Chapter 01: Introduction to Health Assessment
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he is “having a heart attack
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.
ANS: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s cardiovascu
health assessment performed by the nurse is also driven by patient need. Personal data and insurance in
but in this situation, these data can wait until after the patient is assessed. Based also on Maslow’s hier
needs take precedence. Rather than asking the patient to wait, the nurse needs to begin data collection,
immediately to determine the patient’s health status. Complications can be prevented if an immediate a
analyze the patient’s symptoms. A comprehensive history is not indicated in this situation at this time.
collected, such as allergies and medical history related to cardiovascular disease. Eyes, ears, or a comp
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 Prioriti
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.
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
glucose level.
ANS: B
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a scre
disease detection. A detailed history and physical examination conducted during a first-time visit to an
example of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
an example of a problem-based/focused assessment. A patient’s return appointment 1 month after toda
fasting blood glucose levels is an example of an episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
ANS: B
A screening assessment is performed for the purpose of disease detection. In this case this person may
shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A co
performed during admission to a facility to obtain a detailed history and complete physical examination
assessment is performed after knee replacement to evaluate the outcome of the procedure.
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he is “having a heart attack
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.
ANS: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s cardiovascu
health assessment performed by the nurse is also driven by patient need. Personal data and insurance in
but in this situation, these data can wait until after the patient is assessed. Based also on Maslow’s hier
needs take precedence. Rather than asking the patient to wait, the nurse needs to begin data collection,
immediately to determine the patient’s health status. Complications can be prevented if an immediate a
analyze the patient’s symptoms. A comprehensive history is not indicated in this situation at this time.
collected, such as allergies and medical history related to cardiovascular disease. Eyes, ears, or a comp
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 Prioriti
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.
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
glucose level.
ANS: B
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a scre
disease detection. A detailed history and physical examination conducted during a first-time visit to an
example of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
an example of a problem-based/focused assessment. A patient’s return appointment 1 month after toda
fasting blood glucose levels is an example of an episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
ANS: B
A screening assessment is performed for the purpose of disease detection. In this case this person may
shift assessment is most appropriate for the person who is recovering in the hospital from surgery. A co
performed during admission to a facility to obtain a detailed history and complete physical examination
assessment is performed after knee replacement to evaluate the outcome of the procedure.
