Test Bank for Health Assessment for
oo oo oo oo oo
Nursing Practice 7th Edition by Wilson
oo oo oo oo oo oo
Chapter 1 - 24
oo oo oo oo
,Chapter 01: Introduction to Health Assessment
oo oo oo oo oo
MULTIPLE CHOICE oo
1. A patient comes to the emergency department and tells the triage nurse that
oo oo oo oo oo oo oo oo oo oo oo oo
oo heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
o oo oo oo oo oo oo oo oo oo oo oo oo oo
a. Determine the patient‘s personal data oo oo oo oo
andinsurance coverage. oo o oo
b. Ask the patient to take a seat in the
oo oo oo oo oo oo oo oo
waitingroom until his name is called.
oo o oo oo oo oo oo
c. Request that a nurse collect data for oo oo oo oo oo oo
acomprehensive history.
oo o oo
d. Ask a nurse to start a focused
oo oo oo oo oo oo
assessmentof this patient now.
oo o oo oo oo
ANSWER: D oo
The nurse needs to begin an assessment as soon as possible that is focused on this
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
patient‘scardiovascular system. The type of health assessment performed by the nurse is
oo o oo oo oo oo oo oo oo oo oo oo oo
also drivenby patient need. Personal data and insurance information will be obtained,
oo oo o oo oo oo oo oo oo oo oo oo oo
but in this situation, these data can wait until after the patient is assessed. Based also on
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the
oo oo oo oo oo oo oo oo oo oo oo oo
patient to wait, the nurse needs to begin data collection, such as vital signs, immediately
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
to determinethe patient‘s health status. Complications can be prevented if an immediate
oo oo o oo oo oo oo oo oo oo oo oo oo
assessment is made to analyze the patient‘s symptoms. A comprehensive history is not
oo oo oo oo oo oo oo oo oo oo oo oo oo
indicated in this situation at this time. Some subjective data will be collected, such as
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete
oo oo oo oo oo oo oo oo oo oo oo oo oo
musculoskeletal or mental health assessment is not a priority at this time.
oo oo oo oo oo oo oo oo oo oo oo oo
DIF: Cognitive Level: Apply
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
2. Which situation illustrates a screening assessment?
oo oo oo oo oo
a. A patient visits an obstetric clinic for the oo oo oo oo oo oo oo
first time and the nurse conducts a oo oo oo oo oo oo oo
detailedhistory and physical examination. oo o oo oo oo
b. A hospital sponsors a health fair at a oo oo oo oo oo oo oo
localmall and provides cholesterol and oo o oo oo oo oo
blood pressure checks to mall patrons. oo oo oo oo oo oo
c. The nurse in an urgent care center oo oo oo oo oo oo
checksthe vital signs of a patient who oo o oo oo oo oo oo oo
is complaining of leg pain. oo oo oo oo oo
, d. A patient newly diagnosed with
oo oo oo oo
diabetesmellitus comes to test his
oo o oo oo oo oo
fasting blood glucose level.
oo oo oo oo
ANSWER: B oo
A health fair at a local mall that provides cholesterol and blood pressure checks is an
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
example of a screening assessment focused on disease detection. A detailed history and
oo oo oo oo oo oo oo oo oo oo oo oo oo
physical examination conducted during a first-time visit to an obstetric clinic is an
oo oo oo oo oo oo oo oo oo oo oo oo oo
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
oo o oo oo oo oo oo oo oo oo oo oo oo
the triage area of an urgent care center is an example of a problem-based/focused
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
assessment. A patient‘s return appointment 1 month after today‘s office visit to report
oo oo oo oo oo oo oo oo oo oo oo oo oo
fasting blood glucose levels is an example of an episodic or follow-up assessment.
oo oo oo oo oo oo oo oo oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
oo oo oo oo oo oo oo oo oo
3. For which person is a screening assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his
oo oo oo oo oo oo
highserum glucose levels
oo o oo oo
c. The person who is being admitted to
oo oo oo oo oo oo
along-term care facility
oo o oo oo
d. The person who is beginning
oo oo oo oo
rehabilitationafter a knee replacement
oo o oo oo oo
ANSWER: B oo
A screening assessment is performed for the purpose of disease detection. In this case
oo oo oo oo oo oo oo oo oo oo oo oo oo
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
oo o oo oo oo oo oo oo oo oo oo oo oo oo
person who is recovering in the hospital from surgery. A comprehensive assessment is
oo oo oo oo oo oo oo oo oo oo oo oo oo
performedduring admission to a facility to obtain a detailed history and complete
oo o oo oo oo oo oo oo oo oo oo oo oo
physical examination. An episodic or follow-up assessment is performed after knee
oo oo oo oo oo oo oo oo oo oo oo
replacement toevaluate the outcome of the procedure.
oo oo o oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
4. For which person is a shift assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to a oo oo oo oo oo oo oo
long-term care facility oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: A oo
A shift assessment is most appropriate for the person who is recovering in the hospital
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
fromsurgery. A screening assessment is performed for the purpose of disease detection,
oo o oo oo oo oo oo oo oo oo oo oo oo
in this case diabetes mellitus. A comprehensive assessment is performed during admission
oo oo oo oo oo oo oo oo oo oo oo oo
to a
oo oo
, facility to obtain a detailed history and complete physical examination. An episodic or
oo oo oo oo oo oo oo oo oo oo oo oo
follow-up assessment is performed after knee replacement to evaluate the outcome of
oo oo oo oo oo oo oo oo oo oo oo oo
theprocedure.
oo o
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
4TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
5. For which person is a comprehensive assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to oo oo oo oo oo oo
along-term care facility oo o oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: C oo
A comprehensive assessment is performed during admission to a facility to obtain a
oo oo oo oo oo oo oo oo oo oo oo oo
detailed history and complete physical examination. A shift assessment is most
oo oo oo oo oo oo oo oo oo oo
appropriatefor the person who is recovering in the hospital from surgery. A screening
oo o oo oo oo oo oo oo oo oo oo oo oo oo
assessment is performed for the purpose of disease detection, in this case diabetes
oo oo oo oo oo oo oo oo oo oo oo oo oo
mellitus. An episodic or follow-up assessment is performed after knee replacement to
oo oo oo oo oo oo oo oo oo oo oo oo
evaluate the outcome of the procedure.
oo oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
6. For which person is an episodic or follow-up assessment indicated?
oo oo oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to a oo oo oo oo oo oo oo
long-term care facility oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: D oo
An episodic or follow-up assessment is performed after the knee replacement to
oo oo oo oo oo oo oo oo oo oo oo
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
person who isrecovering in the hospital from surgery. A screening assessment is
oo oo oo o oo oo oo oo oo oo oo oo oo
performed for the purpose of disease detection, in this case diabetes mellitus. A
oo oo oo oo oo oo oo oo oo oo oo oo oo
comprehensive assessment is performed during admission to a facility to obtain a
oo oo oo oo oo oo oo oo oo oo oo oo
detailed history and complete physicalexamination.
oo oo oo oo oo o
DIF: Cognitive Level: Understand
oo oo o o oo oo REF: Box 1-3 | p. oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
oo oo oo oo oo
Nursing Practice 7th Edition by Wilson
oo oo oo oo oo oo
Chapter 1 - 24
oo oo oo oo
,Chapter 01: Introduction to Health Assessment
oo oo oo oo oo
MULTIPLE CHOICE oo
1. A patient comes to the emergency department and tells the triage nurse that
oo oo oo oo oo oo oo oo oo oo oo oo
oo heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
o oo oo oo oo oo oo oo oo oo oo oo oo oo
a. Determine the patient‘s personal data oo oo oo oo
andinsurance coverage. oo o oo
b. Ask the patient to take a seat in the
oo oo oo oo oo oo oo oo
waitingroom until his name is called.
oo o oo oo oo oo oo
c. Request that a nurse collect data for oo oo oo oo oo oo
acomprehensive history.
oo o oo
d. Ask a nurse to start a focused
oo oo oo oo oo oo
assessmentof this patient now.
oo o oo oo oo
ANSWER: D oo
The nurse needs to begin an assessment as soon as possible that is focused on this
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
patient‘scardiovascular system. The type of health assessment performed by the nurse is
oo o oo oo oo oo oo oo oo oo oo oo oo
also drivenby patient need. Personal data and insurance information will be obtained,
oo oo o oo oo oo oo oo oo oo oo oo oo
but in this situation, these data can wait until after the patient is assessed. Based also on
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the
oo oo oo oo oo oo oo oo oo oo oo oo
patient to wait, the nurse needs to begin data collection, such as vital signs, immediately
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
to determinethe patient‘s health status. Complications can be prevented if an immediate
oo oo o oo oo oo oo oo oo oo oo oo oo
assessment is made to analyze the patient‘s symptoms. A comprehensive history is not
oo oo oo oo oo oo oo oo oo oo oo oo oo
indicated in this situation at this time. Some subjective data will be collected, such as
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete
oo oo oo oo oo oo oo oo oo oo oo oo oo
musculoskeletal or mental health assessment is not a priority at this time.
oo oo oo oo oo oo oo oo oo oo oo oo
DIF: Cognitive Level: Apply
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
2. Which situation illustrates a screening assessment?
oo oo oo oo oo
a. A patient visits an obstetric clinic for the oo oo oo oo oo oo oo
first time and the nurse conducts a oo oo oo oo oo oo oo
detailedhistory and physical examination. oo o oo oo oo
b. A hospital sponsors a health fair at a oo oo oo oo oo oo oo
localmall and provides cholesterol and oo o oo oo oo oo
blood pressure checks to mall patrons. oo oo oo oo oo oo
c. The nurse in an urgent care center oo oo oo oo oo oo
checksthe vital signs of a patient who oo o oo oo oo oo oo oo
is complaining of leg pain. oo oo oo oo oo
, d. A patient newly diagnosed with
oo oo oo oo
diabetesmellitus comes to test his
oo o oo oo oo oo
fasting blood glucose level.
oo oo oo oo
ANSWER: B oo
A health fair at a local mall that provides cholesterol and blood pressure checks is an
oo oo oo oo oo oo oo oo oo oo oo oo oo oo oo
example of a screening assessment focused on disease detection. A detailed history and
oo oo oo oo oo oo oo oo oo oo oo oo oo
physical examination conducted during a first-time visit to an obstetric clinic is an
oo oo oo oo oo oo oo oo oo oo oo oo oo
exampleof a comprehensive assessment. Assessing a patient complaining of leg pain in
oo o oo oo oo oo oo oo oo oo oo oo oo
the triage area of an urgent care center is an example of a problem-based/focused
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
assessment. A patient‘s return appointment 1 month after today‘s office visit to report
oo oo oo oo oo oo oo oo oo oo oo oo oo
fasting blood glucose levels is an example of an episodic or follow-up assessment.
oo oo oo oo oo oo oo oo oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
oo oo oo oo oo oo oo oo oo
3. For which person is a screening assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his
oo oo oo oo oo oo
highserum glucose levels
oo o oo oo
c. The person who is being admitted to
oo oo oo oo oo oo
along-term care facility
oo o oo oo
d. The person who is beginning
oo oo oo oo
rehabilitationafter a knee replacement
oo o oo oo oo
ANSWER: B oo
A screening assessment is performed for the purpose of disease detection. In this case
oo oo oo oo oo oo oo oo oo oo oo oo oo
thisperson may have diabetes mellitus. A shift assessment is most appropriate for the
oo o oo oo oo oo oo oo oo oo oo oo oo oo
person who is recovering in the hospital from surgery. A comprehensive assessment is
oo oo oo oo oo oo oo oo oo oo oo oo oo
performedduring admission to a facility to obtain a detailed history and complete
oo o oo oo oo oo oo oo oo oo oo oo oo
physical examination. An episodic or follow-up assessment is performed after knee
oo oo oo oo oo oo oo oo oo oo oo
replacement toevaluate the outcome of the procedure.
oo oo o oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
4. For which person is a shift assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to a oo oo oo oo oo oo oo
long-term care facility oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: A oo
A shift assessment is most appropriate for the person who is recovering in the hospital
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
fromsurgery. A screening assessment is performed for the purpose of disease detection,
oo o oo oo oo oo oo oo oo oo oo oo oo
in this case diabetes mellitus. A comprehensive assessment is performed during admission
oo oo oo oo oo oo oo oo oo oo oo oo
to a
oo oo
, facility to obtain a detailed history and complete physical examination. An episodic or
oo oo oo oo oo oo oo oo oo oo oo oo
follow-up assessment is performed after knee replacement to evaluate the outcome of
oo oo oo oo oo oo oo oo oo oo oo oo
theprocedure.
oo o
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
4TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
5. For which person is a comprehensive assessment indicated?
oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to oo oo oo oo oo oo
along-term care facility oo o oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: C oo
A comprehensive assessment is performed during admission to a facility to obtain a
oo oo oo oo oo oo oo oo oo oo oo oo
detailed history and complete physical examination. A shift assessment is most
oo oo oo oo oo oo oo oo oo oo
appropriatefor the person who is recovering in the hospital from surgery. A screening
oo o oo oo oo oo oo oo oo oo oo oo oo oo
assessment is performed for the purpose of disease detection, in this case diabetes
oo oo oo oo oo oo oo oo oo oo oo oo oo
mellitus. An episodic or follow-up assessment is performed after knee replacement to
oo oo oo oo oo oo oo oo oo oo oo oo
evaluate the outcome of the procedure.
oo oo oo oo oo oo
DIF: Cognitive Level: Understand
oo oo o o REF: Box 1-3 | p. oo oo oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
oo oo oo oo oo oo oo oo oo oo
Care:Establishing Priorities
oo o oo
6. For which person is an episodic or follow-up assessment indicated?
oo oo oo oo oo oo oo oo oo
a. The person who had abdominal oo oo oo oo
surgeryyesterday oo o
b. The person who is unaware of his oo oo oo oo oo oo
highserum glucose levels oo o oo oo
c. The person who is being admitted to a oo oo oo oo oo oo oo
long-term care facility oo oo
d. The person who is beginning oo oo oo oo
rehabilitationafter a knee replacement oo o oo oo oo
ANSWER: D oo
An episodic or follow-up assessment is performed after the knee replacement to
oo oo oo oo oo oo oo oo oo oo oo
evaluate the outcome of the procedure. A shift assessment is most appropriate for the
oo oo oo oo oo oo oo oo oo oo oo oo oo oo
person who isrecovering in the hospital from surgery. A screening assessment is
oo oo oo o oo oo oo oo oo oo oo oo oo
performed for the purpose of disease detection, in this case diabetes mellitus. A
oo oo oo oo oo oo oo oo oo oo oo oo oo
comprehensive assessment is performed during admission to a facility to obtain a
oo oo oo oo oo oo oo oo oo oo oo oo
detailed history and complete physicalexamination.
oo oo oo oo oo o
DIF: Cognitive Level: Understand
oo oo o o oo oo REF: Box 1-3 | p. oo oo oo oo
3TOP: Nursing Process: Assessment
oo o oo oo oo
