Test Bank For Health Assessment for Nursing Practice, 7th Edition by Susan F Wilson, Jean Foret Giddens All Chapters 1-24

,
,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 7th Edition
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MULTIPLE CHOICE 2p




1. A patient comes to the emergency department and tells the triage nurse that he is ―having
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a heart attack.‖ What is the nurse‘s top priority at this time?
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a. Determine the patient‘s personal data and insurance coverage. 2p 2p 2p 2p 2p 2p 2p


b. Ask the patient to take a seat in the waiting room until his name is called.
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c. Request that a nurse collect data for a comprehensive history.
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d. Ask a nurse to start a focused assessment of this patient now.
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ANS: D 2 p


The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
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cardiovascular system. The type of health assessment performed by the nurse is also driven
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pby patient need. Personal data and insurance information will be obtained, but in this situat
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ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
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y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
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urse needs to begin data collection, such as vital signs, immediately to determine the patien
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t‘s health status. Complications can be prevented if an immediate assessment is made to an
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alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
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his time. Some subjective data will be collected, such as allergies and medical history relat
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ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
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essment is not a priority at this time. 2p 2p 2p 2p 2p 2p 2p




DIF:Cognitive Level: Apply REF: Box 1- 2p 2p 2 p 2p


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
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hing Priorities 2p




2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse conduct
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s a detailed history and physical examination.
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b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
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od pressure checks to mall patrons.
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c. The nurse in an urgent care center checks the vital signs of a patient who
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is complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
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od glucose level. 2p 2p




ANS: B 2 p


A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
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ple of a screening assessment focused on disease detection. A detailed history and physical
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pexamination conducted during a first- 2p 2p 2p 2p


time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
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patient complaining of leg pain in the triage area of an urgent care center is an example of
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pa problem-
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based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
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to report fasting blood glucose levels is an example of an episodic or follow-
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up assessment.
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DIF:Cognitive Level: Understand 2p 2p REF: Box 1-3 2p 2p

, TOP:Nursing Process: Assessment 2p 2p


MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: B 2p


A screening assessment is performed for the purpose of disease detection. In this case this
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person may have diabetes mellitus. A shift assessment is most appropriate for the person w
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ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
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ring admission to a facility to obtain a detailed history and complete physical examination.
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An episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedur
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e.

DIF:Cognitive Level: Understand REF: Box 1- 2p 2p 2p 2p


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
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hing Priorities 2p




4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: A 2p


A shift assessment is most appropriate for the person who is recovering in the hospital from
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2psurgery. A screening assessment is performed for the purpose of disease detection, in this c
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ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
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ty to obtain a detailed history and complete physical examination. An episodic or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the procedure
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.

DIF:Cognitive Level: Understand REF: Box 1- 2p 2p 2p 2p


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
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hing Priorities 2p




5. For which person is a comprehensive assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: C 2p


A comprehensive assessment is performed during admission to a facility to obtain a detaile
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d history and complete physical examination. A shift assessment is most appropriate for th
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e person who is recovering in the hospital from surgery. A screening assessment is perfor
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med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
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ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
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re.