Test Bank for Health Assessment for Nursing Practice 5e
l l l l l l l l
Susan Wilson, Jean Foret Giddens (All Chapters)
l l l l l l l
Chapter 1: Importance of Health Assessment
l l l l l
MULTIPLE lCHOICE
1. A lpatient lcomes lto lthe lemergency ldepartment land ltells lthe ltriage lnurse lthat lhe lis l“having
a lheart lattack.” lWhat lis lthe lnurse’s ltop lpriority lat lthis ltime?
l
a. Determine lthe lpatient’s lpersonal ldata land linsurance lcoverage.
b. Ask lthe lpatient lto ltake la lseat lin lthe lwaiting lroom luntil lhis lname lis lcalled.
c. Request lthat la lnurse lcollect ldata lfor la lcomprehensive lhistory.
d. Ask la lnurse lto lstart la lfocused lassessment lof lthis lpatient lnow.
ANS: l D
Feedback
A Personal ldata land linsurance linformation lwill lbe lobtained, lbut lin lthis lsituation,
lthese ldata lcan lwait luntil lafter lthe lpatient lis lassessed.
B Rather lthan lasking lthe lpatient lto lwait, lthe lnurse lneeds lto lbegin ldata lcollection,
lsuch las lvital lsigns, limmediately lto ldetermine lthe l patient’s lhealth lstatus.
C A lcomprehensive lhistory lis lnot lindicated lin lthis lsituation lat lthis ltime. lSome
lsubjective ldata lwill lbe lcollected, lsuch las lallergies land lmedical lhistory lrelated lto
lcardiovascular ldisease.
D The lnurse lneeds lto lbegin lan lassessment las lsoon las lpossible lthat lis lfocused lon
this lpatient’s lcardiovascular lsystem. lThe ltype lof lhealth lassessment lperformed lby
lthe lnurse lis lalso ldriven lby lpatient lneed.
DIF: Cognitive lLevel: lApply REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
2. Which lsituation lillustrates la lscreening lassessment?
a. A lpatient lvisits lan lobstetric lclinic lfor lthe lfirst ltime land lthe lnurse lconducts
a ldetailed lhistory land lphysical lexamination.
l
b. A lhospital lsponsors la lhealth lfair lat la llocal lmall land lprovides lcholesterol land
lblood lpressure lchecks lto lmall lpatrons.
c. The lnurse lin lan lurgent lcare lcenter lchecks lthe lvital lsigns lof la lpatient lwho
lis lcomplaining lof lleg lpain.
d. A lpatient lnewly ldiagnosed lwith ldiabetes lmellitus lcomes lto ltest lhis lfasting
lblood lglucose llevel.
ANS: l B
Feedback
A A ldetailed lhistory land lphysical lexamination lconducted lduring la lfirst-time lvisit
lto lan lobstetric lclinic lis lan lexample lof la lcomprehensive lassessment.
, B A lhealth lfair lat la llocal lmall lthat lprovides lcholesterol land lblood lpressure
lchecks lis lan lexample lof la lscreening lassessment lfocused lon ldisease ldetection.
C Assessing la lpatient lcomplaining lof lleg lpain lin lthe ltriage larea lof lan lurgent lcare
lcenter lis lan lexample lof la lproblem-based/focused lassessment.
D A lpatient’s lreturn lappointment l1 lmonth lafter ltoday’s loffice lvisit lto lreport lfasting
lblood lglucose llevels lis lan lexample lof lan lepisodic lor lfollow-up lassessment.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lHealth lPromotion land lMaintenance: lHealth lScreening
3. For lwhich lperson lis la lscreening lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l B
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection. lIn lthis
lcase lthis lperson lmay lhave ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
4. For lwhich lperson lis la lshift lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels.
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility.
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement.
ANS: l A
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
, DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
5. For lwhich lperson lis la lcomprehensive lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l C
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
6. For lwhich lperson lis lan lepisodic lor lfollow-up lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l D
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lthe lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
, 7. Which lis lan lexample lof ldata la lnurse lcollects lduring la lphysical lexamination?
a. The lpatient’s llack lof lhair land lshiny lskin lover lboth lshins
b. The lpatient’s lstated lconcern labout llack lof lmoney lfor lprescriptions
c. The lpatient’s lcomplaints lof ltingling lsensations lin lthe lfeet
d. The lpatient’s lmother’s lstatements lthat lthe lpatient lis lvery lnervous llately
ANS: l A
Feedback
A The llack lof lhair land lshiny lskin lover lboth lshins lare lobjective ldata lor lsigns lthat
lare lpart lof lthe lphysical lexamination
B A lpatient’s lconcerns labout llack lof lmoney lare lsubjective ldata land lare lpart lof lthe
lhealth lhistory.
C A lpatient’s lcomplaints lof ltingling lsensations lin lthe lfeet lare lsubjective ldata land
lare lpart lof lthe lhealth lhistory.
D A lpatient’s lfamily lstatements lare lconsidered lsecondary ldata, lare lsubjective ldata,
land lare lpart lof lthe lhealth lhistory.
DIF: Cognitive lLevel: lApply REF:
l 1 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lPhysiologic lIntegrity: lReduction lof lRisk lPotential: lSystem lSpecific
lAssessments
8. The lnurse ldocuments lwhich linformation lin lthe lpatient’s lhistory?
a. The lpatient’s lskin lfeels lwarm lto lthe ltouch.
b. The lpatient lis lscratching lhis larm.
c. The lpatient’s ltemperature lis l100°lF.
d. The lpatient lcomplains lof litching.
ANS: l D
Feedback
A The lpatient’s lwarm lskin lis lobjective linformation lgathered lby lthe lnurse lthrough
lpalpation, lis lalso la l sign, land lis ldocumented lin lthe lphysical lexamination.
B The lpatient’s lscratching lis lobjective linformation lgathered lby lthe lnurse lthrough
lobservation, lis lalso la lsign, land lis ldocumented lin l the lphysical lexamination.
C The lpatient’s lelevated ltemperature lis lobjective linformation lgathered lby lthe lnurse
lthrough lmeasurement, lis lalso la lsign, land lis ldocumented lin lthe lphysical
lexamination.
D A lpatient’s lcomplaint lof litching lis lsubjective linformation, lwhich lmeans lit lis la
lsymptom land lis ldocumented lin lthe lhistory.
DIF: Cognitive lLevel: lApply REF:
l 1 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
9. Which lpatient linformation ldoes lthe lnurse ldocument lin lthe lpatient’s lphysical lassessment?
a. Slurred lspeech
b. Immunizations
l l l l l l l l
Susan Wilson, Jean Foret Giddens (All Chapters)
l l l l l l l
Chapter 1: Importance of Health Assessment
l l l l l
MULTIPLE lCHOICE
1. A lpatient lcomes lto lthe lemergency ldepartment land ltells lthe ltriage lnurse lthat lhe lis l“having
a lheart lattack.” lWhat lis lthe lnurse’s ltop lpriority lat lthis ltime?
l
a. Determine lthe lpatient’s lpersonal ldata land linsurance lcoverage.
b. Ask lthe lpatient lto ltake la lseat lin lthe lwaiting lroom luntil lhis lname lis lcalled.
c. Request lthat la lnurse lcollect ldata lfor la lcomprehensive lhistory.
d. Ask la lnurse lto lstart la lfocused lassessment lof lthis lpatient lnow.
ANS: l D
Feedback
A Personal ldata land linsurance linformation lwill lbe lobtained, lbut lin lthis lsituation,
lthese ldata lcan lwait luntil lafter lthe lpatient lis lassessed.
B Rather lthan lasking lthe lpatient lto lwait, lthe lnurse lneeds lto lbegin ldata lcollection,
lsuch las lvital lsigns, limmediately lto ldetermine lthe l patient’s lhealth lstatus.
C A lcomprehensive lhistory lis lnot lindicated lin lthis lsituation lat lthis ltime. lSome
lsubjective ldata lwill lbe lcollected, lsuch las lallergies land lmedical lhistory lrelated lto
lcardiovascular ldisease.
D The lnurse lneeds lto lbegin lan lassessment las lsoon las lpossible lthat lis lfocused lon
this lpatient’s lcardiovascular lsystem. lThe ltype lof lhealth lassessment lperformed lby
lthe lnurse lis lalso ldriven lby lpatient lneed.
DIF: Cognitive lLevel: lApply REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
2. Which lsituation lillustrates la lscreening lassessment?
a. A lpatient lvisits lan lobstetric lclinic lfor lthe lfirst ltime land lthe lnurse lconducts
a ldetailed lhistory land lphysical lexamination.
l
b. A lhospital lsponsors la lhealth lfair lat la llocal lmall land lprovides lcholesterol land
lblood lpressure lchecks lto lmall lpatrons.
c. The lnurse lin lan lurgent lcare lcenter lchecks lthe lvital lsigns lof la lpatient lwho
lis lcomplaining lof lleg lpain.
d. A lpatient lnewly ldiagnosed lwith ldiabetes lmellitus lcomes lto ltest lhis lfasting
lblood lglucose llevel.
ANS: l B
Feedback
A A ldetailed lhistory land lphysical lexamination lconducted lduring la lfirst-time lvisit
lto lan lobstetric lclinic lis lan lexample lof la lcomprehensive lassessment.
, B A lhealth lfair lat la llocal lmall lthat lprovides lcholesterol land lblood lpressure
lchecks lis lan lexample lof la lscreening lassessment lfocused lon ldisease ldetection.
C Assessing la lpatient lcomplaining lof lleg lpain lin lthe ltriage larea lof lan lurgent lcare
lcenter lis lan lexample lof la lproblem-based/focused lassessment.
D A lpatient’s lreturn lappointment l1 lmonth lafter ltoday’s loffice lvisit lto lreport lfasting
lblood lglucose llevels lis lan lexample lof lan lepisodic lor lfollow-up lassessment.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lHealth lPromotion land lMaintenance: lHealth lScreening
3. For lwhich lperson lis la lscreening lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l B
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection. lIn lthis
lcase lthis lperson lmay lhave ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
4. For lwhich lperson lis la lshift lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels.
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility.
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement.
ANS: l A
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
, DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
5. For lwhich lperson lis la lcomprehensive lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l C
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
6. For lwhich lperson lis lan lepisodic lor lfollow-up lassessment lindicated?
a. The lperson lwho lhad labdominal lsurgery lyesterday
b. The lperson lwho lis lunaware lof lhis lhigh lserum lglucose llevels
c. The lperson lwho lis lbeing ladmitted lto la llong-term lcare lfacility
d. The lperson lwho lis lbeginning lrehabilitation lafter la lknee lreplacement
ANS: l D
Feedback
A A lshift lassessment lis lmost lappropriate lfor lthe lperson lwho lis lrecovering lin lthe
lhospital lfrom lsurgery.
B A lscreening lassessment lis lperformed lfor lthe lpurpose lof ldisease ldetection, lin lthis
lcase ldiabetes lmellitus.
C A lcomprehensive lassessment lis lperformed lduring ladmission lto la lfacility lto
lobtain la ldetailed lhistory land lcomplete lphysical lexamination.
D An lepisodic lor lfollow-up lassessment lis lperformed lafter lthe lknee lreplacement lto
levaluate lthe loutcome lof lthe lprocedure.
DIF: Cognitive lLevel: lUnderstand REF:
l 3 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
, 7. Which lis lan lexample lof ldata la lnurse lcollects lduring la lphysical lexamination?
a. The lpatient’s llack lof lhair land lshiny lskin lover lboth lshins
b. The lpatient’s lstated lconcern labout llack lof lmoney lfor lprescriptions
c. The lpatient’s lcomplaints lof ltingling lsensations lin lthe lfeet
d. The lpatient’s lmother’s lstatements lthat lthe lpatient lis lvery lnervous llately
ANS: l A
Feedback
A The llack lof lhair land lshiny lskin lover lboth lshins lare lobjective ldata lor lsigns lthat
lare lpart lof lthe lphysical lexamination
B A lpatient’s lconcerns labout llack lof lmoney lare lsubjective ldata land lare lpart lof lthe
lhealth lhistory.
C A lpatient’s lcomplaints lof ltingling lsensations lin lthe lfeet lare lsubjective ldata land
lare lpart lof lthe lhealth lhistory.
D A lpatient’s lfamily lstatements lare lconsidered lsecondary ldata, lare lsubjective ldata,
land lare lpart lof lthe lhealth lhistory.
DIF: Cognitive lLevel: lApply REF:
l 1 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lPhysiologic lIntegrity: lReduction lof lRisk lPotential: lSystem lSpecific
lAssessments
8. The lnurse ldocuments lwhich linformation lin lthe lpatient’s lhistory?
a. The lpatient’s lskin lfeels lwarm lto lthe ltouch.
b. The lpatient lis lscratching lhis larm.
c. The lpatient’s ltemperature lis l100°lF.
d. The lpatient lcomplains lof litching.
ANS: l D
Feedback
A The lpatient’s lwarm lskin lis lobjective linformation lgathered lby lthe lnurse lthrough
lpalpation, lis lalso la l sign, land lis ldocumented lin lthe lphysical lexamination.
B The lpatient’s lscratching lis lobjective linformation lgathered lby lthe lnurse lthrough
lobservation, lis lalso la lsign, land lis ldocumented lin l the lphysical lexamination.
C The lpatient’s lelevated ltemperature lis lobjective linformation lgathered lby lthe lnurse
lthrough lmeasurement, lis lalso la lsign, land lis ldocumented lin lthe lphysical
lexamination.
D A lpatient’s lcomplaint lof litching lis lsubjective linformation, lwhich lmeans lit lis la
lsymptom land lis ldocumented lin lthe lhistory.
DIF: Cognitive lLevel: lApply REF:
l 1 lTOP: l Nursing lProcess: lAssessment
MSC: l NCLEX lPatient lNeeds: lSafe land lEffective lCare lEnvironment: lManagement lof lCare:
lEstablishing lPriorities
9. Which lpatient linformation ldoes lthe lnurse ldocument lin lthe lpatient’s lphysical lassessment?
a. Slurred lspeech
b. Immunizations
