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