Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01:Introductionto Health Assessment JG JG JG JG JG
MULTIPLE CHOICE JG
1. Apatient comesto the emergencydepartment andtellsthe triage nursethat heis“ha JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
vinga heart attack.” What isthe nurse’stop priorityat thistime?
JG JG JG JG JG JG JG JG JG JG JG JG
a. Determinethepatient’spersonaldata andinsur JG JG JG JG JG JG
ance coverage. JG
b. Ask the patient totake a seat inthe waitingroom JG JG JG JG JG JG JG JG JG JG JG
until his name iscalled. JG JG JG JG
c. Request that a nurse collect data for aco JG JG JG JG JG JG JG JG
mprehensive history. JG
d. Ask a nurseto start a focused assessmentoft JG JG JG JG JG JG JG JG JG
hispatient now. JG JG
ANSWER: D J G
The nurse needs to begin an assessment as soon as possible that is focused on this patient’scardio
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
vascular system. The type of health assessment performed by the nurse is also drivenby patient n
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
eed. Personal data and insurance information will be obtained, but in this situation, these data ca
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
n wait until after the patient is assessed. Based also on Maslow’s hierarchy of needs, physiologic
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
needs take precedence. Rather than asking the patient to wait, the nurse needs to begin data colle
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
ction, such as vital signs, immediately to determinethe patient’s health status. Complications ca
JG JG JG JG JG JG JG JG JG JG JG JG JG
n be prevented if an immediate assessment is made to analyze the patient’s symptoms. A compre
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
hensive history is not indicated in this situation at this time. Some subjective data will be collecte
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
d, such as allergies and medical history related to cardiovascular disease. Eyes, ears, or a comple
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
te musculoskeletal or mental healthassessment is not a priorityat thistime.
JG JG JG JG JG JG JG JG JG JG JG JG
DIF: Cognitive Level: ApplyJGJGJ G REF: Box 1- JG JG JG JG
3 | p. 3TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG
MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment: Managementof Care:EstablishingP
JG JG JG JG JG JG JG JG JG JG JG JG JG
riorities
2. Which situationillustratesa screeningassessment? JG JG JG JG JG
a. A patient visits an obstetric clinic for the firstti JG JG JG JG JG JG JG JG JG
meandthe nurseconductsa detailedhistoryand JG JG JG JG JG JG JG JG JG
physical examination. JG
b. Ahospital sponsorsa health fair ata localma JG JG JG JG JG JG JG JG JG
ll and provides cholesterol and blood press JG JG JG JG JG JG
ure checksto mall patrons. JG JG JG JG
c. The nurse inan urgent care centerchecksthe JG JG JG JG JG JG JG JG J
vital signs of a patient who is complainingo G JG JG JG JG JG JG JG JG
f legpain. JG JG
, d. Apatient newlydiagnosed withdiabetesm
JG JG JG JG JG JG
ellitus comes to test his fasting blood gluco JG JG JG JG JG JG JG
selevel. JG
ANSWER: B JG
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG J
screening assessment focused on disease detection. A detailed history and physical examinatio
G JG JG JG JG JG JG JG JG JG JG JG
nconducted duringa first-
JG JG JG JG
time visit to anobstetric clinic is anexampleof a comprehensive assessment. Assessing a patient
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
complaining of leg pain in the triage area of an urgent care center is an example of a problem- JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
based/focused assessment. A patient’s return appointment 1 month after today’s office visit to r JG JG JG JG JG JG JG JG JG JG JG JG JG
eport fasting blood glucose levelsisan example ofan episodic or follow-up assessment.
JG JG JG JG JG JG JG JG JG JG JG JG JG
DIF: Cognitive Level: Understand REF: Box 1-
JGJGJ G JG JG JG JG
3 | p. 3TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG
MSC: NCLEXPatient Needs: HealthPromotionand Maintenance: HealthScreening
JG JG JG JG JG JG JG JG JG
3. For whichpersonisa screeningassessment indicated?
JG JG JG JG JG JG JG
a. Thepersonwho had abdominal surgeryy JG JG JG JG JG JG
esterday
b. The personwho is unaware of hishighser JG JG JG JG JG JG JG JG
um glucose levels JG JG
c. The personwho isbeing admitted to alo JG JG JG JG JG JG JG JG
ng-termcare facility JG JG
d. The personwho isbeginning rehabilitationaft JG JG JG JG JG JG
er a knee replacement JG JG JG
ANSWER: B JG
A screening assessment is performed for the purpose of disease detection. In this case thisperso
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
n may have diabetes mellitus. A shift assessment is most appropriate for the person who is reco
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
vering in the hospital from surgery. A comprehensive assessment is performedduring admissio
JG JG JG JG JG JG JG JG JG JG JG JG
n to a facility to obtain a detailed history and complete physical examination. An episodic or fol
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
low-
up assessment is performed after knee replacement toevaluate the outcome of the procedure.
JG JG JG JG JG JG JG JG JG JG JG JG JG
DIF: Cognitive Level: Understand REF: Box 1-
JGJGJ G JG JG JG JG
3 | p. 3TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG
MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment: Managementof Care:EstablishingP
JG JG JG JG JG JG JG JG JG JG JG JG JG
riorities
4. For whichperson isa shift assessment indicated?
JG JG JG JG JG JG JG
a. Thepersonwho had abdominal surgeryy JG JG JG JG JG JG
esterday
b. The personwho is unaware of hishighser JG JG JG JG JG JG JG JG
um glucose levels JG JG
c. The personwho isbeingadmitted to a JG JG JG JG JG JG JG
long-termcare facility JG JG
d. The personwho isbeginningrehabilitationaf JG JG JG JG JG JG
ter aknee replacement JG JG JG
ANSWER: A J G
A shift assessment is most appropriate for the person who is recovering in the hospital fromsurge
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
ry. A screening assessment is performed for the purpose of disease detection, in this case diabete
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
smellitus. Acomprehensive assessmentisperformed duringadmissionto a
JG JG JG JG JG JG JG JG JG JG
, facility to obtain a detailed history and complete physical examination. An episodic or follow
JG JG JG JG JG JG JG JG JG JG JG JG JG
-up assessment isperformed after knee replacement to evaluate the outcome oftheprocedure.
JG JG JG JG JG JG JG JG JG JG JG JG JG
DIF: Cognitive Level: Understand REF: Box 1-JGJGJ G JG JG JG JG
3 | p. 4TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG
MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment: Managementof Care:EstablishingP
JG JG JG JG JG JG JG JG JG JG JG JG JG
riorities
5. For whichpersonisacomprehensive assessment indicated?
JG JG JG JG JG JG JG
a. Thepersonwho had abdominal surgeryy JG JG JG JG JG JG
esterday
b. The personwho is unaware of hishighser JG JG JG JG JG JG JG JG
um glucose levels JG JG
c. The personwho isbeing admitted to alo JG JG JG JG JG JG JG JG
ng-termcare facility JG JG
d. The personwho isbeginning rehabilitationafte JG JG JG JG JG JG
r a knee replacement JG JG JG
ANSWER: C JG
Acomprehensive assessment isperformed duringadmission to a facilityto obtain a
JG JG JG JG JG JG JG JG JG JG JG JG
detailed history and complete physical examination. A shift assessment is most appropriatefor t
JG JG JG JG JG JG JG JG JG JG JG JG JG
he person who is recovering in the hospital from surgery. A screening assessment is performed f
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
or the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
JG JG JG JG JG JG JG JG JG JG JG JG JG JG
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
JG JG JG JG JG JG JG JG JG JG JG JG JG
DIF: Cognitive Level: Understand REF: Box 1-JGJGJ G JG JG JG JG
3 | p. 3TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG
MSC: NCLEXPatient Needs: Safe and EffectiveCare Environment: Managementof Care:EstablishingP
JG JG JG JG JG JG JG JG JG JG JG JG JG
riorities
6. For whichperson isanepisodic or follow-up assessment indicated?
JG JG JG JG JG JG JG JG JG
a. Thepersonwho had abdominal surgeryy JG JG JG JG JG JG
esterday
b. The personwho isunaware of hishighser JG JG JG JG JG JG JG JG
um glucose levels JG JG
c. The personwho isbeingadmitted to a JG JG JG JG JG JG JG
long-termcare facility JG JG
d. The personwho isbeginning rehabilitationafte JG JG JG JG JG JG
r a knee replacement JG JG JG
ANSWER: D J G
An episodic or follow- JG JG JG
up assessment is performed after the knee replacement to evaluate the outcome of the procedure
JG JG JG JG JG JG JG JG JG JG JG JG JG JG
. A shift assessment is most appropriate for the person who isrecovering in the hospital from sur
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
gery. A screening assessment is performed for the purposeofdisease detection, inthiscasediabe
JG JG JG JG JG JG JG JG JG JG JG JG JG JG JG
tesmellitus. Acomprehensive assessment is performed during admission to a facility to obtain a
JG JG JG JG JG JG JG JG JG JG JG JG JG JG J
detailed history and complete physicalexamination.
G JG JG JG JG JG
DIF: Cognitive Level: Understand JGJGJ G JG JG REF: Box 1- JG JG
3 | p. 3TOP: NursingProcess: Assessment
JG JG JG JG JG JG JG