Test Bank for Health Assessment for Nu
n n n n n n
rsing Practice 7th Edition by Wilson Chap
n n n n n n
ter 1 - 24
n n n
,Chaptern01:nIntroductionntonHealthnAssessment
MULTIPLEnCHOICE
1. Anpatientncomesntonthenemergencyndepartmentnandntellsnthentriagen nursenthatn heni
sn“havingnanheartnattack.”nWhatnisnthennurse’sntopnprioritynatnthisntime?
a. Determinenthenpatient’snpersonalndatanandnins
urancencoverage.
b. Asknthenpatientntontakenanseatninnthenwaitingnro
omnuntiln hisnnamenisncalled.
c. Requestnthatnannursencollectndatanfornan
comprehensivenhistory.
d. Asknannursentonstartnanfocusednassessmentn
ofnthisnpatientnnow.
ANSWER:n D
Thennursenneedsntonbeginnannassessmentnasnsoonnasnpossiblenthatnisnfocusednonnthisnpatient’snc
ardiovascularnsystem.nThentypenofnhealthnassessmentnperformednbynthennursenisnalsondrivennb
ynpatientnneed.nPersonalndatanandninsuranceninformationnwillnbenobtained,nbutninnthisnsituatio
n,nthesendatancannwaitnuntilnafternthenpatientnisnassessed.nBasednalsononnMaslow’snhierarchynof
nneeds,nphysiologicnneedsntakenprecedence.nRathernthannaskingnthenpatientntonwait,nthennursen
needsntonbeginndatancollection,nsuchnasnvitalnsigns,nimmediatelyntondeterminenthenpatient’snhea
lthnstatus.nComplicationsncannbenpreventednifnannimmediatenassessmentnisnmadentonanalyzenth
enpatient’snsymptoms.nAncomprehensivenhistorynisnnotnindicatedninnthisnsituationnatnthisntime.n
Somensubjectivendatanwillnbencollected,nsuchnasnallergiesnandnmedicalnhistorynrelatedntoncardi
ovascularndisease.nEyes,nears,nornancompletenmusculoskeletalnornmentaln healthnassessmentnisn
notnanprioritynatnthisntime.
DIF:nnn CognitivenLevel:nApply REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
2. Whichnsituationnillustratesnan screeningnassessment?
a. Anpatientnvisitsnannobstetricnclinicnfornthenfirs
tntimenandnthennursenconductsnandetailednhistor
ynandnphysicalnexamination.
b. Anhospitalnsponsorsnanhealthnfairnatnanlocaln
mallnandnprovidesncholesterolnandnbloodnp
ressurenchecksntonmallnpatrons.
c. Thennurseninnannurgentncarencenternchecksnt
henvitalnsignsnofnanpatientnwhonisncomplai
ningnofnlegnpain.
, d. Anpatientn newlyndiagnosednwithndiabetesn
mellitusncomesntontestnhisnfastingnbloodng
lucosenlevel.
ANSWER:nB
Anhealthnfairnatnanlocalnmallnthatnprovidesncholesterolnandnbloodnpressurenchecksnisnannexampl
enofnanscreeningnassessmentnfocusednonndiseasendetection.nAndetailednhistorynandnphysicalnex
aminationnconductednduringnanfirst-
timenvisitntonannobstetricnclinicnisnannexamplenofnancomprehensivenassessment.nAssessingnanpat
ientncomplainingnofnlegnpainninnthentriagenareanofnannurgentncarencenternisnannexamplenofnanpro
blem-
based/focusednassessment.nAnpatient’snreturnnappointmentn1nmonthnafterntoday’snofficenvisitn
tonreportnfastingnbloodnglucosenlevelsnisnannexamplenofnannepisodicnornfollow-upnassessment.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientn Needs:n HealthnPromotionnandnMaintenance:nHealthnScreening
3. Fornwhichnpersonnisnanscreeningnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntonanl
ong-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:nB
Anscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection.nInnthisncasenthisnp
ersonnmaynhavendiabetesnmellitus.nAnshiftnassessmentnisnmostnappropriatenfornthenpersonnwh
onisnrecoveringninnthenhospitalnfromnsurgery.nAncomprehensivenassessmentnisnperformednduri
ngnadmissionntonanfacilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.n
Annepisodicnornfollow-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedur
e.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
4. Fornwhichnpersonnisnanshiftnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntona
long-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationn
afternankneenreplacement
ANSWER:n A
Anshiftnassessmentnisnmostnappropriatenfornthenpersonnwhonisnrecoveringninnthenhospitalnfromns
urgery.nAnscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection,ninnthisncas
endiabetesnmellitus.n Ancomprehensivenassessmentnisnperformednduringnadmissionntona
, facilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.nAnnepisodicnornfol
low-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedu
re.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n4nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
5. Fornwhichnpersonnisnancomprehensivenassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntonanl
ong-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:nC
Ancomprehensivenassessmentnisnperformednduringnadmissionntonanfacilityntonobtainna
detailednhistorynandncompletenphysicalnexamination.nAnshiftnassessmentnisnmostnappropriatenf
ornthenpersonnwhonisnrecoveringninnthenhospitalnfromnsurgery.nAnscreeningnassessmentnisnper
formednfornthenpurposenofndiseasendetection,ninnthisncasendiabetesnmellitus.nAnnepisodicnornfo
llow-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedur
e.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
6. Fornwhichnpersonnisnannepisodicnornfollow-upnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntona
long-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:n D
Annepisodicnornfollow-
upnassessmentnisnperformednafternthenkneenreplacementntonevaluatenthenoutcomenofnthenproce
dure.nAnshiftnassessmentnisnmostnappropriatenfornthenpersonnwhonisnrecoveringninnthenhospitaln
fromnsurgery.nAnscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection,ninnt
hisncasendiabetesnmellitus.nAncomprehensivenassessmentnisnperformednduringnadmissionntonan
facilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
n n n n n n
rsing Practice 7th Edition by Wilson Chap
n n n n n n
ter 1 - 24
n n n
,Chaptern01:nIntroductionntonHealthnAssessment
MULTIPLEnCHOICE
1. Anpatientncomesntonthenemergencyndepartmentnandntellsnthentriagen nursenthatn heni
sn“havingnanheartnattack.”nWhatnisnthennurse’sntopnprioritynatnthisntime?
a. Determinenthenpatient’snpersonalndatanandnins
urancencoverage.
b. Asknthenpatientntontakenanseatninnthenwaitingnro
omnuntiln hisnnamenisncalled.
c. Requestnthatnannursencollectndatanfornan
comprehensivenhistory.
d. Asknannursentonstartnanfocusednassessmentn
ofnthisnpatientnnow.
ANSWER:n D
Thennursenneedsntonbeginnannassessmentnasnsoonnasnpossiblenthatnisnfocusednonnthisnpatient’snc
ardiovascularnsystem.nThentypenofnhealthnassessmentnperformednbynthennursenisnalsondrivennb
ynpatientnneed.nPersonalndatanandninsuranceninformationnwillnbenobtained,nbutninnthisnsituatio
n,nthesendatancannwaitnuntilnafternthenpatientnisnassessed.nBasednalsononnMaslow’snhierarchynof
nneeds,nphysiologicnneedsntakenprecedence.nRathernthannaskingnthenpatientntonwait,nthennursen
needsntonbeginndatancollection,nsuchnasnvitalnsigns,nimmediatelyntondeterminenthenpatient’snhea
lthnstatus.nComplicationsncannbenpreventednifnannimmediatenassessmentnisnmadentonanalyzenth
enpatient’snsymptoms.nAncomprehensivenhistorynisnnotnindicatedninnthisnsituationnatnthisntime.n
Somensubjectivendatanwillnbencollected,nsuchnasnallergiesnandnmedicalnhistorynrelatedntoncardi
ovascularndisease.nEyes,nears,nornancompletenmusculoskeletalnornmentaln healthnassessmentnisn
notnanprioritynatnthisntime.
DIF:nnn CognitivenLevel:nApply REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
2. Whichnsituationnillustratesnan screeningnassessment?
a. Anpatientnvisitsnannobstetricnclinicnfornthenfirs
tntimenandnthennursenconductsnandetailednhistor
ynandnphysicalnexamination.
b. Anhospitalnsponsorsnanhealthnfairnatnanlocaln
mallnandnprovidesncholesterolnandnbloodnp
ressurenchecksntonmallnpatrons.
c. Thennurseninnannurgentncarencenternchecksnt
henvitalnsignsnofnanpatientnwhonisncomplai
ningnofnlegnpain.
, d. Anpatientn newlyndiagnosednwithndiabetesn
mellitusncomesntontestnhisnfastingnbloodng
lucosenlevel.
ANSWER:nB
Anhealthnfairnatnanlocalnmallnthatnprovidesncholesterolnandnbloodnpressurenchecksnisnannexampl
enofnanscreeningnassessmentnfocusednonndiseasendetection.nAndetailednhistorynandnphysicalnex
aminationnconductednduringnanfirst-
timenvisitntonannobstetricnclinicnisnannexamplenofnancomprehensivenassessment.nAssessingnanpat
ientncomplainingnofnlegnpainninnthentriagenareanofnannurgentncarencenternisnannexamplenofnanpro
blem-
based/focusednassessment.nAnpatient’snreturnnappointmentn1nmonthnafterntoday’snofficenvisitn
tonreportnfastingnbloodnglucosenlevelsnisnannexamplenofnannepisodicnornfollow-upnassessment.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientn Needs:n HealthnPromotionnandnMaintenance:nHealthnScreening
3. Fornwhichnpersonnisnanscreeningnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntonanl
ong-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:nB
Anscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection.nInnthisncasenthisnp
ersonnmaynhavendiabetesnmellitus.nAnshiftnassessmentnisnmostnappropriatenfornthenpersonnwh
onisnrecoveringninnthenhospitalnfromnsurgery.nAncomprehensivenassessmentnisnperformednduri
ngnadmissionntonanfacilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.n
Annepisodicnornfollow-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedur
e.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
4. Fornwhichnpersonnisnanshiftnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntona
long-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationn
afternankneenreplacement
ANSWER:n A
Anshiftnassessmentnisnmostnappropriatenfornthenpersonnwhonisnrecoveringninnthenhospitalnfromns
urgery.nAnscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection,ninnthisncas
endiabetesnmellitus.n Ancomprehensivenassessmentnisnperformednduringnadmissionntona
, facilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.nAnnepisodicnornfol
low-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedu
re.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n4nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
5. Fornwhichnpersonnisnancomprehensivenassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntonanl
ong-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:nC
Ancomprehensivenassessmentnisnperformednduringnadmissionntonanfacilityntonobtainna
detailednhistorynandncompletenphysicalnexamination.nAnshiftnassessmentnisnmostnappropriatenf
ornthenpersonnwhonisnrecoveringninnthenhospitalnfromnsurgery.nAnscreeningnassessmentnisnper
formednfornthenpurposenofndiseasendetection,ninnthisncasendiabetesnmellitus.nAnnepisodicnornfo
llow-
upnassessmentnisnperformednafternkneenreplacementntonevaluatenthenoutcomenofnthenprocedur
e.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffectivenCarenEnvironment:nManagementnofnCare:nEstablishi
ngnPriorities
6. Fornwhichnpersonnisnannepisodicnornfollow-upnassessmentnindicated?
a. Thenpersonnwhonhadnabdominalnsurgeryn
yesterday
b. Thenpersonnwhonisnunawarenofnhisnhighn
serumnglucosenlevels
c. Thenpersonnwhonisnbeingnadmittedntona
long-termncarenfacility
d. Thenpersonnwhonisnbeginningnrehabilitationnaf
ternankneenreplacement
ANSWER:n D
Annepisodicnornfollow-
upnassessmentnisnperformednafternthenkneenreplacementntonevaluatenthenoutcomenofnthenproce
dure.nAnshiftnassessmentnisnmostnappropriatenfornthenpersonnwhonisnrecoveringninnthenhospitaln
fromnsurgery.nAnscreeningnassessmentnisnperformednfornthenpurposenofndiseasendetection,ninnt
hisncasendiabetesnmellitus.nAncomprehensivenassessmentnisnperformednduringnadmissionntonan
facilityntonobtainnandetailednhistorynandncompletenphysicalnexamination.
DIF:nnn CognitivenLevel:nUnderstand REF:nBoxn1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
