Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1401:14Introduction14to14Health14Assessment
MULTIPLE14CHOICE
1. A14patient14comes14to14the14emergency14department14and14tells14the14triage14 n
urse14that14 he14is14“having14a14heart14attack.”14What14is14the14nurse’s14top14priority14at14th
is14time?
a. Determine14the14patient’s14personal14data14a
nd14insurance14coverage.
b. Ask14the14patient14to14take14a14seat14in14the1
4waiting14room14until14 his14name14is14called.
c. Request14that14a14nurse14collect14data
14for14a14comprehensive14 history.
d. Ask14a14nurse14to14start14a14focused14ass
essment14of14this14patient14now.
ANSWER:14 D
The14nurse14needs14to14begin14an14assessment14as14soon14as14possible14that14is14focused14
on14this14patient’s14cardiovascular14system.14The14type14of14health14assessment14performed
14by14the14nurse14is14also14driven14by14patient14need.14Personal14data14and14insurance14info
rmation14will14be14obtained,14but14in14this14situation,14these14data14can14wait14until14after1
4the14patient14is14assessed.14Based14also14on14Maslow’s14hierarchy14of14needs,14physiolog
ic14needs14take14precedence.14Rather14than14asking14the14patient14to14wait,14the14nurse14ne
eds14to14begin14data14collection,14such14as14vital14signs,14immediately14to14determine14the14
patient’s14health14status.14Complications14can14be14prevented14if14an14immediate14assessm
ent14is14made14to14analyze14the14patient’s14symptoms.14A14comprehensive14history14is14no
t14indicated14in14this14situation14at14this14time.14Some14subjective14data14will14be14collecte
d,14such14as14allergies14and14medical14history14related14to14cardiovascular14disease.14Eyes,
14ears,14or14a14complete14musculoskeletal14or14mental14 health14assessment14is14not14a14pri
ority14at14this14time.
DIF:141414 Cognitive14Level:14Apply REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
2. Which14situation14illustrates14a14 screening14assessment?
a. A14patient14visits14an14obstetric14clinic14for
14the14first14time14and14the14nurse14conducts
14a14detailed14history14and14physical14examin
ation.
b. A14hospital14sponsors14a14health14fair14at1
4a14local14mall14and14provides14cholestero
l14and14blood14pressure14checks14to14mall
14patrons.
c. The14nurse14in14an14urgent14care14center1
4checks14the14vital14signs14of14a14patient14
who14is14complaining14of14leg14pain.
, d. A14patient14 newly14diagnosed14with14dia
betes14mellitus14comes14to14test14his14fast
ing14blood14glucose14level.
ANSWER:14B
A14health14fair14at14a14local14mall14that14provides14cholesterol14and14blood14pressure14che
cks14is14an14example14of14a14screening14assessment14focused14on14disease14detection.14A14
detailed14history14and14physical14examination14conducted14during14a14first-
time14visit14to14an14obstetric14clinic14is14an14example14of14a14comprehensive14assessment.14
Assessing14a14patient14complaining14of14leg14pain14in14the14triage14area14of14an14urgent14c
are14center14is14an14example14of14a14problem-
based/focused14assessment.14A14patient’s14return14appointment14114month14after14today’s1
4office14visit14to14report14fasting14blood14glucose14levels14is14an14example14of14an14episodi
c14or14follow-up14assessment.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Health14Promotion14and14Maintenance:14Health14Screening
3. For14which14person14is14a14screening14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitte
d14to14a14long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14B
A14screening14assessment14is14performed14for14the14purpose14of14disease14detection.14In1
4this14case14this14person14may14have14diabetes14mellitus.14A14shift14assessment14is14most1
4appropriate14for14the14person14who14is14recovering14in14the14hospital14from14surgery.14A
14comprehensive14assessment14is14performed14during14admission14to14a14facility14to14obtai
n14a14detailed14history14and14complete14physical14examination.14An14episodic14or14follo
w-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14of1
4the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
4. For14which14person14is14a14shift14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitted14to1
4a
long-term14care14facility
d. The14person14who14is14beginning14rehabilit
ation14after14a14knee14replacement
ANSWER:14 A
A14shift14assessment14is14most14appropriate14for14the14person14who14is14recovering14in14th
e14hospital14from14surgery.14A14screening14assessment14is14performed14for14the14purpose14o
f14disease14detection,14in14this14case14diabetes14mellitus.14 A14comprehensive14assessment14
is14performed14during14admission14to14a
, facility14to14obtain14a14detailed14history14and14complete14physical14examination.14An14e
pisodic14or14follow-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14o
f14the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14414TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
5. For14which14person14is14a14comprehensive14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitte
d14to14a14long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14C
A14comprehensive14assessment14is14performed14during14admission14to14a14facility14to14obtain14a
detailed14history14and14complete14physical14examination.14A14shift14assessment14is14most1
4appropriate14for14the14person14who14is14recovering14in14the14hospital14from14surgery.14A1
4screening14assessment14is14performed14for14the14purpose14of14disease14detection,14in14thi
s14case14diabetes14mellitus.14An14episodic14or14follow-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14of
14the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
6. For14which14person14is14an14episodic14or14follow-up14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitted14to14
a
long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14 D
An14episodic14or14follow-
up14assessment14is14performed14after14the14knee14replacement14to14evaluate14the14outcom
e14of14the14procedure.14A14shift14assessment14is14most14appropriate14for14the14person14wh
o14is14recovering14in14the14hospital14from14surgery.14A14screening14assessment14is14perfor
med14for14the14purpose14of14disease14detection,14in14this14case14diabetes14mellitus.14A14com
prehensive14assessment14is14performed14during14admission14to14a14facility14to14obtain14a1
4detailed14history14and14complete14physical14examination.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter1401:14Introduction14to14Health14Assessment
MULTIPLE14CHOICE
1. A14patient14comes14to14the14emergency14department14and14tells14the14triage14 n
urse14that14 he14is14“having14a14heart14attack.”14What14is14the14nurse’s14top14priority14at14th
is14time?
a. Determine14the14patient’s14personal14data14a
nd14insurance14coverage.
b. Ask14the14patient14to14take14a14seat14in14the1
4waiting14room14until14 his14name14is14called.
c. Request14that14a14nurse14collect14data
14for14a14comprehensive14 history.
d. Ask14a14nurse14to14start14a14focused14ass
essment14of14this14patient14now.
ANSWER:14 D
The14nurse14needs14to14begin14an14assessment14as14soon14as14possible14that14is14focused14
on14this14patient’s14cardiovascular14system.14The14type14of14health14assessment14performed
14by14the14nurse14is14also14driven14by14patient14need.14Personal14data14and14insurance14info
rmation14will14be14obtained,14but14in14this14situation,14these14data14can14wait14until14after1
4the14patient14is14assessed.14Based14also14on14Maslow’s14hierarchy14of14needs,14physiolog
ic14needs14take14precedence.14Rather14than14asking14the14patient14to14wait,14the14nurse14ne
eds14to14begin14data14collection,14such14as14vital14signs,14immediately14to14determine14the14
patient’s14health14status.14Complications14can14be14prevented14if14an14immediate14assessm
ent14is14made14to14analyze14the14patient’s14symptoms.14A14comprehensive14history14is14no
t14indicated14in14this14situation14at14this14time.14Some14subjective14data14will14be14collecte
d,14such14as14allergies14and14medical14history14related14to14cardiovascular14disease.14Eyes,
14ears,14or14a14complete14musculoskeletal14or14mental14 health14assessment14is14not14a14pri
ority14at14this14time.
DIF:141414 Cognitive14Level:14Apply REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
2. Which14situation14illustrates14a14 screening14assessment?
a. A14patient14visits14an14obstetric14clinic14for
14the14first14time14and14the14nurse14conducts
14a14detailed14history14and14physical14examin
ation.
b. A14hospital14sponsors14a14health14fair14at1
4a14local14mall14and14provides14cholestero
l14and14blood14pressure14checks14to14mall
14patrons.
c. The14nurse14in14an14urgent14care14center1
4checks14the14vital14signs14of14a14patient14
who14is14complaining14of14leg14pain.
, d. A14patient14 newly14diagnosed14with14dia
betes14mellitus14comes14to14test14his14fast
ing14blood14glucose14level.
ANSWER:14B
A14health14fair14at14a14local14mall14that14provides14cholesterol14and14blood14pressure14che
cks14is14an14example14of14a14screening14assessment14focused14on14disease14detection.14A14
detailed14history14and14physical14examination14conducted14during14a14first-
time14visit14to14an14obstetric14clinic14is14an14example14of14a14comprehensive14assessment.14
Assessing14a14patient14complaining14of14leg14pain14in14the14triage14area14of14an14urgent14c
are14center14is14an14example14of14a14problem-
based/focused14assessment.14A14patient’s14return14appointment14114month14after14today’s1
4office14visit14to14report14fasting14blood14glucose14levels14is14an14example14of14an14episodi
c14or14follow-up14assessment.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Health14Promotion14and14Maintenance:14Health14Screening
3. For14which14person14is14a14screening14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitte
d14to14a14long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14B
A14screening14assessment14is14performed14for14the14purpose14of14disease14detection.14In1
4this14case14this14person14may14have14diabetes14mellitus.14A14shift14assessment14is14most1
4appropriate14for14the14person14who14is14recovering14in14the14hospital14from14surgery.14A
14comprehensive14assessment14is14performed14during14admission14to14a14facility14to14obtai
n14a14detailed14history14and14complete14physical14examination.14An14episodic14or14follo
w-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14of1
4the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
4. For14which14person14is14a14shift14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitted14to1
4a
long-term14care14facility
d. The14person14who14is14beginning14rehabilit
ation14after14a14knee14replacement
ANSWER:14 A
A14shift14assessment14is14most14appropriate14for14the14person14who14is14recovering14in14th
e14hospital14from14surgery.14A14screening14assessment14is14performed14for14the14purpose14o
f14disease14detection,14in14this14case14diabetes14mellitus.14 A14comprehensive14assessment14
is14performed14during14admission14to14a
, facility14to14obtain14a14detailed14history14and14complete14physical14examination.14An14e
pisodic14or14follow-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14o
f14the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14414TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
5. For14which14person14is14a14comprehensive14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitte
d14to14a14long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14C
A14comprehensive14assessment14is14performed14during14admission14to14a14facility14to14obtain14a
detailed14history14and14complete14physical14examination.14A14shift14assessment14is14most1
4appropriate14for14the14person14who14is14recovering14in14the14hospital14from14surgery.14A1
4screening14assessment14is14performed14for14the14purpose14of14disease14detection,14in14thi
s14case14diabetes14mellitus.14An14episodic14or14follow-
up14assessment14is14performed14after14knee14replacement14to14evaluate14the14outcome14of
14the14procedure.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
MSC:14NCLEX14Patient14Needs:14Safe14and14Effective14Care14Environment:14Management14of14C
are:14Establishing14Priorities
6. For14which14person14is14an14episodic14or14follow-up14assessment14indicated?
a. The14person14who14had14abdominal14su
rgery14yesterday
b. The14person14who14is14unaware14of14h
is14high14serum14glucose14levels
c. The14person14who14is14being14admitted14to14
a
long-term14care14facility
d. The14person14who14is14beginning14rehabilita
tion14after14a14knee14replacement
ANSWER:14 D
An14episodic14or14follow-
up14assessment14is14performed14after14the14knee14replacement14to14evaluate14the14outcom
e14of14the14procedure.14A14shift14assessment14is14most14appropriate14for14the14person14wh
o14is14recovering14in14the14hospital14from14surgery.14A14screening14assessment14is14perfor
med14for14the14purpose14of14disease14detection,14in14this14case14diabetes14mellitus.14A14com
prehensive14assessment14is14performed14during14admission14to14a14facility14to14obtain14a1
4detailed14history14and14complete14physical14examination.
DIF:141414 Cognitive14Level:14Understand REF:14Box141-
314|14p.14314TOP:14Nursing14Process:14Assessment
