Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapterg v 01:g v Introductiong v tog v Healthg v Assessment
MULTIPLEg v CHOICE
1. Ag v patientg v comesg v tog v theg v emergencyg v departmentg v andg v tellsg v theg v tria
geg v nursegvthatg v heisg v “havingg v ag v heartg v attack.”g v Whatg v isg v theg v nurse’sg v top
g v priorityg v atg v thisg v time?
a. Determineg v theg v patient’sgv personalg v datag v a
nd11g v insuranceg v coverage.
b. Askg v theg v patientg v tog v takeg v ag v seatg v ing v
theg v wagviting11roomg v untilg v hisg v nameg v is
g v called.
c. Requestg v thatg v ag v nurseg v collectg v d
atag v fgvorg v a11comprehensiveg v histor
y.
d. Askg v ag v nurseg v tog v startg v ag v focusedg v ass
essgvment11ofg v thisgvpatientg v now.
ANSWER:g v D
Theg v nurseg v needsg v tog v beging v ang v assessmentg v asg v soong v asg v possibleg v thatg v is
g v focusedg v ong v thigvsg v patient’scardiovascularg v system.g v Theg v typeg v ofg v healthg v asses
smentg v performedg v byg v theg v ngvursegvisgvalsogvdriven11bygvpatientgvneed.gvPersonalgvdatagvan
dgvinsurancegvinformationgvwillgvbegvobtained,g v butg v ing v thisg v situation,g v theseg v datag v
cang v waitg v untilg v afterg v theg v patientg v isg v assesse
d.g v Basedg v alsog v ong v Maslow’sg v hierarchyg v ofg v needs,g v physiologicg v needsg v takeg v pre
cedence.g v Ratherg v thang v askingg v theg v patientg v tog v wait,g v theg v nurseg v needsg v tog v
beging v datag v collection,g v sugvchg v asg v vitalg v signs,g v immediatelyg v tog v determinetheg v p
atient’sg v healthg v status.g v Complicationsgvcang v beg v preventedg v ifg v ang v immediateg v asses
smentg v isg v madeg v tog v analyzeg v theg v patient’sg v syg v mptoms.g v Ag v comprehensiveg v hist
oryg v isg v notg v indicatedg v ing v thisg v situationg v atg v thisg v time.g v Sog v meg v subjectiveg v dat
ag v willg v beg v collected,g v suchg v asg v allergiesg v andg v medicalg v historyg v relatedg v tgvog
v cardiovascularg v disease.g v Eyes,g v ears,g v org v ag v completeg v musculoskeletalg v org v m
entalg v healtgvhg v assessmentg v isg v notg v ag v priorityg v atg v thisg v time.
DIF: Cognitiveg v Level:g v Apply REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Safeg v andg v Effectiveg v Careg v Environment:g v Managementg v ofg v Car
e:Egvstablishingg v Priorities
2. Whichg v situationg v illustratesg v ag v screeningg v assessment?
a. Ag v patientg v visitsg v ang v obstetricg v clinicg v f
org v thg v egvfirstgvtimegvandgvthegvnursegvcond
uctsgvagvdetgvailedhistorygvandg v physicalg v ex
amination.
b. Ag v hospitalg v sponsorsg v ag v healthg v fairg v
atg v agvlocalmallg v andg v providesg v choles
terolg v andgvbloodg v pressureg v checksg v to
g v mallg v patron
s.
c. Thegvnursegvingvangvurgentgvcaregvcentergvc
hgvecks11theg v vitalg v signsg v ofg v ag v patien
tg v whog v igvsg v complainingg v ofg v legg v pa
in.
, d. Agvpatientgvnewlygvdiagnosedgvwithgvdia
bgvetesmellitusgvcomesgvtogvtestgvhisgvfast
inggvbloodg v glucoseg v level.
ANSWER:g v B
Ag v healthg v fairg v atg v ag v localg v mallg v thatg v providesg v cholesterolg v andg v bloodg v press
ureg v checksg v isgvang v exampleg v ofg v ag v screeningg v assessmentg v focusedg v ong v diseaseg v d
etection.g v Ag v detailedg v higvstoryg v andg v physicalg v examinationg v conductedg v duringg v ag v f
irst-
timeg v visitg v tog v ang v obstetricg v clinicg v isg v ang v example11ofg v ag v comprehensiveg v assess
ment.g v Assesgvsingg v ag v patientg v complainingg v ofg v legg v paing v ing v theg v triageg v are
ag v ofg v ang v urgentg v careg v centergvisg v ang v exampleg v ofg v ag v problem-
based/focusedg v assessment.g v Ag v patient’sg v returng v appointmentg v 1g v monthg v afterg v toda
y’sg v offig v ceg v visitg v tog v reportg v fastingg v bloodg v glucoseg v levelsg v isg v ang v exampleg v ofg
v ang v episodicg v org v follogvw-upg v assessment.
DIF: Cognitiveg v Level:g v Understand REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Healthg v Promotiong v andg v Maintenance:g v Healthg v Screening
3. Forg v whichg v persong v isg v ag v screeningg v assessmentg v indicated?
a. Theg v persong v whog v hadg v abdominalg v surg
gveryyesterday
b. Theg v persong v whog v isg v unawareg v ofg v hisgv
high11serumg v glucoseg v levels
c. Theg v persong v whog v isg v beingg v adm
ittedgvtog v along-termg v careg v facility
d. Theg v persong v whog v isg v beginningg v rehabil
itatigvon11afterg v ag v kneeg v replacement
ANSWER:g v B
Ag v screeningg v assessmentg v isg v performedg v forg v theg v purposeg v ofg v diseaseg v detection.
g v Ing v thisg v caseg v thispersong v mayg v haveg v diabetesg v mellitus.g v Ag v shiftg v assessm
entg v isg v mostg v appropriatgveg v forg v theg v persong v whog v isg v recoveringg v ing v theg v hospi
talg v fromg v surgery.g v Ag v comprehensivegvassessmentg v isg v performed11duringg v admissio
ng v tog v ag v facilityg v tog v obtaing v ag v detailedg v historygvandg v completeg v physicalg v examin
ation.g v Ang v episodicg v org v follow-
upg v assessmentg v isg v performedg v afterg v kneeg v replacementg v toevaluateg v theg v outcomeg v
ofg v thegvprocedure.
DIF: Cognitiveg v Level:g v Understand REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Safeg v andg v Effectiveg v Careg v Environment:g v Managementg v ofg v Car
e:Egvstablishingg v Priorities
4. Forg v whichg v persong v isg v ag v shiftg v assessmentg v indicated?
a. Theg v persong v whog v hadg v abdominalg v surg
gveryyesterday
b. Theg v persong v whog v isg v unawareg v ofg v hisgv
high11serumg v glucoseg v levels
c. Theg v persong v whog v isg v beingg v admitted
g v tog v agvlong-termg v careg v facility
d. Theg v persong v whog v isg v beginningg v rehabil
itatgvionafterg v ag v kneeg v replacement
ANSWER:g v A
Ag v shiftg v assessmentg v isg v mostg v appropriateg v forg v theg v persong v whog v isg v recoveringg
v ing v theg v hosg v pitalg v from11surgery.g v Ag v screeningg v assessmentg v isg v performedg v forg v
theg v purposeg v ofg v diseasegvdetection,g v ing v thisg v caseg v diabetesg v mellitus.g v Ag v compre
, hensiveg v assessmentg v isg v performedg v dgvuringgvadmissiong v tog v a
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapterg v 01:g v Introductiong v tog v Healthg v Assessment
MULTIPLEg v CHOICE
1. Ag v patientg v comesg v tog v theg v emergencyg v departmentg v andg v tellsg v theg v tria
geg v nursegvthatg v heisg v “havingg v ag v heartg v attack.”g v Whatg v isg v theg v nurse’sg v top
g v priorityg v atg v thisg v time?
a. Determineg v theg v patient’sgv personalg v datag v a
nd11g v insuranceg v coverage.
b. Askg v theg v patientg v tog v takeg v ag v seatg v ing v
theg v wagviting11roomg v untilg v hisg v nameg v is
g v called.
c. Requestg v thatg v ag v nurseg v collectg v d
atag v fgvorg v a11comprehensiveg v histor
y.
d. Askg v ag v nurseg v tog v startg v ag v focusedg v ass
essgvment11ofg v thisgvpatientg v now.
ANSWER:g v D
Theg v nurseg v needsg v tog v beging v ang v assessmentg v asg v soong v asg v possibleg v thatg v is
g v focusedg v ong v thigvsg v patient’scardiovascularg v system.g v Theg v typeg v ofg v healthg v asses
smentg v performedg v byg v theg v ngvursegvisgvalsogvdriven11bygvpatientgvneed.gvPersonalgvdatagvan
dgvinsurancegvinformationgvwillgvbegvobtained,g v butg v ing v thisg v situation,g v theseg v datag v
cang v waitg v untilg v afterg v theg v patientg v isg v assesse
d.g v Basedg v alsog v ong v Maslow’sg v hierarchyg v ofg v needs,g v physiologicg v needsg v takeg v pre
cedence.g v Ratherg v thang v askingg v theg v patientg v tog v wait,g v theg v nurseg v needsg v tog v
beging v datag v collection,g v sugvchg v asg v vitalg v signs,g v immediatelyg v tog v determinetheg v p
atient’sg v healthg v status.g v Complicationsgvcang v beg v preventedg v ifg v ang v immediateg v asses
smentg v isg v madeg v tog v analyzeg v theg v patient’sg v syg v mptoms.g v Ag v comprehensiveg v hist
oryg v isg v notg v indicatedg v ing v thisg v situationg v atg v thisg v time.g v Sog v meg v subjectiveg v dat
ag v willg v beg v collected,g v suchg v asg v allergiesg v andg v medicalg v historyg v relatedg v tgvog
v cardiovascularg v disease.g v Eyes,g v ears,g v org v ag v completeg v musculoskeletalg v org v m
entalg v healtgvhg v assessmentg v isg v notg v ag v priorityg v atg v thisg v time.
DIF: Cognitiveg v Level:g v Apply REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Safeg v andg v Effectiveg v Careg v Environment:g v Managementg v ofg v Car
e:Egvstablishingg v Priorities
2. Whichg v situationg v illustratesg v ag v screeningg v assessment?
a. Ag v patientg v visitsg v ang v obstetricg v clinicg v f
org v thg v egvfirstgvtimegvandgvthegvnursegvcond
uctsgvagvdetgvailedhistorygvandg v physicalg v ex
amination.
b. Ag v hospitalg v sponsorsg v ag v healthg v fairg v
atg v agvlocalmallg v andg v providesg v choles
terolg v andgvbloodg v pressureg v checksg v to
g v mallg v patron
s.
c. Thegvnursegvingvangvurgentgvcaregvcentergvc
hgvecks11theg v vitalg v signsg v ofg v ag v patien
tg v whog v igvsg v complainingg v ofg v legg v pa
in.
, d. Agvpatientgvnewlygvdiagnosedgvwithgvdia
bgvetesmellitusgvcomesgvtogvtestgvhisgvfast
inggvbloodg v glucoseg v level.
ANSWER:g v B
Ag v healthg v fairg v atg v ag v localg v mallg v thatg v providesg v cholesterolg v andg v bloodg v press
ureg v checksg v isgvang v exampleg v ofg v ag v screeningg v assessmentg v focusedg v ong v diseaseg v d
etection.g v Ag v detailedg v higvstoryg v andg v physicalg v examinationg v conductedg v duringg v ag v f
irst-
timeg v visitg v tog v ang v obstetricg v clinicg v isg v ang v example11ofg v ag v comprehensiveg v assess
ment.g v Assesgvsingg v ag v patientg v complainingg v ofg v legg v paing v ing v theg v triageg v are
ag v ofg v ang v urgentg v careg v centergvisg v ang v exampleg v ofg v ag v problem-
based/focusedg v assessment.g v Ag v patient’sg v returng v appointmentg v 1g v monthg v afterg v toda
y’sg v offig v ceg v visitg v tog v reportg v fastingg v bloodg v glucoseg v levelsg v isg v ang v exampleg v ofg
v ang v episodicg v org v follogvw-upg v assessment.
DIF: Cognitiveg v Level:g v Understand REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Healthg v Promotiong v andg v Maintenance:g v Healthg v Screening
3. Forg v whichg v persong v isg v ag v screeningg v assessmentg v indicated?
a. Theg v persong v whog v hadg v abdominalg v surg
gveryyesterday
b. Theg v persong v whog v isg v unawareg v ofg v hisgv
high11serumg v glucoseg v levels
c. Theg v persong v whog v isg v beingg v adm
ittedgvtog v along-termg v careg v facility
d. Theg v persong v whog v isg v beginningg v rehabil
itatigvon11afterg v ag v kneeg v replacement
ANSWER:g v B
Ag v screeningg v assessmentg v isg v performedg v forg v theg v purposeg v ofg v diseaseg v detection.
g v Ing v thisg v caseg v thispersong v mayg v haveg v diabetesg v mellitus.g v Ag v shiftg v assessm
entg v isg v mostg v appropriatgveg v forg v theg v persong v whog v isg v recoveringg v ing v theg v hospi
talg v fromg v surgery.g v Ag v comprehensivegvassessmentg v isg v performed11duringg v admissio
ng v tog v ag v facilityg v tog v obtaing v ag v detailedg v historygvandg v completeg v physicalg v examin
ation.g v Ang v episodicg v org v follow-
upg v assessmentg v isg v performedg v afterg v kneeg v replacementg v toevaluateg v theg v outcomeg v
ofg v thegvprocedure.
DIF: Cognitiveg v Level:g v Understand REF:g v Boxg v 1-
3g v |g v p.g v 3TOP:g v Nursingg v Process:g v Assessment
MSC:g v NCLEXg v Patientg v Needs:g v Safeg v andg v Effectiveg v Careg v Environment:g v Managementg v ofg v Car
e:Egvstablishingg v Priorities
4. Forg v whichg v persong v isg v ag v shiftg v assessmentg v indicated?
a. Theg v persong v whog v hadg v abdominalg v surg
gveryyesterday
b. Theg v persong v whog v isg v unawareg v ofg v hisgv
high11serumg v glucoseg v levels
c. Theg v persong v whog v isg v beingg v admitted
g v tog v agvlong-termg v careg v facility
d. Theg v persong v whog v isg v beginningg v rehabil
itatgvionafterg v ag v kneeg v replacement
ANSWER:g v A
Ag v shiftg v assessmentg v isg v mostg v appropriateg v forg v theg v persong v whog v isg v recoveringg
v ing v theg v hosg v pitalg v from11surgery.g v Ag v screeningg v assessmentg v isg v performedg v forg v
theg v purposeg v ofg v diseasegvdetection,g v ing v thisg v caseg v diabetesg v mellitus.g v Ag v compre
, hensiveg v assessmentg v isg v performedg v dgvuringgvadmissiong v tog v a
