Chapter 01: Introduction to Health Assessment
k k k k k
Wilson: Health Assessment for Nursing Practice, 6th Edition
k k k k k k k
MULTIPLEkCHOICE
1. Akpatientkcomesktokthekemergencykdepartmentkandktellskthektriageknursekthatkhekisk“havingkakh
eartkattack.”kWhatkisktheknurse’sktopkprioritykatkthisktime?
a. Determinekthekpatient’skpersonalkdatakandkinsurancekcoverage.
b. Askkthekpatientktoktakekakseatkinkthekwaitingkroomkuntilkhisknamekiskcalled.
c. Requestkthatkaknursekcollectkdatakforkakcomprehensivekhistory.
d. Askkaknursektokstartkakfocusedkassessmentkofkthiskpatientknow.
ANS:k D
Theknursekneedsktokbeginkankassessmentkasksoonkaskpossiblekthatkiskfocusedkonkthiskpatient’skcard
iovascularksystem.kThektypekofkhealthkassessmentkperformedkbyktheknursekiskalsokdrivenkbykpatie
ntkneed.kPersonalkdatakandkinsurancekinformationkwillkbekobtained,kbutkinkthisksituation,kthesekda
takcankwaitkuntilkafterkthekpatientkiskassessed.kBasedkalsokonkMaslow’skhierarchykofkneeds,kphysi
ologickneedsktakekprecedence.kRatherkthankaskingkthekpatientktokwait,ktheknursekneedsktokbeginkd
atakcollection,ksuchkaskvitalksigns,kimmediatelyktokdeterminekthekpatient’skhealthkstatus.kComplic
ationskcankbekpreventedkifkankimmediatekassessmentkiskmadektokanalyzekthekpatient’sksymptoms.k
Akcomprehensivekhistorykisknotkindicatedkinkthisksituationkatkthisktime.kSomeksubjectivekdatakwill
kbekcollected,ksuchkaskallergieskandkmedicalkhistorykrelatedktokcardiovascularkdisease.kEyes,kears,
korkakcompletekmusculoskeletalkorkmentalkhealthkassessmentkisknotkakprioritykatkthisktime.
DIF: CognitivekLevel:kApply REF:kBoxk1-
3k|kp.k3kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare:kEstablishin
gkPriorities
2. Whichksituationkillustrateskakscreeningkassessment?
a. Akpatientkvisitskankobstetrickclinickforkthekfirstktimekandktheknursekconductskakd
etailedkhistorykandkphysicalkexamination.
b. Akhospitalksponsorskakhealthkfairkatkaklocalkmallkandkprovideskcholesterolkandkbloodkp
ressurekchecksktokmallkpatrons.
c. Theknursekinkankurgentkcarekcenterkcheckskthekvitalksignskofkakpatientkwhokis
complainingkofklegkpain.
d. Akpatientknewlykdiagnosedkwithkdiabeteskmellituskcomesktoktestkhiskfastingkbloodk
glucoseklevel.
ANS:k B
, Akhealthkfairkatkaklocalkmallkthatkprovideskcholesterolkandkbloodkpressurekcheckskiskankexampleko
fkakscreeningkassessmentkfocusedkonkdiseasekdetection.kAkdetailedkhistorykandkphysicalkexamina
tionkconductedkduringkakfirst-
timekvisitktokankobstetrickclinickiskankexamplekofkakcomprehensivekassessment.kAssessingkakpatie
ntkcomplainingkofklegkpainkinkthektriagekareakofkankurgentkcarekcenterkiskankexamplekofkakproblem-
based/focusedkassessment.kAkpatient’skreturnkappointmentk1kmonthkafterktoday’skofficekvisitktokr
eportkfastingkbloodkglucoseklevelskiskankexamplekofkankepisodickorkfollow-upkassessment.
DIF: CognitivekLevel:kUnderstand REF:kBoxk1-
3k|kp.k3kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kHealthkPromotionkandkMaintenance:kHealthkScreening
3. Forkwhichkpersonkiskakscreeningkassessmentkindicated?
a. Thekpersonkwhokhadkabdominalksurgerykyesterday
b. Thekpersonkwhokiskunawarekofkhiskhighkserumkglucoseklevels
c. Thekpersonkwhokiskbeingkadmittedktokaklong-termkcarekfacility
d. Thekpersonkwhokiskbeginningkrehabilitationkafterkakkneekreplacement
ANS:k B
Akscreeningkassessmentkiskperformedkforkthekpurposekofkdiseasekdetection.kInkthiskcasekthiskpers
onkmaykhavekdiabeteskmellitus.kAkshiftkassessmentkiskmostkappropriatekforkthekpersonkwhokiskrec
overingkinkthekhospitalkfromksurgery.kAkcomprehensivekassessmentkiskperformedkduringkadmissi
onktokakfacilityktokobtainkakdetailedkhistorykandkcompletekphysicalkexamination.kAnkepisodickorkf
ollow-
upkassessmentkiskperformedkafterkkneekreplacementktokevaluatekthekoutcomekofkthekprocedure.
DIF: CognitivekLevel:kUnderstand REF:kBoxk1-
3k|kp.k3kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare:kEstablishin
gkPriorities
4. Forkwhichkpersonkiskakshiftkassessmentkindicated?
a. Thekpersonkwhokhadkabdominalksurgerykyesterday
b. Thekpersonkwhokiskunawarekofkhiskhighkserumkglucoseklevels
c. Thekpersonkwhokiskbeingkadmittedktokaklong-termkcarekfacility
d. Thekpersonkwhokiskbeginningkrehabilitationkafterkakkneekreplacement
ANS:k A
Akshiftkassessmentkiskmostkappropriatekforkthekpersonkwhokiskrecoveringkinkthekhospitalkfromksur
gery.kAkscreeningkassessmentkiskperformedkforkthekpurposekofkdiseasekdetection,kinkthiskcasekdiab
eteskmellitus.kAkcomprehensivekassessmentkiskperformedkduringkadmissionktokakfacilityktokobtai
nkakdetailedkhistorykandkcompletekphysicalkexamination.kAnkepisodickorkfollow-
upkassessmentkiskperformedkafterkkneekreplacementktokevaluatekthekoutcomekofkthekprocedure.
DIF: CognitivekLevel:kUnderstand REF:kBoxk1-
3k|kp.k4kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare:kEstablishin
gkPriorities
, 5. Forkwhichkpersonkiskakcomprehensivekassessmentkindicated?
a. Thekpersonkwhokhadkabdominalksurgerykyesterday
b. Thekpersonkwhokiskunawarekofkhiskhighkserumkglucoseklevels
c. Thekpersonkwhokiskbeingkadmittedktokaklong-termkcarekfacility
d. Thekpersonkwhokiskbeginningkrehabilitationkafterkakkneekreplacement
ANS:k C
Akcomprehensivekassessmentkiskperformedkduringkadmissionktokakfacilityktokobtainkakdetailedkhis
torykandkcompletekphysicalkexamination.kAkshiftkassessmentkiskmostkappropriatekforkthekpersonk
whokiskrecoveringkinkthekhospitalkfromksurgery.kAkscreeningkassessmentkiskperformedkforkthekpu
rposekofkdiseasekdetection,kinkthiskcasekdiabeteskmellitus.kAnkepisodickorkfollow-
upkassessmentkiskperformedkafterkkneekreplacementktokevaluatekthekoutcomekofkthekprocedure.
DIF: CognitivekLevel:kUnderstand REF:kBoxk1-
3k|kp.k3kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare:kEstablishin
gkPriorities
6. Forkwhichkpersonkiskankepisodickorkfollow-upkassessmentkindicated?
a. Thekpersonkwhokhadkabdominalksurgerykyesterday
b. Thekpersonkwhokiskunawarekofkhiskhighkserumkglucoseklevels
c. Thekpersonkwhokiskbeingkadmittedktokaklong-termkcarekfacility
d. Thekpersonkwhokiskbeginningkrehabilitationkafterkakkneekreplacement
ANS:k D
Ankepisodickorkfollow-
upkassessmentkiskperformedkafterkthekkneekreplacementktokevaluatekthekoutcomekofkthekprocedur
e.kAkshiftkassessmentkiskmostkappropriatekforkthekpersonkwhokiskrecoveringkinkthekhospitalkfromks
urgery.kAkscreeningkassessmentkiskperformedkforkthekpurposekofkdiseasekdetection,kinkthiskcasekdi
abeteskmellitus.kAkcomprehensivekassessmentkiskperformedkduringkadmissionktokakfacilityktokobta
inkakdetailedkhistorykandkcompletekphysicalkexamination.
DIF: CognitivekLevel:kUnderstand REF:kBoxk1-
3k|kp.k3kTOP:k NursingkProcess:kAssessment
MSC:k NCLEXkPatientkNeeds:kSafekandkEffectivekCarekEnvironment:kManagementkofkCare:kEstablishin
gkPriorities
7. Whichkiskankexamplekofkdatakaknursekcollectskduringkakphysicalkexamination?
a. Thekpatient’sklackkofkhairkandkshinykskinkoverkbothkshins
b. Thekpatient’skstatedkconcernkaboutklackkofkmoneykforkprescriptions
c. Thekpatient’skcomplaintskofktinglingksensationskinkthekfeet
d. Thekpatient’skmother’skstatementskthatkthekpatientkiskveryknervousklately
ANS:k A