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