assessment is performed for the purpose of disease detection, in this case
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
diabetes mellitus. A comprehensive assessment is performed during admission to a facility to
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
obtain a detailed history and complete physical examination. An episodic or follow-
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
5. For which person is a comprehensive assessment indicated?
r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: C r1
A comprehensive assessment is performed during admission to a facility to obtain a detailed
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
history and complete physical examination. A shift assessment is most appropriate for the pe
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rson who is recovering in the hospital from surgery. A screening assessment is performed fo
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
r the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
up assessment is performed after knee replacement to evaluate the outcome of the procedure
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
.
, DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
6. For which person is an episodic or follow-up assessment indicated?
r1 r1 r1 r1 r1 r1 r1 r1 r1
a. The person who had abdominal surgery yesterday
r1 r1 r1 r1 r1 r1
b. The person who is unaware of his high serum glucose levels
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
c. The person who is being admitted to a long-term care facility
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
d. The person who is beginning rehabilitation after a knee replacement
r1 r1 r1 r1 r1 r1 r1 r1 r1
ANS: D r1
An episodic or follow-
r1 r1 r1
up assessment is performed after the knee replacement to evaluate the outcome of the proced
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ure. A shift assessment is most appropriate for the person who is recovering in the hospital f
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
rom surgery. A screening assessment is performed for the purpose of disease detection, in thi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
s case diabetes mellitus. A comprehensive assessment is performed during admission to a fac
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ility to obtain a detailed history and complete physical examination.
r1 r1 r1 r1 r1 r1 r1 r1 r1
DIF:Cognitive Level: Understand REF: Box 1- r1 r1 r1 r1
3 TOP:Nursing Process: Assessment
r1 r1 r1
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishi
r1 r1 r1 r1 r1 r1 r1 r1 r1 r1 r1
ng Priorities
r1
7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A r1
The lack of hair and shiny skin over both shins are objective data or signs that are part of th
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e physical examination. A patient‘s concerns about lack of money are subjective data and ar
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e part of the health history. A patient‘s complaints of tingling sensations in the feet are subje
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ctive data and are part of the health history. A patient‘s family statements are considered sec
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ondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- r1 r1 r 1 r1
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.r1 r1 r1 r1 r1
c. The patient‘s temperature is 100 F.
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d. The patient complains of itching. r1 r1 r1 r1
ANS: D r1
