Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapterg b 01:g b Introductiong b tog b Healthg b Assessment
MULTIPLEg b CHOICE
1. Ag b patientg b comesg b tog b theg b emergencyg b departmentg b andg b tellsg b theg b tria
geg b nursegbthatg b heisg b “havingg b ag b heartg b attack.”g b Whatg b isg b theg b nurse’sg b top
g b priorityg b atg b thisg b time?
a. Determineg b theg b patient’sgb personalg b datag b a
nd11g b insuranceg b coverage.
b. Askg b theg b patientg b tog b takeg b ag b seatg b ing b
theg b wagbiting11roomg b untilg b hisg b nameg b is
g b called.
c. Requestg b thatg b ag b nurseg b collectg b d
atag b fgborg b a11comprehensiveg b histor
y.
d. Askg b ag b nurseg b tog b startg b ag b focusedg b ass
essgbment11ofg b thisgbpatientg b now.
ANSWER:g b D
Theg b nurseg b needsg b tog b beging b ang b assessmentg b asg b soong b asg b possibleg b thatg b is
g b focusedg b ong b thigbsg b patient’scardiovascularg b system.g b Theg b typeg b ofg b healthg b asses
smentg b performedg b byg b theg b ngbursegbisgbalsogbdriven11bygbpatientgbneed.gbPersonalgbdatagban
dgbinsurancegbinformationgbwillgbbegbobtained,g b butg b ing b thisg b situation,g b theseg b datag b
cang b waitg b untilg b afterg b theg b patientg b isg b assesse
d.g b Basedg b alsog b ong b Maslow’sg b hierarchyg b ofg b needs,g b physiologicg b needsg b takeg b pre
cedence.g b Ratherg b thang b askingg b theg b patientg b tog b wait,g b theg b nurseg b needsg b tog b
beging b datag b collection,g b sugbchg b asg b vitalg b signs,g b immediatelyg b tog b determinetheg b p
atient’sg b healthg b status.g b Complicationsgbcang b beg b preventedg b ifg b ang b immediateg b asses
smentg b isg b madeg b tog b analyzeg b theg b patient’sg b syg b mptoms.g b Ag b comprehensiveg b hist
oryg b isg b notg b indicatedg b ing b thisg b situationg b atg b thisg b time.g b Sog b meg b subjectiveg b dat
ag b willg b beg b collected,g b suchg b asg b allergiesg b andg b medicalg b historyg b relatedg b tgbog
b cardiovascularg b disease.g b Eyes,g b ears,g b org b ag b completeg b musculoskeletalg b org b m
entalg b healtgbhg b assessmentg b isg b notg b ag b priorityg b atg b thisg b time.
DIF: Cognitiveg b Level:g b Apply REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Safeg b andg b Effectiveg b Careg b Environment:g b Managementg b ofg b Car
e:Egbstablishingg b Priorities
2. Whichg b situationg b illustratesg b ag b screeningg b assessment?
a. Ag b patientg b visitsg b ang b obstetricg b clinicg b f
org b thg b egbfirstgbtimegbandgbthegbnursegbcond
uctsgbagbdetgbailedhistorygbandg b physicalg b ex
amination.
b. Ag b hospitalg b sponsorsg b ag b healthg b fairg b
atg b agblocalmallg b andg b providesg b choles
terolg b andgbbloodg b pressureg b checksg b to
g b mallg b patron
s.
c. Thegbnursegbingbangburgentgbcaregbcentergbc
hgbecks11theg b vitalg b signsg b ofg b ag b patien
tg b whog b igbsg b complainingg b ofg b legg b pa
in.
, d. Agbpatientgbnewlygbdiagnosedgbwithgbdia
bgbetesmellitusgbcomesgbtogbtestgbhisgbfast
inggbbloodg b glucoseg b level.
ANSWER:g b B
Ag b healthg b fairg b atg b ag b localg b mallg b thatg b providesg b cholesterolg b andg b bloodg b press
ureg b checksg b isgbang b exampleg b ofg b ag b screeningg b assessmentg b focusedg b ong b diseaseg b d
etection.g b Ag b detailedg b higbstoryg b andg b physicalg b examinationg b conductedg b duringg b ag b f
irst-
timeg b visitg b tog b ang b obstetricg b clinicg b isg b ang b example11ofg b ag b comprehensiveg b assess
ment.g b Assesgbsingg b ag b patientg b complainingg b ofg b legg b paing b ing b theg b triageg b are
ag b ofg b ang b urgentg b careg b centergbisg b ang b exampleg b ofg b ag b problem-
based/focusedg b assessment.g b Ag b patient’sg b returng b appointmentg b 1g b monthg b afterg b toda
y’sg b offig b ceg b visitg b tog b reportg b fastingg b bloodg b glucoseg b levelsg b isg b ang b exampleg b ofg
b ang b episodicg b org b follogbw-upg b assessment.
DIF: Cognitiveg b Level:g b Understand REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Healthg b Promotiong b andg b Maintenance:g b Healthg b Screening
3. Forg b whichg b persong b isg b ag b screeningg b assessmentg b indicated?
a. Theg b persong b whog b hadg b abdominalg b surg
gberyyesterday
b. Theg b persong b whog b isg b unawareg b ofg b hisgb
high11serumg b glucoseg b levels
c. Theg b persong b whog b isg b beingg b adm
ittedgbtog b along-termg b careg b facility
d. Theg b persong b whog b isg b beginningg b rehabil
itatigbon11afterg b ag b kneeg b replacement
ANSWER:g b B
Ag b screeningg b assessmentg b isg b performedg b forg b theg b purposeg b ofg b diseaseg b detection.
g b Ing b thisg b caseg b thispersong b mayg b haveg b diabetesg b mellitus.g b Ag b shiftg b assessm
entg b isg b mostg b appropriatgbeg b forg b theg b persong b whog b isg b recoveringg b ing b theg b hospi
talg b fromg b surgery.g b Ag b comprehensivegbassessmentg b isg b performed11duringg b admissio
ng b tog b ag b facilityg b tog b obtaing b ag b detailedg b historygbandg b completeg b physicalg b examin
ation.g b Ang b episodicg b org b follow-
upg b assessmentg b isg b performedg b afterg b kneeg b replacementg b toevaluateg b theg b outcomeg b
ofg b thegbprocedure.
DIF: Cognitiveg b Level:g b Understand REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Safeg b andg b Effectiveg b Careg b Environment:g b Managementg b ofg b Car
e:Egbstablishingg b Priorities
4. Forg b whichg b persong b isg b ag b shiftg b assessmentg b indicated?
a. Theg b persong b whog b hadg b abdominalg b surg
gberyyesterday
b. Theg b persong b whog b isg b unawareg b ofg b hisgb
high11serumg b glucoseg b levels
c. Theg b persong b whog b isg b beingg b admitted
g b tog b agblong-termg b careg b facility
d. Theg b persong b whog b isg b beginningg b rehabil
itatgbionafterg b ag b kneeg b replacement
ANSWER:g b A
Ag b shiftg b assessmentg b isg b mostg b appropriateg b forg b theg b persong b whog b isg b recoveringg
b ing b theg b hosg b pitalg b from11surgery.g b Ag b screeningg b assessmentg b isg b performedg b forg b
theg b purposeg b ofg b diseasegbdetection,g b ing b thisg b caseg b diabetesg b mellitus.g b Ag b compre
, hensiveg b assessmentg b isg b performedg b dgburinggbadmissiong b tog b a
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapterg b 01:g b Introductiong b tog b Healthg b Assessment
MULTIPLEg b CHOICE
1. Ag b patientg b comesg b tog b theg b emergencyg b departmentg b andg b tellsg b theg b tria
geg b nursegbthatg b heisg b “havingg b ag b heartg b attack.”g b Whatg b isg b theg b nurse’sg b top
g b priorityg b atg b thisg b time?
a. Determineg b theg b patient’sgb personalg b datag b a
nd11g b insuranceg b coverage.
b. Askg b theg b patientg b tog b takeg b ag b seatg b ing b
theg b wagbiting11roomg b untilg b hisg b nameg b is
g b called.
c. Requestg b thatg b ag b nurseg b collectg b d
atag b fgborg b a11comprehensiveg b histor
y.
d. Askg b ag b nurseg b tog b startg b ag b focusedg b ass
essgbment11ofg b thisgbpatientg b now.
ANSWER:g b D
Theg b nurseg b needsg b tog b beging b ang b assessmentg b asg b soong b asg b possibleg b thatg b is
g b focusedg b ong b thigbsg b patient’scardiovascularg b system.g b Theg b typeg b ofg b healthg b asses
smentg b performedg b byg b theg b ngbursegbisgbalsogbdriven11bygbpatientgbneed.gbPersonalgbdatagban
dgbinsurancegbinformationgbwillgbbegbobtained,g b butg b ing b thisg b situation,g b theseg b datag b
cang b waitg b untilg b afterg b theg b patientg b isg b assesse
d.g b Basedg b alsog b ong b Maslow’sg b hierarchyg b ofg b needs,g b physiologicg b needsg b takeg b pre
cedence.g b Ratherg b thang b askingg b theg b patientg b tog b wait,g b theg b nurseg b needsg b tog b
beging b datag b collection,g b sugbchg b asg b vitalg b signs,g b immediatelyg b tog b determinetheg b p
atient’sg b healthg b status.g b Complicationsgbcang b beg b preventedg b ifg b ang b immediateg b asses
smentg b isg b madeg b tog b analyzeg b theg b patient’sg b syg b mptoms.g b Ag b comprehensiveg b hist
oryg b isg b notg b indicatedg b ing b thisg b situationg b atg b thisg b time.g b Sog b meg b subjectiveg b dat
ag b willg b beg b collected,g b suchg b asg b allergiesg b andg b medicalg b historyg b relatedg b tgbog
b cardiovascularg b disease.g b Eyes,g b ears,g b org b ag b completeg b musculoskeletalg b org b m
entalg b healtgbhg b assessmentg b isg b notg b ag b priorityg b atg b thisg b time.
DIF: Cognitiveg b Level:g b Apply REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Safeg b andg b Effectiveg b Careg b Environment:g b Managementg b ofg b Car
e:Egbstablishingg b Priorities
2. Whichg b situationg b illustratesg b ag b screeningg b assessment?
a. Ag b patientg b visitsg b ang b obstetricg b clinicg b f
org b thg b egbfirstgbtimegbandgbthegbnursegbcond
uctsgbagbdetgbailedhistorygbandg b physicalg b ex
amination.
b. Ag b hospitalg b sponsorsg b ag b healthg b fairg b
atg b agblocalmallg b andg b providesg b choles
terolg b andgbbloodg b pressureg b checksg b to
g b mallg b patron
s.
c. Thegbnursegbingbangburgentgbcaregbcentergbc
hgbecks11theg b vitalg b signsg b ofg b ag b patien
tg b whog b igbsg b complainingg b ofg b legg b pa
in.
, d. Agbpatientgbnewlygbdiagnosedgbwithgbdia
bgbetesmellitusgbcomesgbtogbtestgbhisgbfast
inggbbloodg b glucoseg b level.
ANSWER:g b B
Ag b healthg b fairg b atg b ag b localg b mallg b thatg b providesg b cholesterolg b andg b bloodg b press
ureg b checksg b isgbang b exampleg b ofg b ag b screeningg b assessmentg b focusedg b ong b diseaseg b d
etection.g b Ag b detailedg b higbstoryg b andg b physicalg b examinationg b conductedg b duringg b ag b f
irst-
timeg b visitg b tog b ang b obstetricg b clinicg b isg b ang b example11ofg b ag b comprehensiveg b assess
ment.g b Assesgbsingg b ag b patientg b complainingg b ofg b legg b paing b ing b theg b triageg b are
ag b ofg b ang b urgentg b careg b centergbisg b ang b exampleg b ofg b ag b problem-
based/focusedg b assessment.g b Ag b patient’sg b returng b appointmentg b 1g b monthg b afterg b toda
y’sg b offig b ceg b visitg b tog b reportg b fastingg b bloodg b glucoseg b levelsg b isg b ang b exampleg b ofg
b ang b episodicg b org b follogbw-upg b assessment.
DIF: Cognitiveg b Level:g b Understand REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Healthg b Promotiong b andg b Maintenance:g b Healthg b Screening
3. Forg b whichg b persong b isg b ag b screeningg b assessmentg b indicated?
a. Theg b persong b whog b hadg b abdominalg b surg
gberyyesterday
b. Theg b persong b whog b isg b unawareg b ofg b hisgb
high11serumg b glucoseg b levels
c. Theg b persong b whog b isg b beingg b adm
ittedgbtog b along-termg b careg b facility
d. Theg b persong b whog b isg b beginningg b rehabil
itatigbon11afterg b ag b kneeg b replacement
ANSWER:g b B
Ag b screeningg b assessmentg b isg b performedg b forg b theg b purposeg b ofg b diseaseg b detection.
g b Ing b thisg b caseg b thispersong b mayg b haveg b diabetesg b mellitus.g b Ag b shiftg b assessm
entg b isg b mostg b appropriatgbeg b forg b theg b persong b whog b isg b recoveringg b ing b theg b hospi
talg b fromg b surgery.g b Ag b comprehensivegbassessmentg b isg b performed11duringg b admissio
ng b tog b ag b facilityg b tog b obtaing b ag b detailedg b historygbandg b completeg b physicalg b examin
ation.g b Ang b episodicg b org b follow-
upg b assessmentg b isg b performedg b afterg b kneeg b replacementg b toevaluateg b theg b outcomeg b
ofg b thegbprocedure.
DIF: Cognitiveg b Level:g b Understand REF:g b Boxg b 1-
3g b |g b p.g b 3TOP:g b Nursingg b Process:g b Assessment
MSC:g b NCLEXg b Patientg b Needs:g b Safeg b andg b Effectiveg b Careg b Environment:g b Managementg b ofg b Car
e:Egbstablishingg b Priorities
4. Forg b whichg b persong b isg b ag b shiftg b assessmentg b indicated?
a. Theg b persong b whog b hadg b abdominalg b surg
gberyyesterday
b. Theg b persong b whog b isg b unawareg b ofg b hisgb
high11serumg b glucoseg b levels
c. Theg b persong b whog b isg b beingg b admitted
g b tog b agblong-termg b careg b facility
d. Theg b persong b whog b isg b beginningg b rehabil
itatgbionafterg b ag b kneeg b replacement
ANSWER:g b A
Ag b shiftg b assessmentg b isg b mostg b appropriateg b forg b theg b persong b whog b isg b recoveringg
b ing b theg b hosg b pitalg b from11surgery.g b Ag b screeningg b assessmentg b isg b performedg b forg b
theg b purposeg b ofg b diseasegbdetection,g b ing b thisg b caseg b diabetesg b mellitus.g b Ag b compre
, hensiveg b assessmentg b isg b performedg b dgburinggbadmissiong b tog b a
