TEST BANK
b
Health Assessment for Nursing Practice
b b b b b
b 7th Edition by Wilson Chapter 1 - 24
b b b b b b b
,TABLE OF CONTENTS b b b
Unit I: Foundations for Health Assessment
b b b b b
1. Introduction to Health Assessment b b b
2. Interviewing Patients to Obtain a Health History b b b b b b
3. Techniques and Equipment for Physical Assessment b b b b b
4. General Inspection and Measurement of Vital Signs
b b b b b b
5. Ethnic, Cultural, and Spiritual Considerations
b b b b
6. Pain Assessment
b
7. Mental Health and Abusive Behavior Assessment
b b b b b
8. Nutritional Assessment b
Unit II: Health Assessment of the Adult
b b b b b b
9. Skin, Hair, and Nails
b b b
10. Head, Eyes, Ears, Nose, and Throat
b b b b b
11. Lungs and Respiratory Systemb b b
12. Heart and Peripheral Vascular System
b b b b
13. Abdomen and Gastrointestinal System b b b
14. Musculoskeletal System b
15. Neurologic System b
16. Breasts and Axillae b b
17. Reproductive System and the Perineum b b b b
Unit III: Health Assessment Across the Life Span
b b b b b b b
18. Developmental Assessment Throughout the Life Span b b b b b
19. Assessment of the Infant, Child, and Adolescent b b b b b b
20. Assessment of the Pregnant Patient b b b b
21. Assessment of the Older Adult b b b b
Unit IV: Synthesis and Application of Health Assessment
b b b b b b b
22. Conducting a Head-to-Toe Examination b b b
23. Documenting the Head-to-Toe Health Assessment b b b b
24. Adapting Health Assessment b b
Chapter 01: Introduction to Health Assessment
b b b b b
,MULTIPLE CHOICE b
1. A patient comes to the emergency department and tells the triage nurse that
b b b b b b b b b b b b
b heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
b b b b b b b b b b b b b
a. Determine the patient‘s personal data and b b b b b
insurance coverage. b b
b. Ask the patient to take a seat in the waiting
b b b b b b b b b
room until his name is called.
b b b b b b
c. Request that a nurse collect data for b b b b b b
acomprehensive history. b
d. Ask a nurse to start a focused assessment
b b b b b b b
of this patient now.
b b b
ANSWER: D b
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
b b b b b b b b b b b b b b b b
cardiovascular system. The type of health assessment performed by the nurse is also driven
b b b b b b b b b b b b b b
by patient need. Personal data and insurance information will be obtained, but in this
b b b b b b b b b b b b b b
situation, these data can wait until after the patient is assessed. Based also on Maslow‘s
b b b b b b b b b b b b b b b
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
b b b b b b b b b b b b b
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
b b b b b b b b b b b b b b b
the patient‘s health status. Complications can be prevented if an immediate assessment is
b b b b b b b b b b b b b
made to analyze the patient‘s symptoms. A comprehensive history is not indicated in this
b b b b b b b b b b b b b b
situation at this time. Some subjective data will be collected, such as allergies and medical
b b b b b b b b b b b b b b b
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
b b b b b b b b b b b b
mental health assessment is not a priority at this time.
b b b b b b b b b b
DIF: Cognitive Level: Apply
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
b b b b b b b b b b
Care:Establishing Priorities
b b
2. Which situation illustrates a screening assessment?
b b b b b
a. A patient visits an obstetric clinic for the first b b b b b b b b
time and the nurse conducts a detailedhistory b b b b b b
and physical examination. b b b
b. A hospital sponsors a health fair at a
b b b b b b b
localmall and provides cholesterol and b b b b
bblood pressure checks to mall patrons.
b b b b b
c. The nurse in an urgent care center checks
b b b b b b b
the vital signs of a patient who is
b b b b b b b
bcomplaining of leg pain. b b b
, d. A patient newly diagnosed with
b b b b
diabetesmellitus comes to test his fasting b b b b b
blood glucose level.
b b b
ANSWER: B b
A health fair at a local mall that provides cholesterol and blood pressure checks is an
b b b b b b b b b b b b b b b
example of a screening assessment focused on disease detection. A detailed history and
b b b b b b b b b b b b b
physical examination conducted during a first-time visit to an obstetric clinic is an exampleof
b b b b b b b b b b b b b b
a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
b b b b b b b b b b b b b b
of an urgent care center is an example of a problem-based/focused assessment. A
b b b b b b b b b b b b b
patient‘s return appointment 1 month after today‘s office visit to report fasting blood
b b b b b b b b b b b b b
glucose levels is an example of an episodic or follow-up assessment.
b b b b b b b b b b b
DIF: Cognitive Level: Understand
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
b b b b b b b b b
3. For which person is a screening assessment indicated?
b b b b b b b
a. The person who had abdominal surgery b b b b b
yesterday
b. The person who is unaware of his high
b b b b b b b
serum glucose levels
b b b
c. The person who is being admitted to a
b b b b b b b
long-term care facility b b
d. The person who is beginning rehabilitation
b b b b b
after a knee replacement b b b
ANSWER: B b
A screening assessment is performed for the purpose of disease detection. In this case this
b b b b b b b b b b b b b b
person may have diabetes mellitus. A shift assessment is most appropriate for the person
b b b b b b b b b b b b b b
who is recovering in the hospital from surgery. A comprehensive assessment is performed
b b b b b b b b b b b b b
during admission to a facility to obtain a detailed history and complete physical
b b b b b b b b b b b b b
examination. An episodic or follow-up assessment is performed after knee replacement to
b b b b b b b b b b b b
evaluate the outcome of the procedure.
b b b b b b
DIF: Cognitive Level: Understand
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
b b b b b b b b b b
Care:Establishing Priorities
b b
4. For which person is a shift assessment indicated?
b b b b b b b
a. The person who had abdominal surgery b b b b b
yesterday
b. The person who is unaware of his high
b b b b b b b
serum glucose levels b b
c. The person who is being admitted to a
b b b b b b b
long-term care facility b b
d. The person who is beginning rehabilitation
b b b b b
after a knee replacement b b b
ANSWER: A b
A shift assessment is most appropriate for the person who is recovering in the hospital from
b b b b b b b b b b b b b b b
surgery. A screening assessment is performed for the purpose of disease detection, in this
b b b b b b b b b b b b b b
case diabetes mellitus. A comprehensive assessment is performed during admission to a
b b b b b b b b b b b b
b
Health Assessment for Nursing Practice
b b b b b
b 7th Edition by Wilson Chapter 1 - 24
b b b b b b b
,TABLE OF CONTENTS b b b
Unit I: Foundations for Health Assessment
b b b b b
1. Introduction to Health Assessment b b b
2. Interviewing Patients to Obtain a Health History b b b b b b
3. Techniques and Equipment for Physical Assessment b b b b b
4. General Inspection and Measurement of Vital Signs
b b b b b b
5. Ethnic, Cultural, and Spiritual Considerations
b b b b
6. Pain Assessment
b
7. Mental Health and Abusive Behavior Assessment
b b b b b
8. Nutritional Assessment b
Unit II: Health Assessment of the Adult
b b b b b b
9. Skin, Hair, and Nails
b b b
10. Head, Eyes, Ears, Nose, and Throat
b b b b b
11. Lungs and Respiratory Systemb b b
12. Heart and Peripheral Vascular System
b b b b
13. Abdomen and Gastrointestinal System b b b
14. Musculoskeletal System b
15. Neurologic System b
16. Breasts and Axillae b b
17. Reproductive System and the Perineum b b b b
Unit III: Health Assessment Across the Life Span
b b b b b b b
18. Developmental Assessment Throughout the Life Span b b b b b
19. Assessment of the Infant, Child, and Adolescent b b b b b b
20. Assessment of the Pregnant Patient b b b b
21. Assessment of the Older Adult b b b b
Unit IV: Synthesis and Application of Health Assessment
b b b b b b b
22. Conducting a Head-to-Toe Examination b b b
23. Documenting the Head-to-Toe Health Assessment b b b b
24. Adapting Health Assessment b b
Chapter 01: Introduction to Health Assessment
b b b b b
,MULTIPLE CHOICE b
1. A patient comes to the emergency department and tells the triage nurse that
b b b b b b b b b b b b
b heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
b b b b b b b b b b b b b
a. Determine the patient‘s personal data and b b b b b
insurance coverage. b b
b. Ask the patient to take a seat in the waiting
b b b b b b b b b
room until his name is called.
b b b b b b
c. Request that a nurse collect data for b b b b b b
acomprehensive history. b
d. Ask a nurse to start a focused assessment
b b b b b b b
of this patient now.
b b b
ANSWER: D b
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
b b b b b b b b b b b b b b b b
cardiovascular system. The type of health assessment performed by the nurse is also driven
b b b b b b b b b b b b b b
by patient need. Personal data and insurance information will be obtained, but in this
b b b b b b b b b b b b b b
situation, these data can wait until after the patient is assessed. Based also on Maslow‘s
b b b b b b b b b b b b b b b
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
b b b b b b b b b b b b b
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
b b b b b b b b b b b b b b b
the patient‘s health status. Complications can be prevented if an immediate assessment is
b b b b b b b b b b b b b
made to analyze the patient‘s symptoms. A comprehensive history is not indicated in this
b b b b b b b b b b b b b b
situation at this time. Some subjective data will be collected, such as allergies and medical
b b b b b b b b b b b b b b b
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
b b b b b b b b b b b b
mental health assessment is not a priority at this time.
b b b b b b b b b b
DIF: Cognitive Level: Apply
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
b b b b b b b b b b
Care:Establishing Priorities
b b
2. Which situation illustrates a screening assessment?
b b b b b
a. A patient visits an obstetric clinic for the first b b b b b b b b
time and the nurse conducts a detailedhistory b b b b b b
and physical examination. b b b
b. A hospital sponsors a health fair at a
b b b b b b b
localmall and provides cholesterol and b b b b
bblood pressure checks to mall patrons.
b b b b b
c. The nurse in an urgent care center checks
b b b b b b b
the vital signs of a patient who is
b b b b b b b
bcomplaining of leg pain. b b b
, d. A patient newly diagnosed with
b b b b
diabetesmellitus comes to test his fasting b b b b b
blood glucose level.
b b b
ANSWER: B b
A health fair at a local mall that provides cholesterol and blood pressure checks is an
b b b b b b b b b b b b b b b
example of a screening assessment focused on disease detection. A detailed history and
b b b b b b b b b b b b b
physical examination conducted during a first-time visit to an obstetric clinic is an exampleof
b b b b b b b b b b b b b b
a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
b b b b b b b b b b b b b b
of an urgent care center is an example of a problem-based/focused assessment. A
b b b b b b b b b b b b b
patient‘s return appointment 1 month after today‘s office visit to report fasting blood
b b b b b b b b b b b b b
glucose levels is an example of an episodic or follow-up assessment.
b b b b b b b b b b b
DIF: Cognitive Level: Understand
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
b b b b b b b b b
3. For which person is a screening assessment indicated?
b b b b b b b
a. The person who had abdominal surgery b b b b b
yesterday
b. The person who is unaware of his high
b b b b b b b
serum glucose levels
b b b
c. The person who is being admitted to a
b b b b b b b
long-term care facility b b
d. The person who is beginning rehabilitation
b b b b b
after a knee replacement b b b
ANSWER: B b
A screening assessment is performed for the purpose of disease detection. In this case this
b b b b b b b b b b b b b b
person may have diabetes mellitus. A shift assessment is most appropriate for the person
b b b b b b b b b b b b b b
who is recovering in the hospital from surgery. A comprehensive assessment is performed
b b b b b b b b b b b b b
during admission to a facility to obtain a detailed history and complete physical
b b b b b b b b b b b b b
examination. An episodic or follow-up assessment is performed after knee replacement to
b b b b b b b b b b b b
evaluate the outcome of the procedure.
b b b b b b
DIF: Cognitive Level: Understand
b REF: Box 1-3 | p. 3 b b b b b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
b b b b b b b b b b
Care:Establishing Priorities
b b
4. For which person is a shift assessment indicated?
b b b b b b b
a. The person who had abdominal surgery b b b b b
yesterday
b. The person who is unaware of his high
b b b b b b b
serum glucose levels b b
c. The person who is being admitted to a
b b b b b b b
long-term care facility b b
d. The person who is beginning rehabilitation
b b b b b
after a knee replacement b b b
ANSWER: A b
A shift assessment is most appropriate for the person who is recovering in the hospital from
b b b b b b b b b b b b b b b
surgery. A screening assessment is performed for the purpose of disease detection, in this
b b b b b b b b b b b b b b
case diabetes mellitus. A comprehensive assessment is performed during admission to a
b b b b b b b b b b b b