,Chapter 01: Introduction to Health Assessment
s! s! s! s! s!
Wilson: Health Assessment for Nursing Practice, 8th Edition
s! s! s! s! s! s! s!
MULTIPLE CHOICE s!
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a h
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
eart attack.‖ What is the nurse‘s top priority at this time?
s! s! s! s! s! s! s! s! s! s!
a. Determine the patient‘s personal data and insurance coverage. s! s! s! s! s! s! s!
b. Ask the patient to take a seat in the waiting room until his name is called.
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
c. Request that a nurse collect data for a comprehensive history. s! s! s! s! s! s! s! s! s!
d. Ask a nurse to start a focused assessment of this patient now.
s! s! s! s! s! s! s! s! s! s! s!
ANS: D s !
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s car
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
diovascular system. The type of health assessment performed by the nurse is also driven by pati
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ent need. Personal data and insurance information will be obtained, but in this situation, these
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy of needs, ph
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ysiologic needs take precedence. Rather than asking the patient to wait, the nurse needs to begi
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
n data collection, such as vital signs, immediately to determine the patient‘s health status. Com
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
plications can be prevented if an immediate assessment is made to analyze the patient‘s sympt
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
oms. A comprehensive history is not indicated in this situation at this time. Some subjective da
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ta will be collected, such as allergies and medical history related to cardiovascular disease. Ey
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
es, ears, or a complete musculoskeletal or mental health assessment is not a priority at this tim
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
e.
DIF:Cognitive Level: Apply REF: Box 1- s! s! s ! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
2. Which situation illustrates a screening assessment?
s! s! s! s! s!
a. A patient visits an obstetric clinic for the first time and the nurse conducts a
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
detailed history and physical examination. s! s! s! s!
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
pressure checks to mall patrons. s! s! s! s!
c. The nurse in an urgent care center checks the vital signs of a patient who is
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
complaining of leg pain. s! s! s!
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
s! s! s! s! s! s! s! s! s! s! s! s! s!
glucose level. s!
ANS: B s !
A health fair at a local mall that provides cholesterol and blood pressure checks is an example
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
of a screening assessment focused on disease detection. A detailed history and physical exami
s! s! s! s! s! s! s! s! s! s! s! s! s!
nation conducted during a first- s! s! s! s!
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a pati
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ent complaining of leg pain in the triage area of an urgent care center is an example of a probl
s! s! s! s! s! s! s! s! s! s ! s! s! s! s! s! s! s! s! s!
em-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit to
s! s! s! s! s! s! s! s! s! s! s! s! s!
report fasting blood glucose levels is an example of an episodic or follow-up assessment.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand s! s! REF: Box 1-3 s! s!
, TOP:Nursing Process: Assessment s! s!
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening s! s! s! s! s! s! s! s!
3. For which person is a screening assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterdays! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: B s!
A screening assessment is performed for the purpose of disease detection. In this case this pers
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
on may have diabetes mellitus. A shift assessment is most appropriate for the person who is re
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
covering in the hospital from surgery. A comprehensive assessment is performed during admis
s! s! s! s! s! s! s! s! s! s! s! s!
sion to a facility to obtain a detailed history and complete physical examination. An episodic o
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
r follow-
s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
4. For which person is a shift assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: A s!
A shift assessment is most appropriate for the person who is recovering in the hospital from sur
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
gery. A screening assessment is performed for the purpose of disease detection, in this case diab
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
etes mellitus. A comprehensive assessment is performed during admission to a facility to obtai
s! s! s! s! s! s! s! s! s! s! s! s! s!
n a detailed history and complete physical examination. An episodic or follow-
s! s! s! s! s! s! s! s! s! s! s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
5. For which person is a comprehensive assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: C s!
A comprehensive assessment is performed during admission to a facility to obtain a detailed hi
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
story and complete physical examination. A shift assessment is most appropriate for the perso
s! s! s! s! s! s! s! s! s! s! s! s! s!
n who is recovering in the hospital from surgery. A screening assessment is performed for the
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s
purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
! s! s! s! s! s! s! s! s! s! s! s! s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
, DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
6. For which person is an episodic or follow-up assessment indicated?
s! s! s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: D s!
An episodic or follow-
s! s! s!
up assessment is performed after the knee replacement to evaluate the outcome of the procedu
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
re. A shift assessment is most appropriate for the person who is recovering in the hospital fro
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
m surgery. A screening assessment is performed for the purpose of disease detection, in this ca
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
se diabetes mellitus. A comprehensive assessment is performed during admission to a facility t
s! s! s! s! s! s! s! s! s! s! s! s! s!
o obtain a detailed history and complete physical examination.
s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
7. Which is an example of data a nurse collects during a physical examination?
s! s! s! s! s! s! s! s! s! s! s! s!
a. The patient‘s lack of hair and shiny skin over both shins
s! s! s! s! s! s! s! s! s! s!
b. The patient‘s stated concern about lack of money for prescriptions
s! s! s! s! s! s! s! s! s!
c. The patient‘s complaints of tingling sensations in the feet
s! s! s! s! s! s! s! s!
d. The patient‘s mother‘s statements that the patient is very nervous lately
s! s! s! s! s! s! s! s! s! s!
ANS: A s!
The lack of hair and shiny skin over both shins are objective data or signs that are part of the
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
physical examination. A patient‘s concerns about lack of money are subjective data and are p
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
art of the health history. A patient‘s complaints of tingling sensations in the feet are subjectiv
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
e data and are part of the health history. A patient‘s family statements are considered secondar
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
y data, are subjective data, and are part of the health history.
s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Apply REF: Box 1- s! s! s ! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific A
s! s! s! s! s! s! s! s! s! s! s!
ssessments
8. The nurse documents which information in the patient‘s history?
s! s! s! s! s! s! s! s!
a. The patient‘s skin feels warm to the touch.
s! s! s! s! s! s! s!
b. The patient is scratching his arm.s! s! s! s! s!
c. The patient‘s temperature is 100 F.
s! s! s! s! s!
d. The patient complains of itching. s! s! s! s!
ANS: D s!
s! s! s! s! s!
Wilson: Health Assessment for Nursing Practice, 8th Edition
s! s! s! s! s! s! s!
MULTIPLE CHOICE s!
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a h
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
eart attack.‖ What is the nurse‘s top priority at this time?
s! s! s! s! s! s! s! s! s! s!
a. Determine the patient‘s personal data and insurance coverage. s! s! s! s! s! s! s!
b. Ask the patient to take a seat in the waiting room until his name is called.
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
c. Request that a nurse collect data for a comprehensive history. s! s! s! s! s! s! s! s! s!
d. Ask a nurse to start a focused assessment of this patient now.
s! s! s! s! s! s! s! s! s! s! s!
ANS: D s !
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s car
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
diovascular system. The type of health assessment performed by the nurse is also driven by pati
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ent need. Personal data and insurance information will be obtained, but in this situation, these
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy of needs, ph
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ysiologic needs take precedence. Rather than asking the patient to wait, the nurse needs to begi
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
n data collection, such as vital signs, immediately to determine the patient‘s health status. Com
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
plications can be prevented if an immediate assessment is made to analyze the patient‘s sympt
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
oms. A comprehensive history is not indicated in this situation at this time. Some subjective da
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ta will be collected, such as allergies and medical history related to cardiovascular disease. Ey
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
es, ears, or a complete musculoskeletal or mental health assessment is not a priority at this tim
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
e.
DIF:Cognitive Level: Apply REF: Box 1- s! s! s ! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
2. Which situation illustrates a screening assessment?
s! s! s! s! s!
a. A patient visits an obstetric clinic for the first time and the nurse conducts a
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
detailed history and physical examination. s! s! s! s!
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
pressure checks to mall patrons. s! s! s! s!
c. The nurse in an urgent care center checks the vital signs of a patient who is
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
complaining of leg pain. s! s! s!
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
s! s! s! s! s! s! s! s! s! s! s! s! s!
glucose level. s!
ANS: B s !
A health fair at a local mall that provides cholesterol and blood pressure checks is an example
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
of a screening assessment focused on disease detection. A detailed history and physical exami
s! s! s! s! s! s! s! s! s! s! s! s! s!
nation conducted during a first- s! s! s! s!
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a pati
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
ent complaining of leg pain in the triage area of an urgent care center is an example of a probl
s! s! s! s! s! s! s! s! s! s ! s! s! s! s! s! s! s! s! s!
em-
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit to
s! s! s! s! s! s! s! s! s! s! s! s! s!
report fasting blood glucose levels is an example of an episodic or follow-up assessment.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand s! s! REF: Box 1-3 s! s!
, TOP:Nursing Process: Assessment s! s!
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening s! s! s! s! s! s! s! s!
3. For which person is a screening assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterdays! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: B s!
A screening assessment is performed for the purpose of disease detection. In this case this pers
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
on may have diabetes mellitus. A shift assessment is most appropriate for the person who is re
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
covering in the hospital from surgery. A comprehensive assessment is performed during admis
s! s! s! s! s! s! s! s! s! s! s! s!
sion to a facility to obtain a detailed history and complete physical examination. An episodic o
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
r follow-
s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
4. For which person is a shift assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: A s!
A shift assessment is most appropriate for the person who is recovering in the hospital from sur
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
gery. A screening assessment is performed for the purpose of disease detection, in this case diab
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
etes mellitus. A comprehensive assessment is performed during admission to a facility to obtai
s! s! s! s! s! s! s! s! s! s! s! s! s!
n a detailed history and complete physical examination. An episodic or follow-
s! s! s! s! s! s! s! s! s! s! s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
5. For which person is a comprehensive assessment indicated?
s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: C s!
A comprehensive assessment is performed during admission to a facility to obtain a detailed hi
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
story and complete physical examination. A shift assessment is most appropriate for the perso
s! s! s! s! s! s! s! s! s! s! s! s! s!
n who is recovering in the hospital from surgery. A screening assessment is performed for the
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s
purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
! s! s! s! s! s! s! s! s! s! s! s! s!
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
s! s! s! s! s! s! s! s! s! s! s! s! s!
, DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
6. For which person is an episodic or follow-up assessment indicated?
s! s! s! s! s! s! s! s! s!
a. The person who had abdominal surgery yesterday
s! s! s! s! s! s!
b. The person who is unaware of his high serum glucose levels
s! s! s! s! s! s! s! s! s! s!
c. The person who is being admitted to a long-term care facility
s! s! s! s! s! s! s! s! s! s!
d. The person who is beginning rehabilitation after a knee replacement
s! s! s! s! s! s! s! s! s!
ANS: D s!
An episodic or follow-
s! s! s!
up assessment is performed after the knee replacement to evaluate the outcome of the procedu
s! s! s! s! s! s! s! s! s! s! s! s! s! s!
re. A shift assessment is most appropriate for the person who is recovering in the hospital fro
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
m surgery. A screening assessment is performed for the purpose of disease detection, in this ca
s! s! s! s! s! s! s! s! s! s! s! s! s! s! s!
se diabetes mellitus. A comprehensive assessment is performed during admission to a facility t
s! s! s! s! s! s! s! s! s! s! s! s! s!
o obtain a detailed history and complete physical examination.
s! s! s! s! s! s! s! s!
DIF:Cognitive Level: Understand REF: Box 1- s! s! s! s!
3 TOP:Nursing Process: Assessment
s! s! s!
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishin
s! s! s! s! s! s! s! s! s! s! s!
g Priorities
s!
7. Which is an example of data a nurse collects during a physical examination?
s! s! s! s! s! s! s! s! s! s! s! s!
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 s!
The lack of hair and shiny skin over both shins are objective data or signs that are part of the
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physical examination. A patient‘s concerns about lack of money are subjective data and are p
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art of the health history. A patient‘s complaints of tingling sensations in the feet are subjectiv
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e data and are part of the health history. A patient‘s family statements are considered secondar
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y data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- s! s! s ! s!
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific A
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ssessments
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.s! s! s! s! s!
c. The patient‘s temperature is 100 F.
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d. The patient complains of itching. s! s! s! s!
ANS: D s!
