Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment vr vr vr vr vr
MULTIPLE CHOICE vr
1. A patient comes to the emergency department and tells the triage nurse that
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vr heis “having a heart attack.” What is the nurse’s top priority at this time?
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a. Determine the patient’s personal data vr vr vr vr
andinsurance coverage. vr r
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b. Ask the patient to take a seat in the
vr vr vr vr vr vr vr vr
waitingroom until his name is called.
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v vr vr vr vr vr
c. Request that a nurse collect data for vr vr vr vr vr vr
acomprehensive history.
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v vr
d. Ask a nurse to start a focused
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assessmentof this patient now.
vr r
v vr vr vr
ANSWER: D vr
The nurse needs to begin an assessment as soon as possible that is focused on this
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
patient’scardiovascular system. The type of health assessment performed by the nurse
vr vr vr vr vr vr vr vr vr vr vr vr
is also drivenby patient need. Personal data and insurance information will be
vr vr vr vr vr vr vr vr vr vr vr vr vr
obtained, but in this situation, these data can wait until after the patient is assessed.
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
Based also on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather
vr vr vr vr vr vr vr vr vr vr vr vr
than asking the patient to wait, the nurse needs to begin data collection, such as vital
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
signs, immediately to determinethe patient’s health status. Complications can be
vr vr vr vr vr vr vr vr vr vr vr
prevented if an immediate assessment is made to analyze the patient’s symptoms. A
vr vr vr vr vr vr vr vr vr vr vr vr vr
comprehensive history is not indicated in this situation at this time. Some subjective
vr vr vr vr vr vr vr vr vr vr vr vr vr
data will be collected, such as allergies and medical history related to cardiovascular
vr vr vr vr vr vr vr vr vr vr vr vr vr
disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
priority at this time.
vr vr vr vr
DIF: Cognitive Level: Apply
vr vr v r REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the vr vr vr vr vr vr vr
first time and the nurse conducts a vr vr vr vr vr vr vr
detailedhistory and physical examination. vr r
v vr vr vr
b. A hospital sponsors a health fair at a vr vr vr vr vr vr vr
localmall and provides cholesterol and vr r
v vr vr vr vr
blood pressure checks to mall patrons. vr vr vr vr vr vr
c. The nurse in an urgent care center vr vr vr vr vr vr
checksthe vital signs of a patient who vr r
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is complaining of leg pain. vr vr vr vr vr
, d. A patient newly diagnosed with
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diabetesmellitus comes to test his
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fasting blood glucose level.
vr vr vr vr
ANSWER: B vr
A health fair at a local mall that provides cholesterol and blood pressure checks is an
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
example of a screening assessment focused on disease detection. A detailed history
vr vr vr vr vr vr vr vr vr vr vr vr
and physical examination conducted during a first-time visit to an obstetric clinic is an
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
vr vr vr vr vr vr vr vr vr vr vr vr vr
the triage area of an urgent care center is an example of a problem-based/focused
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
assessment. A patient’s return appointment 1 month after today’s office visit to report
vr vr vr vr vr vr vr vr vr vr vr vr vr
fasting blood glucose levels is an example of an episodic or follow-up assessment.
vr vr vr vr vr vr vr vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
vr vr vr vr vr vr vr vr vr
3. For which person is a screening assessment indicated?
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a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
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b. The person who is unaware of his
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highserum glucose levels
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v vr vr
c. The person who is being admitted to
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along-term care facility
vr r
v vr vr
d. The person who is beginning
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rehabilitationafter a knee replacement
vr r
v vr vr vr
ANSWER: B vr
A screening assessment is performed for the purpose of disease detection. In this case
vr vr vr vr vr vr vr vr vr vr vr vr vr
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
vr r
v vr vr vr vr vr vr vr vr vr vr vr vr
person who is recovering in the hospital from surgery. A comprehensive assessment
vr vr vr vr vr vr vr vr vr vr vr vr
is performedduring admission to a facility to obtain a detailed history and complete
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
physical examination. An episodic or follow-up assessment is performed after knee
vr vr vr vr vr vr vr vr vr vr vr
replacement toevaluate the outcome of the procedure.
vr vr vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
4. For which person is a shift assessment indicated?
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a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to a vr vr vr vr vr vr vr
long-term care facility vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: A vr
A shift assessment is most appropriate for the person who is recovering in the hospital
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
fromsurgery. A screening assessment is performed for the purpose of disease detection,
vr r
v vr vr vr vr vr vr vr vr vr vr vr
in this case diabetes mellitus. A comprehensive assessment is performed during
vr vr vr vr vr vr vr vr vr vr vr
admission to a
vr vr vr
, facility to obtain a detailed history and complete physical examination. An episodic
vr vr vr vr vr vr vr vr vr vr vr
or follow-up assessment is performed after knee replacement to evaluate the outcome
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of theprocedure.
vr vr r
v
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
4TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
5. For which person is a comprehensive assessment indicated?
vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to vr vr vr vr vr vr
along-term care facility vr r
v vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: C vr
A comprehensive assessment is performed during admission to a facility to obtain a
vr vr vr vr vr vr vr vr vr vr vr vr
detailed history and complete physical examination. A shift assessment is most
vr vr vr vr vr vr vr vr vr vr
appropriatefor the person who is recovering in the hospital from surgery. A screening
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
assessment is performed for the purpose of disease detection, in this case diabetes
vr vr vr vr vr vr vr vr vr vr vr vr vr
mellitus. An episodic or follow-up assessment is performed after knee replacement to
vr vr vr vr vr vr vr vr vr vr vr vr
evaluate the outcome of the procedure.
vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
6. For which person is an episodic or follow-up assessment indicated?
vr vr vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to a vr vr vr vr vr vr vr
long-term care facility vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: D vr
An episodic or follow-up assessment is performed after the knee replacement to
vr vr vr vr vr vr vr vr vr vr vr
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
person who isrecovering in the hospital from surgery. A screening assessment is
vr vr vr vr vr vr vr vr vr vr vr vr vr
performed for the purpose of disease detection, in this case diabetes mellitus. A
vr vr vr vr vr vr vr vr vr vr vr vr vr
comprehensive assessment is performed during admission to a facility to obtain a
vr vr vr vr vr vr vr vr vr vr vr vr
detailed history and complete physicalexamination.
vr vr vr vr vr r
v
DIF: Cognitive Level: Understand
vr vr vr vr vr REF: Box 1-3 | p. vr vr vr vr
3TOP: Nursing Process: Assessment
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v vr vr vr
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment vr vr vr vr vr
MULTIPLE CHOICE vr
1. A patient comes to the emergency department and tells the triage nurse that
vr vr vr vr vr vr vr vr vr vr vr vr
vr heis “having a heart attack.” What is the nurse’s top priority at this time?
r
v vr vr vr vr vr vr vr vr vr vr vr vr vr
a. Determine the patient’s personal data vr vr vr vr
andinsurance coverage. vr r
v vr
b. Ask the patient to take a seat in the
vr vr vr vr vr vr vr vr
waitingroom until his name is called.
vr r
v vr vr vr vr vr
c. Request that a nurse collect data for vr vr vr vr vr vr
acomprehensive history.
vr r
v vr
d. Ask a nurse to start a focused
vr vr vr vr vr vr
assessmentof this patient now.
vr r
v vr vr vr
ANSWER: D vr
The nurse needs to begin an assessment as soon as possible that is focused on this
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
patient’scardiovascular system. The type of health assessment performed by the nurse
vr vr vr vr vr vr vr vr vr vr vr vr
is also drivenby patient need. Personal data and insurance information will be
vr vr vr vr vr vr vr vr vr vr vr vr vr
obtained, but in this situation, these data can wait until after the patient is assessed.
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
Based also on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather
vr vr vr vr vr vr vr vr vr vr vr vr
than asking the patient to wait, the nurse needs to begin data collection, such as vital
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
signs, immediately to determinethe patient’s health status. Complications can be
vr vr vr vr vr vr vr vr vr vr vr
prevented if an immediate assessment is made to analyze the patient’s symptoms. A
vr vr vr vr vr vr vr vr vr vr vr vr vr
comprehensive history is not indicated in this situation at this time. Some subjective
vr vr vr vr vr vr vr vr vr vr vr vr vr
data will be collected, such as allergies and medical history related to cardiovascular
vr vr vr vr vr vr vr vr vr vr vr vr vr
disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
priority at this time.
vr vr vr vr
DIF: Cognitive Level: Apply
vr vr v r REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
2. Which situation illustrates a screening assessment?
vr vr vr vr vr
a. A patient visits an obstetric clinic for the vr vr vr vr vr vr vr
first time and the nurse conducts a vr vr vr vr vr vr vr
detailedhistory and physical examination. vr r
v vr vr vr
b. A hospital sponsors a health fair at a vr vr vr vr vr vr vr
localmall and provides cholesterol and vr r
v vr vr vr vr
blood pressure checks to mall patrons. vr vr vr vr vr vr
c. The nurse in an urgent care center vr vr vr vr vr vr
checksthe vital signs of a patient who vr r
v vr vr vr vr vr vr
is complaining of leg pain. vr vr vr vr vr
, d. A patient newly diagnosed with
vr vr vr vr
diabetesmellitus comes to test his
vr r
v vr vr vr vr
fasting blood glucose level.
vr vr vr vr
ANSWER: B vr
A health fair at a local mall that provides cholesterol and blood pressure checks is an
vr vr vr vr vr vr vr vr vr vr vr vr vr vr vr
example of a screening assessment focused on disease detection. A detailed history
vr vr vr vr vr vr vr vr vr vr vr vr
and physical examination conducted during a first-time visit to an obstetric clinic is an
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
vr vr vr vr vr vr vr vr vr vr vr vr vr
the triage area of an urgent care center is an example of a problem-based/focused
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
assessment. A patient’s return appointment 1 month after today’s office visit to report
vr vr vr vr vr vr vr vr vr vr vr vr vr
fasting blood glucose levels is an example of an episodic or follow-up assessment.
vr vr vr vr vr vr vr vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
vr vr vr vr vr vr vr vr vr
3. For which person is a screening assessment indicated?
vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his
vr vr vr vr vr vr
highserum glucose levels
vr r
v vr vr
c. The person who is being admitted to
vr vr vr vr vr vr
along-term care facility
vr r
v vr vr
d. The person who is beginning
vr vr vr vr
rehabilitationafter a knee replacement
vr r
v vr vr vr
ANSWER: B vr
A screening assessment is performed for the purpose of disease detection. In this case
vr vr vr vr vr vr vr vr vr vr vr vr vr
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
vr r
v vr vr vr vr vr vr vr vr vr vr vr vr
person who is recovering in the hospital from surgery. A comprehensive assessment
vr vr vr vr vr vr vr vr vr vr vr vr
is performedduring admission to a facility to obtain a detailed history and complete
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
physical examination. An episodic or follow-up assessment is performed after knee
vr vr vr vr vr vr vr vr vr vr vr
replacement toevaluate the outcome of the procedure.
vr vr vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
4. For which person is a shift assessment indicated?
vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to a vr vr vr vr vr vr vr
long-term care facility vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: A vr
A shift assessment is most appropriate for the person who is recovering in the hospital
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
fromsurgery. A screening assessment is performed for the purpose of disease detection,
vr r
v vr vr vr vr vr vr vr vr vr vr vr
in this case diabetes mellitus. A comprehensive assessment is performed during
vr vr vr vr vr vr vr vr vr vr vr
admission to a
vr vr vr
, facility to obtain a detailed history and complete physical examination. An episodic
vr vr vr vr vr vr vr vr vr vr vr
or follow-up assessment is performed after knee replacement to evaluate the outcome
vr vr vr vr vr vr vr vr vr vr vr vr
of theprocedure.
vr vr r
v
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
4TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
5. For which person is a comprehensive assessment indicated?
vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to vr vr vr vr vr vr
along-term care facility vr r
v vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: C vr
A comprehensive assessment is performed during admission to a facility to obtain a
vr vr vr vr vr vr vr vr vr vr vr vr
detailed history and complete physical examination. A shift assessment is most
vr vr vr vr vr vr vr vr vr vr
appropriatefor the person who is recovering in the hospital from surgery. A screening
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
assessment is performed for the purpose of disease detection, in this case diabetes
vr vr vr vr vr vr vr vr vr vr vr vr vr
mellitus. An episodic or follow-up assessment is performed after knee replacement to
vr vr vr vr vr vr vr vr vr vr vr vr
evaluate the outcome of the procedure.
vr vr vr vr vr vr
DIF: Cognitive Level: Understand
vr vr vr REF: Box 1-3 | p. vr vr vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
vr vr vr vr vr vr vr vr vr vr
Care:Establishing Priorities
vr r
v vr
6. For which person is an episodic or follow-up assessment indicated?
vr vr vr vr vr vr vr vr vr
a. The person who had abdominal vr vr vr vr
surgeryyesterday vr r
v
b. The person who is unaware of his vr vr vr vr vr vr
highserum glucose levels vr r
v vr vr
c. The person who is being admitted to a vr vr vr vr vr vr vr
long-term care facility vr vr
d. The person who is beginning vr vr vr vr
rehabilitationafter a knee replacement vr r
v vr vr vr
ANSWER: D vr
An episodic or follow-up assessment is performed after the knee replacement to
vr vr vr vr vr vr vr vr vr vr vr
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
vr vr vr vr vr vr vr vr vr vr vr vr vr vr
person who isrecovering in the hospital from surgery. A screening assessment is
vr vr vr vr vr vr vr vr vr vr vr vr vr
performed for the purpose of disease detection, in this case diabetes mellitus. A
vr vr vr vr vr vr vr vr vr vr vr vr vr
comprehensive assessment is performed during admission to a facility to obtain a
vr vr vr vr vr vr vr vr vr vr vr vr
detailed history and complete physicalexamination.
vr vr vr vr vr r
v
DIF: Cognitive Level: Understand
vr vr vr vr vr REF: Box 1-3 | p. vr vr vr vr
3TOP: Nursing Process: Assessment
vr r
v vr vr vr
