,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 8th Edition
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MULTIPLE CHOICE C/
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
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a heart attack.‖ What is the nurse‘s top priority at this time?
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a. Determine the patient‘s personal data and insurance coverage. C/ C/ C/ C/ C/ C/ C/
b. Ask the patient to take a seat in the waiting room until his name is called.
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c. Request that a nurse collect data for a comprehensive history.
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d. Ask a nurse to start a focused assessment of this patient now.
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ANS: D C /
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
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cardiovascular system. The type of health assessment performed by the nurse is also driven b
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y patient need. Personal data and insurance information will be obtained, but in this situatio
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n, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy o
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f needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
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needs to begin data collection, such as vital signs, immediately to determine the patient‘s h
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ealth status. Complications can be prevented if an immediate assessment is made to analyze
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the patient‘s symptoms. A comprehensive history is not indicated in this situation at this tim
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e. Some subjective data will be collected, such as allergies and medical history related to ca
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rdiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment
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is not a priority at this time.
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DIF:Cognitive Level: Apply REF: Box 1- C/ C/ C / C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities C/
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse conducts
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a detailed history and physical examination.
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b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
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od pressure checks to mall patrons.
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c. The nurse in an urgent care center checks the vital signs of a patient who
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is complaining of leg pain.C/ C/ C/ C/
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
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d glucose level. C/ C/
ANS: B C /
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
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ple of a screening assessment focused on disease detection. A detailed history and physical
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examination conducted during a first- C/ C/ C/ C/
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
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atient complaining of leg pain in the triage area of an urgent care center is an example of a
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problem-
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based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
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to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
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DIF:Cognitive Level: Understand C/ C/ REF: Box 1-3 C/ C/
, TOP:Nursing Process: Assessment C/ C/
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: B C/
A screening assessment is performed for the purpose of disease detection. In this case this p
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erson may have diabetes mellitus. A shift assessment is most appropriate for the person who
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C/is recovering in the hospital from surgery. A comprehensive assessment is performed durin
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g admission to a facility to obtain a detailed history and complete physical examination. An
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episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedure
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.
DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities C/
4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: A C/
A shift assessment is most appropriate for the person who is recovering in the hospital from
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surgery. A screening assessment is performed for the purpose of disease detection, in this cas
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e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
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to obtain a detailed history and complete physical examination. An episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedure.
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DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities C/
5. For which person is a comprehensive assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: C C/
A comprehensive assessment is performed during admission to a facility to obtain a detailed
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history and complete physical examination. A shift assessment is most appropriate for the
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person who is recovering in the hospital from surgery. A screening assessment is performe
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d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedur
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e.
, DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities
C/
6. For which person is an episodic or follow-up assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: D C/
An episodic or follow-
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up assessment is performed after the knee replacement to evaluate the outcome of the proc
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edure. A shift assessment is most appropriate for the person who is recovering in the hospit
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al from surgery. A screening assessment is performed for the purpose of disease detection, i
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n this case diabetes mellitus. A comprehensive assessment is performed during admission to
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a facility to obtain a detailed history and complete physical examination.
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DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities
C/
7. Which is an example of data a nurse collects during a physical examination?
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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 C/
The lack of hair and shiny skin over both shins are objective data or signs that are part of t
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he physical examination. A patient‘s concerns about lack of money are subjective data and
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are part of the health history. A patient‘s complaints of tingling sensations in the feet are s
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ubjective data and are part of the health history. A patient‘s family statements are considere
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d secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- C/ C/ C / C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
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.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.
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ANS: D C/
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Wilson: Health Assessment for Nursing Practice, 8th Edition
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MULTIPLE CHOICE C/
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
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a heart attack.‖ What is the nurse‘s top priority at this time?
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
a. Determine the patient‘s personal data and insurance coverage. C/ C/ C/ C/ C/ C/ C/
b. Ask the patient to take a seat in the waiting room until his name is called.
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
c. Request that a nurse collect data for a comprehensive history.
C/ C/ C/ C/ C/ C/ C/ C/ C/
d. Ask a nurse to start a focused assessment of this patient now.
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ANS: D C /
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
cardiovascular system. The type of health assessment performed by the nurse is also driven b
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y patient need. Personal data and insurance information will be obtained, but in this situatio
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
n, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy o
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
f needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
needs to begin data collection, such as vital signs, immediately to determine the patient‘s h
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ealth status. Complications can be prevented if an immediate assessment is made to analyze
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C
the patient‘s symptoms. A comprehensive history is not indicated in this situation at this tim
/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
e. Some subjective data will be collected, such as allergies and medical history related to ca
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
rdiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
is not a priority at this time.
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DIF:Cognitive Level: Apply REF: Box 1- C/ C/ C / C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
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ing Priorities C/
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse conducts
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
a detailed history and physical examination.
C/ C/ C/ C/ C/ C/
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
od pressure checks to mall patrons.
C/ C/ C/ C/ C/
c. The nurse in an urgent care center checks the vital signs of a patient who
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
is complaining of leg pain.C/ C/ C/ C/
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d glucose level. C/ C/
ANS: B C /
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ple of a screening assessment focused on disease detection. A detailed history and physical
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
examination conducted during a first- C/ C/ C/ C/
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
atient complaining of leg pain in the triage area of an urgent care center is an example of a
C/ C/ C/ C/ C/ C/ C/ C/ C/ C / C/ C/ C/ C/ C/ C/ C/ C/ C
problem-
/
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
DIF:Cognitive Level: Understand C/ C/ REF: Box 1-3 C/ C/
, TOP:Nursing Process: Assessment C/ C/
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
c. The person who is being admitted to a long-term care facility
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d. The person who is beginning rehabilitation after a knee replacement
C/ C/ C/ C/ C/ C/ C/ C/ C/
ANS: B C/
A screening assessment is performed for the purpose of disease detection. In this case this p
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erson may have diabetes mellitus. A shift assessment is most appropriate for the person who
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C/is recovering in the hospital from surgery. A comprehensive assessment is performed durin
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
g admission to a facility to obtain a detailed history and complete physical examination. An
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C
episodic or follow-
/ C/ C/
up assessment is performed after knee replacement to evaluate the outcome of the procedure
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.
DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
C/ C/ C/
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ing Priorities C/
4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery yesterday
C/ C/ C/ C/ C/ C/
b. The person who is unaware of his high serum glucose levels
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
c. The person who is being admitted to a long-term care facility
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d. The person who is beginning rehabilitation after a knee replacement
C/ C/ C/ C/ C/ C/ C/ C/ C/
ANS: A C/
A shift assessment is most appropriate for the person who is recovering in the hospital from
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
surgery. A screening assessment is performed for the purpose of disease detection, in this cas
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
to obtain a detailed history and complete physical examination. An episodic or follow-
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
C/ C/ C/
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ing Priorities C/
5. For which person is a comprehensive assessment indicated?
C/ C/ C/ C/ C/ C/ C/
a. The person who had abdominal surgery yesterday
C/ C/ C/ C/ C/ C/
b. The person who is unaware of his high serum glucose levels
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
c. The person who is being admitted to a long-term care facility
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d. The person who is beginning rehabilitation after a knee replacement
C/ C/ C/ C/ C/ C/ C/ C/ C/
ANS: C C/
A comprehensive assessment is performed during admission to a facility to obtain a detailed
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
history and complete physical examination. A shift assessment is most appropriate for the
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
person who is recovering in the hospital from surgery. A screening assessment is performe
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
up assessment is performed after knee replacement to evaluate the outcome of the procedur
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
e.
, DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
C/ C/ C/
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ing Priorities
C/
6. For which person is an episodic or follow-up assessment indicated?
C/ C/ C/ C/ C/ C/ C/ C/ C/
a. The person who had abdominal surgery yesterday
C/ C/ C/ C/ C/ C/
b. The person who is unaware of his high serum glucose levels
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
c. The person who is being admitted to a long-term care facility
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
d. The person who is beginning rehabilitation after a knee replacement
C/ C/ C/ C/ C/ C/ C/ C/ C/
ANS: D C/
An episodic or follow-
C/ C/ C/
up assessment is performed after the knee replacement to evaluate the outcome of the proc
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
edure. A shift assessment is most appropriate for the person who is recovering in the hospit
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
al from surgery. A screening assessment is performed for the purpose of disease detection, i
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
n this case diabetes mellitus. A comprehensive assessment is performed during admission to
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
a facility to obtain a detailed history and complete physical examination.
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
DIF:Cognitive Level: Understand REF: Box 1- C/ C/ C/ C/
3 TOP:Nursing Process: Assessment
C/ C/ C/
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
C/ C/ C/ C/ C/ C/ C/ C/ C/ C/ C/
ing Priorities
C/
7. Which is an example of data a nurse collects during a physical examination?
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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 C/
The lack of hair and shiny skin over both shins are objective data or signs that are part of t
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he physical examination. A patient‘s concerns about lack of money are subjective data and
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are part of the health history. A patient‘s complaints of tingling sensations in the feet are s
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ubjective data and are part of the health history. A patient‘s family statements are considere
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d secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- C/ C/ C / C/
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
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.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.
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ANS: D C/
