,
,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 7th Edition
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MULTIPLE CHOICE nw
1. A patient comes to the emergency department and tells the triage nurse that he is ―havi
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ng a 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.
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b. Ask the patient to take a seat in the waiting room until his name is called.
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c. Request that a nurse collect data for a comprehensive history.
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d. Ask a nurse to start a focused assessment of this patient now.
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ANS: D n w
The nurse needs to begin an assessment as soon as possible that is focused on this patie
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nt‘s cardiovascular system. The type of health assessment performed by the nurse is also
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driven by patient need. Personal data and insurance information will be obtained, but in t
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his situation, these data can wait until after the patient is assessed. Based also on Maslo
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w‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the patient
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to wait, the nurse needs to begin data collection, such as vital signs, immediately to det
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ermine the patient‘s health status. Complications can be prevented if an immediate assess
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ment is made to analyze the patient‘s symptoms. A comprehensive history is not indicate
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d in this situation at this time. Some subjective data will be collected, such as allergies a
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nd medical history related to cardiovascular disease. Eyes, ears, or a complete musculosk
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eletal or mental health assessment is not a priority at this time.
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DIF:Cognitive Level: Apply REF: Box 1- nw nw n w nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities nw
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse condu
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cts a detailed history and physical examination.
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b. A hospital sponsors a health fair at a local mall and provides cholesterol and
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blood pressure checks to mall patrons.
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c. The nurse in an urgent care center checks the vital signs of a patient w
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ho is complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting b
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lood glucose level. nw nw
ANS: B n w
A health fair at a local mall that provides cholesterol and blood pressure checks is an ex
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ample of a screening assessment focused on disease detection. A detailed history and ph
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ysical examination conducted during a first-
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time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing
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a patient complaining of leg pain in the triage area of an urgent care center is an examp
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le of a problem-
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based/focused assessment. A patient‘s return appointment 1 month after today‘s office vis
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it to report fasting blood glucose levels is an example of an episodic or follow-
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up assessment.
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DIF:Cognitive Level: Understand nw nw REF: Box 1-3 nw nw
, TOP:Nursing Process: Assessment nw nw
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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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
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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
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ANS: B nw
A screening assessment is performed for the purpose of disease detection. In this case thi
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s person may have diabetes mellitus. A shift assessment is most appropriate for the perso
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n who is recovering in the hospital from surgery. A comprehensive assessment is perfor
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med during admission to a facility to obtain a detailed history and complete physical exa
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mination. An episodic or follow- nw nw nw nw
up assessment is performed after knee replacement to evaluate the outcome of the proced
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ure.
DIF:Cognitive Level: Understand REF: Box 1- nw nw nw nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities nw
4. For which person is a shift 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
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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
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ANS: A nw
A shift assessment is most appropriate for the person who is recovering in the hospital fr
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om surgery. A screening assessment is performed for the purpose of disease detection, in t
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his case diabetes mellitus. A comprehensive assessment is performed during admission to
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a facility to obtain a detailed history and complete physical examination. An episodic or f
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ollow-
up assessment is performed after knee replacement to evaluate the outcome of the proced
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ure.
DIF:Cognitive Level: Understand REF: Box 1- nw nw nw nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities nw
5. For which person is a comprehensive 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
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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
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ANS: C nw
A comprehensive assessment is performed during admission to a facility to obtain a detai
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led history and complete physical examination. A shift assessment is most appropriate fo
nw nw nw nw nw nw nw nw nw nw nw nw
r the person who is recovering in the hospital from surgery. A screening assessment is p
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
erformed for the purpose of disease detection, in this case diabetes mellitus. An episodic
nw nw nw nw nw nw nw nw nw nw nw nw nw
or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the proce
nw nw nw nw nw nw nw nw nw nw nw nw nw
dure.
,Chapter 01: Introduction to Health Assessment
nw nw nw nw nw
Wilson: Health Assessment for Nursing Practice, 7th Edition
nw nw nw nw nw nw nw
MULTIPLE CHOICE nw
1. A patient comes to the emergency department and tells the triage nurse that he is ―havi
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ng a heart attack.‖ What is the nurse‘s top priority at this time?
nw nw nw nw nw nw nw nw nw nw nw nw
a. Determine the patient‘s personal data and insurance coverage.
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b. Ask the patient to take a seat in the waiting room until his name is called.
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
c. Request that a nurse collect data for a comprehensive history.
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d. Ask a nurse to start a focused assessment of this patient now.
nw nw nw nw nw nw nw nw nw nw nw
ANS: D n w
The nurse needs to begin an assessment as soon as possible that is focused on this patie
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
nt‘s cardiovascular system. The type of health assessment performed by the nurse is also
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
driven by patient need. Personal data and insurance information will be obtained, but in t
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
his situation, these data can wait until after the patient is assessed. Based also on Maslo
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
w‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the patient
nw nw nw nw nw nw nw nw nw nw nw nw
to wait, the nurse needs to begin data collection, such as vital signs, immediately to det
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ermine the patient‘s health status. Complications can be prevented if an immediate assess
nw nw nw nw nw nw nw nw nw nw nw nw
ment is made to analyze the patient‘s symptoms. A comprehensive history is not indicate
nw nw nw nw nw nw nw nw nw nw nw nw nw
d in this situation at this time. Some subjective data will be collected, such as allergies a
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
nd medical history related to cardiovascular disease. Eyes, ears, or a complete musculosk
nw nw nw nw nw nw nw nw nw nw nw nw
eletal or mental health assessment is not a priority at this time.
nw nw nw nw nw nw nw nw nw nw nw
DIF:Cognitive Level: Apply REF: Box 1- nw nw n w nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
nw nw nw nw nw nw nw nw nw nw nw
ishing Priorities nw
2. Which situation illustrates a screening assessment?
nw nw nw nw nw
a. A patient visits an obstetric clinic for the first time and the nurse condu
nw nw nw nw nw nw nw nw nw nw nw nw nw
cts a detailed history and physical examination.
nw nw nw nw nw nw
b. A hospital sponsors a health fair at a local mall and provides cholesterol and
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
blood pressure checks to mall patrons.
nw nw nw nw nw
c. The nurse in an urgent care center checks the vital signs of a patient w
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ho is complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting b
nw nw nw nw nw nw nw nw nw nw nw nw
lood glucose level. nw nw
ANS: B n w
A health fair at a local mall that provides cholesterol and blood pressure checks is an ex
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ample of a screening assessment focused on disease detection. A detailed history and ph
nw nw nw nw nw nw nw nw nw nw nw nw nw
ysical examination conducted during a first-
nw nw nw nw nw
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
a patient complaining of leg pain in the triage area of an urgent care center is an examp
nw nw nw nw nw nw nw nw nw nw n w nw nw nw nw nw nw
le of a problem-
nw nw nw
based/focused assessment. A patient‘s return appointment 1 month after today‘s office vis
nw nw nw nw nw nw nw nw nw nw nw
it to report fasting blood glucose levels is an example of an episodic or follow-
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
up assessment.
nw
DIF:Cognitive Level: Understand nw nw REF: Box 1-3 nw nw
, TOP:Nursing Process: Assessment nw nw
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
nw nw nw nw nw nw nw nw
3. For which person is a screening assessment indicated?
nw nw nw nw nw nw nw
a. The person who had abdominal surgery yesterday
nw nw nw nw nw nw
b. The person who is unaware of his high serum glucose levels
nw nw nw nw nw nw nw nw nw nw
c. The person who is being admitted to a long-term care facility
nw nw nw nw nw nw nw nw nw nw
d. The person who is beginning rehabilitation after a knee replacement
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ANS: B nw
A screening assessment is performed for the purpose of disease detection. In this case thi
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
s person may have diabetes mellitus. A shift assessment is most appropriate for the perso
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
n who is recovering in the hospital from surgery. A comprehensive assessment is perfor
nw nw nw nw nw nw nw nw nw nw nw nw nw
med during admission to a facility to obtain a detailed history and complete physical exa
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
mination. An episodic or follow- nw nw nw nw
up assessment is performed after knee replacement to evaluate the outcome of the proced
nw nw nw nw nw nw nw nw nw nw nw nw nw
ure.
DIF:Cognitive Level: Understand REF: Box 1- nw nw nw nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
nw nw nw nw nw nw nw nw nw nw nw
ishing Priorities nw
4. For which person is a shift 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
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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
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ANS: A nw
A shift assessment is most appropriate for the person who is recovering in the hospital fr
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
om surgery. A screening assessment is performed for the purpose of disease detection, in t
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
his case diabetes mellitus. A comprehensive assessment is performed during admission to
nw nw nw nw nw nw nw nw nw nw nw nw
a facility to obtain a detailed history and complete physical examination. An episodic or f
nw nw nw nw nw nw nw nw nw nw nw nw nw nw
ollow-
up assessment is performed after knee replacement to evaluate the outcome of the proced
nw nw nw nw nw nw nw nw nw nw nw nw nw
ure.
DIF:Cognitive Level: Understand REF: Box 1- nw nw nw nw
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
nw nw nw nw nw nw nw nw nw nw nw
ishing Priorities nw
5. For which person is a comprehensive assessment indicated?
nw nw nw nw nw nw nw
a. The person who had abdominal surgery yesterday
nw nw nw nw nw nw
b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
nw nw nw nw nw nw nw nw nw nw
d. The person who is beginning rehabilitation after a knee replacement
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ANS: C nw
A comprehensive assessment is performed during admission to a facility to obtain a detai
nw nw nw nw nw nw nw nw nw nw nw nw nw
led history and complete physical examination. A shift assessment is most appropriate fo
nw nw nw nw nw nw nw nw nw nw nw nw
r the person who is recovering in the hospital from surgery. A screening assessment is p
nw nw nw nw nw nw nw nw nw nw nw nw nw nw nw
erformed for the purpose of disease detection, in this case diabetes mellitus. An episodic
nw nw nw nw nw nw nw nw nw nw nw nw nw
or follow-
nw nw
up assessment is performed after knee replacement to evaluate the outcome of the proce
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dure.
