Test Bank For Health Assessment forNursing Practice 6th Edition
m m m m m m m m
by Susan Fickertt Wilson, Jean Fore
m m m m m m
Chapterm01:mIntroductionmtomHealthmAssessment
Wilson:mHealthmAssessmentmformNursingmPractice,m6thmEditio
nmMULTIPLEmCHOICE
1. Ampatientmcomesmtomthememergencymdepartmentmandmtellsmthe mtriagemnursemthatmhe mism“hav
ingmamheartmattack.”mWhatmismthe mnurse’smtopmprioritymatmthismtime?
a. Determine mthe mpatient’smpersonalmdatamandminsurance mcoverage.
b. Askmthe mpatientmtomtake mamseatminmthe mwaitingmroommuntilmhismname mismcalled.
c. Requestmthatmamnurse mcollectmdatamformamcomprehensive mhistory.
d. Askmamnursemtomstartmamfocusedmassessmentmof mthismpatientmn
ow.mANS:mD
The mnurse mneedsmtombeginmanmassessmentmasmsoonmasmpossible mthatmismfocusedmonmthismpatient’s
cardiovascularmsystem.mThe mtypemofmhealthmassessmentmperformedmbymthemnursemismalsomdrivenmbympati
entmneed.mPersonalmdatamandminsuranceminformationmwillmbemobtained,mbutminmthismsituation,mthesemdata
m canm waitm untilm aftermthem patientmismassessed.m BasedmalsomonmMaslow’s mhierarchy mofm needs, mphysiologic
m needs m take
precedence.mRathermthanmaskingmthe mpatientmtomwait,mthemnursemneedsmtombeginmdatamcollection,msuchm
asmvitalmsigns,mimmediatelymtomdetermine mthempatient’smhealthmstatus.mComplicationsmcanmbe mpreventedm
ifmanmimmediatemassessmentmismmademtomanalyzemthe mpatient’smsymptoms.mAmcomprehensivemhistorymis
m notm indicated m inmthismsituation matmthismtime.m Somemsubjective mdatamwillm bemcollected,m suchmasmallergies
m and
medicalmhistorymrelatedmtomcardiovascularmdisease.mEyes,mears,mormamcompletemmusculoskeletalmormmenta
lmhealthmassessmentmismnotmamprioritymatmthismtime.
DIF: Cognitive mLevel:mApplymREF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
,2. Whichmsituationmillustratesmamscreeningmassessment?
a. Ampatientmvisitsmanmobstetricmclinicmformthemfirstmtimemandmthe mnursemconductsmamdetailedmhistor
ymandmphysicalmexamination.
b. Amhospitalmsponsorsmamhealthmfairmatmamlocalmmallmandmprovidesmcholesterolmandmbloodmpre
ssure mchecksmtommallmpatrons.
c. The mnurse minmanmurgentmcaremcentermchecksmthe mvitalmsignsmofmampatientmwhomismcomplainingm
ofmlegmpain.
d. Ampatientmnewlymdiagnosedmwithmdiabetesmmellitusmcomesmtomtestmhismfastingmbl
oodmglucose mlevel.
ANS:mB
Amhealthmfairmatmamlocalmmallmthatmprovidesmcholesterolmandmbloodmpressure mchecksmismanmexamplemof mam
screeningmassessmentmfocusedmonmdisease mdetection.mAmdetailedmhistorymandmphysicalmexamination
conductedmduringmamfirst-
time mvisitmtomanmobstetricmclinicmismanmexamplemof mamcomprehensivemassessment.mAssessingmampatientmc
omplainingmof mlegmpainminmthe mtriage mareamof manmurgentmcare mcentermismanmexample mofmamproblem-
based/focusedmassessment.mAmpatient’smreturnmappointmentm1mmonthmaftermtoday’smofficemvisitmtomrepo
rtmfastingmbloodmglucose mlevelsmismanmexample mof manmepisodicmormfollow-upmassessment.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-
3m|mp.m3mTOP:mNursingmProcess:mAssessmentmMSC:mNCLEXmPatientmNeeds:mHealthmPromotionm
andmMaintenance:mHealthmScreening
3. Formwhichmpersonmismamscreeningmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mB
Amscreeningmassessmentmismperformedmformthempurpose mofmdisease mdetection.mInmthismcasemthismpersonm
maymhave mdiabetesmmellitus.mAmshiftmassessmentmismmostmappropriate mformthe mpersonmwhomismrecoveri
ngminmthe mhospitalmfrommsurgery.mAmcomprehensivemassessmentmismperformedmduringmadmissionmtomamfa
cilitymtomobtainmamdetailedmhistorymandmcomplete mphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee mreplacementmtomevaluate mthe moutcome mof mthe mprocedure.
,DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
4. Formwhichmpersonmismamshiftmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mA
Amshiftmassessmentmismmostmappropriate mformthempersonmwhomismrecoveringminmthe mhospitalmfrommsurgery.mA
screeningmassessmentmismperformedmformthempurposemofmdiseasemdetection,minmthismcase mdiabetesmmellit
us.mAmcomprehensive massessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhis
torymandmcomplete mphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee
replacementmtomevaluate mthe moutcome mofmthe mprocedure.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m4mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
5. Formwhichmpersonmismamcomprehensive massessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mC
Amcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistory
m andm completem physicalmexamination.mAm shiftm assessmentm ismmostm appropriatemform them personm whom ism r
ecoveringminmthemhospitalmfrommsurgery.mAmscreeningmassessmentmismperformedmformthe mpurposemofmdis
ease mdetection,minmthismcasemdiabetesmmellitus.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee mreplacementmtomevaluate mthe moutcome mof mthe mprocedure.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
, MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
6. Formwhichmpersonmismanmepisodicmormfollow-upmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mD
Anmepisodicmormfollow-
upmassessmentmismperformedmaftermthemkneemreplacementmtomevaluatemthemoutcomemofmthemprocedure.
m A m shiftmassessmentmismmostmappropriate mformthempersonmwhomismrecoveringminmthe mhospitalm frommsurger
y.mAmscreeningmassessmentmismperformedmformthempurposemofmdiseasemdetection,minmthismcase mdiabetesm
mellitus.mAmcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetail
edmhistorymandmcomplete mphysicalmexamination.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
7. Whichmismanmexample mof mdatamamnurse mcollectsmduringmamphysicalmexamination?
a. The mpatient’smlackmofmhairmandmshinymskinmovermbothmshins
b. The mpatient’smstatedmconcernmaboutmlackmofmmoneymformprescriptions
c. The mpatient’smcomplaintsmof mtinglingmsensationsminmthe mfeet
d. The mpatient’smmother’smstatementsmthatmthempatientmismverymnervousmlat
elymANS:mA
The mlackmofmhairmandmshinymskinmovermbothmshinsmare mobjective mdatamormsignsmthatmarempartmofmthemphys
icalmexamination.mAmpatient’smconcernsmaboutmlackmofmmoneymare msubjectivemdatamandmare mpartmofmthe m
healthmhistory.mAmpatient’smcomplaintsmofmtinglingmsensationsminmthe mfeetmare msubjective mdatamandmare m
partmofmthe mhealthmhistory.mAmpatient’smfamilymstatementsmare mconsideredmsecondarymdata,maremsubjectiv
e mdata,mandmare mpartmofmthe mhealthmhistory.
m m m m m m m m
by Susan Fickertt Wilson, Jean Fore
m m m m m m
Chapterm01:mIntroductionmtomHealthmAssessment
Wilson:mHealthmAssessmentmformNursingmPractice,m6thmEditio
nmMULTIPLEmCHOICE
1. Ampatientmcomesmtomthememergencymdepartmentmandmtellsmthe mtriagemnursemthatmhe mism“hav
ingmamheartmattack.”mWhatmismthe mnurse’smtopmprioritymatmthismtime?
a. Determine mthe mpatient’smpersonalmdatamandminsurance mcoverage.
b. Askmthe mpatientmtomtake mamseatminmthe mwaitingmroommuntilmhismname mismcalled.
c. Requestmthatmamnurse mcollectmdatamformamcomprehensive mhistory.
d. Askmamnursemtomstartmamfocusedmassessmentmof mthismpatientmn
ow.mANS:mD
The mnurse mneedsmtombeginmanmassessmentmasmsoonmasmpossible mthatmismfocusedmonmthismpatient’s
cardiovascularmsystem.mThe mtypemofmhealthmassessmentmperformedmbymthemnursemismalsomdrivenmbympati
entmneed.mPersonalmdatamandminsuranceminformationmwillmbemobtained,mbutminmthismsituation,mthesemdata
m canm waitm untilm aftermthem patientmismassessed.m BasedmalsomonmMaslow’s mhierarchy mofm needs, mphysiologic
m needs m take
precedence.mRathermthanmaskingmthe mpatientmtomwait,mthemnursemneedsmtombeginmdatamcollection,msuchm
asmvitalmsigns,mimmediatelymtomdetermine mthempatient’smhealthmstatus.mComplicationsmcanmbe mpreventedm
ifmanmimmediatemassessmentmismmademtomanalyzemthe mpatient’smsymptoms.mAmcomprehensivemhistorymis
m notm indicated m inmthismsituation matmthismtime.m Somemsubjective mdatamwillm bemcollected,m suchmasmallergies
m and
medicalmhistorymrelatedmtomcardiovascularmdisease.mEyes,mears,mormamcompletemmusculoskeletalmormmenta
lmhealthmassessmentmismnotmamprioritymatmthismtime.
DIF: Cognitive mLevel:mApplymREF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
,2. Whichmsituationmillustratesmamscreeningmassessment?
a. Ampatientmvisitsmanmobstetricmclinicmformthemfirstmtimemandmthe mnursemconductsmamdetailedmhistor
ymandmphysicalmexamination.
b. Amhospitalmsponsorsmamhealthmfairmatmamlocalmmallmandmprovidesmcholesterolmandmbloodmpre
ssure mchecksmtommallmpatrons.
c. The mnurse minmanmurgentmcaremcentermchecksmthe mvitalmsignsmofmampatientmwhomismcomplainingm
ofmlegmpain.
d. Ampatientmnewlymdiagnosedmwithmdiabetesmmellitusmcomesmtomtestmhismfastingmbl
oodmglucose mlevel.
ANS:mB
Amhealthmfairmatmamlocalmmallmthatmprovidesmcholesterolmandmbloodmpressure mchecksmismanmexamplemof mam
screeningmassessmentmfocusedmonmdisease mdetection.mAmdetailedmhistorymandmphysicalmexamination
conductedmduringmamfirst-
time mvisitmtomanmobstetricmclinicmismanmexamplemof mamcomprehensivemassessment.mAssessingmampatientmc
omplainingmof mlegmpainminmthe mtriage mareamof manmurgentmcare mcentermismanmexample mofmamproblem-
based/focusedmassessment.mAmpatient’smreturnmappointmentm1mmonthmaftermtoday’smofficemvisitmtomrepo
rtmfastingmbloodmglucose mlevelsmismanmexample mof manmepisodicmormfollow-upmassessment.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-
3m|mp.m3mTOP:mNursingmProcess:mAssessmentmMSC:mNCLEXmPatientmNeeds:mHealthmPromotionm
andmMaintenance:mHealthmScreening
3. Formwhichmpersonmismamscreeningmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mB
Amscreeningmassessmentmismperformedmformthempurpose mofmdisease mdetection.mInmthismcasemthismpersonm
maymhave mdiabetesmmellitus.mAmshiftmassessmentmismmostmappropriate mformthe mpersonmwhomismrecoveri
ngminmthe mhospitalmfrommsurgery.mAmcomprehensivemassessmentmismperformedmduringmadmissionmtomamfa
cilitymtomobtainmamdetailedmhistorymandmcomplete mphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee mreplacementmtomevaluate mthe moutcome mof mthe mprocedure.
,DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
4. Formwhichmpersonmismamshiftmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mA
Amshiftmassessmentmismmostmappropriate mformthempersonmwhomismrecoveringminmthe mhospitalmfrommsurgery.mA
screeningmassessmentmismperformedmformthempurposemofmdiseasemdetection,minmthismcase mdiabetesmmellit
us.mAmcomprehensive massessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhis
torymandmcomplete mphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee
replacementmtomevaluate mthe moutcome mofmthe mprocedure.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m4mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
5. Formwhichmpersonmismamcomprehensive massessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mC
Amcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistory
m andm completem physicalmexamination.mAm shiftm assessmentm ismmostm appropriatemform them personm whom ism r
ecoveringminmthemhospitalmfrommsurgery.mAmscreeningmassessmentmismperformedmformthe mpurposemofmdis
ease mdetection,minmthismcasemdiabetesmmellitus.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermknee mreplacementmtomevaluate mthe moutcome mof mthe mprocedure.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
, MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
6. Formwhichmpersonmismanmepisodicmormfollow-upmassessmentmindicated?
a. The mpersonmwhomhadmabdominalmsurgerymyesterday
b. The mpersonmwhomismunaware mof mhismhighmserummglucose mlevels
c. The mpersonmwhomismbeingmadmittedmtomamlong-termmcare mfacility
d. The mpersonmwhomismbeginningmrehabilitationmaftermamkneemreplacem
entmANS:mD
Anmepisodicmormfollow-
upmassessmentmismperformedmaftermthemkneemreplacementmtomevaluatemthemoutcomemofmthemprocedure.
m A m shiftmassessmentmismmostmappropriate mformthempersonmwhomismrecoveringminmthe mhospitalm frommsurger
y.mAmscreeningmassessmentmismperformedmformthempurposemofmdiseasemdetection,minmthismcase mdiabetesm
mellitus.mAmcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetail
edmhistorymandmcomplete mphysicalmexamination.
DIF: Cognitive mLevel:mUnderstand REF:mBox m1-3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffective mCare mEnvironment:mManagementmofmCare:mEstablishingm
Priorities
7. Whichmismanmexample mof mdatamamnurse mcollectsmduringmamphysicalmexamination?
a. The mpatient’smlackmofmhairmandmshinymskinmovermbothmshins
b. The mpatient’smstatedmconcernmaboutmlackmofmmoneymformprescriptions
c. The mpatient’smcomplaintsmof mtinglingmsensationsminmthe mfeet
d. The mpatient’smmother’smstatementsmthatmthempatientmismverymnervousmlat
elymANS:mA
The mlackmofmhairmandmshinymskinmovermbothmshinsmare mobjective mdatamormsignsmthatmarempartmofmthemphys
icalmexamination.mAmpatient’smconcernsmaboutmlackmofmmoneymare msubjectivemdatamandmare mpartmofmthe m
healthmhistory.mAmpatient’smcomplaintsmofmtinglingmsensationsminmthe mfeetmare msubjective mdatamandmare m
partmofmthe mhealthmhistory.mAmpatient’smfamilymstatementsmare mconsideredmsecondarymdata,maremsubjectiv
e mdata,mandmare mpartmofmthe mhealthmhistory.
