month?
,Chapter 01: Introduction to Health Assessment Wilson: Health
Assessment for Nursing Practice, 7th Edition
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the
triage nurse that he is ―having a heart attack.‖ What is the
nurse‘s top priority at this time?
a. Determine the patient‘s personal data and insurance
coverage.
b. Ask the patient to take a seat in the waiting room until his
name is called.
c. Request that a nurse collect data for a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
,CORRECT 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 driven 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 Maslow‘s hierarchy of needs,
physiologic needs take precedence. Rather than asking the
patient to wait, the nurse needs to begin data collection, such as
vital signs, immediately to 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 allergies and medical
history related to cardiovascular disease. Eyes, ears, or a
month?
, complete musculoskeletal or mental health assessment is not a
priority at this time.
DIF:Cognitive Level: Apply REF: Box 1-3
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 first time and the
nurse conducts a detailed history and physical examination.
b. A hospital sponsors a health fair at a local mall and
provides cholesterol and blood pressure checks to mall
patrons.
c. The nurse in an urgent care center checks the vital signs of
a patient who is complaining of leg pain.
,Chapter 01: Introduction to Health Assessment Wilson: Health
Assessment for Nursing Practice, 7th Edition
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the
triage nurse that he is ―having a heart attack.‖ What is the
nurse‘s top priority at this time?
a. Determine the patient‘s personal data and insurance
coverage.
b. Ask the patient to take a seat in the waiting room until his
name is called.
c. Request that a nurse collect data for a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
,CORRECT 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 driven 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 Maslow‘s hierarchy of needs,
physiologic needs take precedence. Rather than asking the
patient to wait, the nurse needs to begin data collection, such as
vital signs, immediately to 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 allergies and medical
history related to cardiovascular disease. Eyes, ears, or a
month?
, complete musculoskeletal or mental health assessment is not a
priority at this time.
DIF:Cognitive Level: Apply REF: Box 1-3
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 first time and the
nurse conducts a detailed history and physical examination.
b. A hospital sponsors a health fair at a local mall and
provides cholesterol and blood pressure checks to mall
patrons.
c. The nurse in an urgent care center checks the vital signs of
a patient who is complaining of leg pain.
