Test Bank for Health Assessment for Nu
5 5 5 5 5 5
rsing Practice 7th Edition by Wilson Chap
5 5 5 5 5 5
ter 1 - 24
5 5 5
,Chapter501:5Introduction5to5Health5Assessment
MULTIPLE5CHOICE
1. A5patient5comes5to5the5emergency5department5and5tells5the5triage5 nurse5that5 he5
is5“having5a5heart5attack.”5What5is5the5nurse’s5top5priority5at5this5time?
a. Determine5the5patient’s5personal5data5and5ins
urance5coverage.
b. Ask5the5patient5to5take5a5seat5in5the5waiting5r
oom5until5 his5name5is5called.
c. Request5that5a5nurse5collect5data5for5a
5comprehensive5 history.
d. Ask5a5nurse5to5start5a5focused5assessment
5of5this5patient5now.
ANSWER:5 D
The5nurse5needs5to5begin5an5assessment5as5soon5as5possible5that5is5focused5on5this5patient’s5
cardiovascular5system.5The5type5of5health5assessment5performed5by5the5nurse5is5also5drive
n5by5patient5need.5Personal5data5and5insurance5information5will5be5obtained,5but5in5this5situ
ation,5these5data5can5wait5until5after5the5patient5is5assessed.5Based5also5on5Maslow’s5hierar
chy5of5needs,5physiologic5needs5take5precedence.5Rather5than5asking5the5patient5to5wait,5th
e5nurse5needs5to5begin5data5collection,5such5as5vital5signs,5immediately5to5determine5the5pat
ient’s5health5status.5Complications5can5be5prevented5if5an5immediate5assessment5is5made5to
5analyze5the5patient’s5symptoms.5A5comprehensive5history5is5not5indicated5in5this5situation5
at5this5time.5Some5subjective5data5will5be5collected,5such5as5allergies5and5medical5history5r
elated5to5cardiovascular5disease.5Eyes,5ears,5or5a5complete5musculoskeletal5or5mental5 healt
h5assessment5is5not5a5priority5at5this5time.
DIF:555 Cognitive5Level:5Apply REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
2. Which5situation5illustrates5a5 screening5assessment?
a. A5patient5visits5an5obstetric5clinic5for5the5fir
st5time5and5the5nurse5conducts5a5detailed5hist
ory5and5physical5examination.
b. A5hospital5sponsors5a5health5fair5at5a5local
5mall5and5provides5cholesterol5and5blood5
pressure5checks5to5mall5patrons.
c. The5nurse5in5an5urgent5care5center5checks
5the5vital5signs5of5a5patient5who5is5compla
ining5of5leg5pain.
, d. A5patient5 newly5diagnosed5with5diabetes5
mellitus5comes5to5test5his5fasting5blood5
glucose5level.
ANSWER:5B
A5health5fair5at5a5local5mall5that5provides5cholesterol5and5blood5pressure5checks5is5an5exam
ple5of5a5screening5assessment5focused5on5disease5detection.5A5detailed5history5and5physical
5examination5conducted5during5a5first-
time5visit5to5an5obstetric5clinic5is5an5example5of5a5comprehensive5assessment.5Assessing5a5p
atient5complaining5of5leg5pain5in5the5triage5area5of5an5urgent5care5center5is5an5example5of5a
5problem-
based/focused5assessment.5A5patient’s5return5appointment515month5after5today’s5office5visi
t5to5report5fasting5blood5glucose5levels5is5an5example5of5an5episodic5or5follow-
up5assessment.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5 Needs:5Health5Promotion5and5Maintenance:5Health5Screening
3. For5which5person5is5a5screening5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5
a5long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5B
A5screening5assessment5is5performed5for5the5purpose5of5disease5detection.5In5this5case5thi
s5person5may5have5diabetes5mellitus.5A5shift5assessment5is5most5appropriate5for5the5person
5who5is5recovering5in5the5hospital5from5surgery.5A5comprehensive5assessment5is5performe
d5during5admission5to5a5facility5to5obtain5a5detailed5history5and5complete5physical5examin
ation.5An5episodic5or5follow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5procedu
re.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
4. For5which5person5is5a5shift5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5a
long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5
after5a5knee5replacement
ANSWER:5 A
A5shift5assessment5is5most5appropriate5for5the5person5who5is5recovering5in5the5hospital5fro
m5surgery.5A5screening5assessment5is5performed5for5the5purpose5of5disease5detection,5in5this
5case5diabetes5mellitus.5 A5comprehensive5assessment5is5performed5during5admission5to5a
, facility5to5obtain5a5detailed5history5and5complete5physical5examination.5An5episodic5or5f
ollow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5proced
ure.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.545TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
5. For5which5person5is5a5comprehensive5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5
a5long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5C
A5comprehensive5assessment5is5performed5during5admission5to5a5facility5to5obtain5a
detailed5history5and5complete5physical5examination.5A5shift5assessment5is5most5appropriat
e5for5the5person5who5is5recovering5in5the5hospital5from5surgery.5A5screening5assessment5is5
performed5for5the5purpose5of5disease5detection,5in5this5case5diabetes5mellitus.5An5episodic
5or5follow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5proced
ure.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
6. For5which5person5is5an5episodic5or5follow-up5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5a
long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5 D
An5episodic5or5follow-
up5assessment5is5performed5after5the5knee5replacement5to5evaluate5the5outcome5of5the5pro
cedure.5A5shift5assessment5is5most5appropriate5for5the5person5who5is5recovering5in5the5hosp
ital5from5surgery.5A5screening5assessment5is5performed5for5the5purpose5of5disease5detectio
n,5in5this5case5diabetes5mellitus.5A5comprehensive5assessment5is5performed5during5admissi
on5to5a5facility5to5obtain5a5detailed5history5and5complete5physical5examination.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
5 5 5 5 5 5
rsing Practice 7th Edition by Wilson Chap
5 5 5 5 5 5
ter 1 - 24
5 5 5
,Chapter501:5Introduction5to5Health5Assessment
MULTIPLE5CHOICE
1. A5patient5comes5to5the5emergency5department5and5tells5the5triage5 nurse5that5 he5
is5“having5a5heart5attack.”5What5is5the5nurse’s5top5priority5at5this5time?
a. Determine5the5patient’s5personal5data5and5ins
urance5coverage.
b. Ask5the5patient5to5take5a5seat5in5the5waiting5r
oom5until5 his5name5is5called.
c. Request5that5a5nurse5collect5data5for5a
5comprehensive5 history.
d. Ask5a5nurse5to5start5a5focused5assessment
5of5this5patient5now.
ANSWER:5 D
The5nurse5needs5to5begin5an5assessment5as5soon5as5possible5that5is5focused5on5this5patient’s5
cardiovascular5system.5The5type5of5health5assessment5performed5by5the5nurse5is5also5drive
n5by5patient5need.5Personal5data5and5insurance5information5will5be5obtained,5but5in5this5situ
ation,5these5data5can5wait5until5after5the5patient5is5assessed.5Based5also5on5Maslow’s5hierar
chy5of5needs,5physiologic5needs5take5precedence.5Rather5than5asking5the5patient5to5wait,5th
e5nurse5needs5to5begin5data5collection,5such5as5vital5signs,5immediately5to5determine5the5pat
ient’s5health5status.5Complications5can5be5prevented5if5an5immediate5assessment5is5made5to
5analyze5the5patient’s5symptoms.5A5comprehensive5history5is5not5indicated5in5this5situation5
at5this5time.5Some5subjective5data5will5be5collected,5such5as5allergies5and5medical5history5r
elated5to5cardiovascular5disease.5Eyes,5ears,5or5a5complete5musculoskeletal5or5mental5 healt
h5assessment5is5not5a5priority5at5this5time.
DIF:555 Cognitive5Level:5Apply REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
2. Which5situation5illustrates5a5 screening5assessment?
a. A5patient5visits5an5obstetric5clinic5for5the5fir
st5time5and5the5nurse5conducts5a5detailed5hist
ory5and5physical5examination.
b. A5hospital5sponsors5a5health5fair5at5a5local
5mall5and5provides5cholesterol5and5blood5
pressure5checks5to5mall5patrons.
c. The5nurse5in5an5urgent5care5center5checks
5the5vital5signs5of5a5patient5who5is5compla
ining5of5leg5pain.
, d. A5patient5 newly5diagnosed5with5diabetes5
mellitus5comes5to5test5his5fasting5blood5
glucose5level.
ANSWER:5B
A5health5fair5at5a5local5mall5that5provides5cholesterol5and5blood5pressure5checks5is5an5exam
ple5of5a5screening5assessment5focused5on5disease5detection.5A5detailed5history5and5physical
5examination5conducted5during5a5first-
time5visit5to5an5obstetric5clinic5is5an5example5of5a5comprehensive5assessment.5Assessing5a5p
atient5complaining5of5leg5pain5in5the5triage5area5of5an5urgent5care5center5is5an5example5of5a
5problem-
based/focused5assessment.5A5patient’s5return5appointment515month5after5today’s5office5visi
t5to5report5fasting5blood5glucose5levels5is5an5example5of5an5episodic5or5follow-
up5assessment.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5 Needs:5Health5Promotion5and5Maintenance:5Health5Screening
3. For5which5person5is5a5screening5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5
a5long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5B
A5screening5assessment5is5performed5for5the5purpose5of5disease5detection.5In5this5case5thi
s5person5may5have5diabetes5mellitus.5A5shift5assessment5is5most5appropriate5for5the5person
5who5is5recovering5in5the5hospital5from5surgery.5A5comprehensive5assessment5is5performe
d5during5admission5to5a5facility5to5obtain5a5detailed5history5and5complete5physical5examin
ation.5An5episodic5or5follow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5procedu
re.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
4. For5which5person5is5a5shift5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5a
long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5
after5a5knee5replacement
ANSWER:5 A
A5shift5assessment5is5most5appropriate5for5the5person5who5is5recovering5in5the5hospital5fro
m5surgery.5A5screening5assessment5is5performed5for5the5purpose5of5disease5detection,5in5this
5case5diabetes5mellitus.5 A5comprehensive5assessment5is5performed5during5admission5to5a
, facility5to5obtain5a5detailed5history5and5complete5physical5examination.5An5episodic5or5f
ollow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5proced
ure.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.545TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
5. For5which5person5is5a5comprehensive5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5
a5long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5C
A5comprehensive5assessment5is5performed5during5admission5to5a5facility5to5obtain5a
detailed5history5and5complete5physical5examination.5A5shift5assessment5is5most5appropriat
e5for5the5person5who5is5recovering5in5the5hospital5from5surgery.5A5screening5assessment5is5
performed5for5the5purpose5of5disease5detection,5in5this5case5diabetes5mellitus.5An5episodic
5or5follow-
up5assessment5is5performed5after5knee5replacement5to5evaluate5the5outcome5of5the5proced
ure.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
MSC:5NCLEX5Patient5Needs:5Safe5and5Effective5Care5Environment:5Management5of5Care:5Establis
hing5Priorities
6. For5which5person5is5an5episodic5or5follow-up5assessment5indicated?
a. The5person5who5had5abdominal5surgery5
yesterday
b. The5person5who5is5unaware5of5his5high
5serum5glucose5levels
c. The5person5who5is5being5admitted5to5a
long-term5care5facility
d. The5person5who5is5beginning5rehabilitation5a
fter5a5knee5replacement
ANSWER:5 D
An5episodic5or5follow-
up5assessment5is5performed5after5the5knee5replacement5to5evaluate5the5outcome5of5the5pro
cedure.5A5shift5assessment5is5most5appropriate5for5the5person5who5is5recovering5in5the5hosp
ital5from5surgery.5A5screening5assessment5is5performed5for5the5purpose5of5disease5detectio
n,5in5this5case5diabetes5mellitus.5A5comprehensive5assessment5is5performed5during5admissi
on5to5a5facility5to5obtain5a5detailed5history5and5complete5physical5examination.
DIF:555 Cognitive5Level:5Understand REF:5Box51-
35|5p.535TOP:5Nursing5Process:5Assessment
