,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 8th Edition
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MULTIPLE CHOICE v8
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. v8 v8 v8 v8 v8 v8 v8
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.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: D v 8
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
cardiovascular system. The type of health assessment performed by the nurse is also driven
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8by patient need. Personal data and insurance information will be obtained, but in this situat
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
urse needs to begin data collection, such as vital signs, immediately to determine the patien
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
t‘s health status. Complications can be prevented if an immediate assessment is made to an
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
his time. Some subjective data will be collected, such as allergies and medical history relat
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
essment is not a priority at this time. v8 v8 v8 v8 v8 v8 v8
DIF:Cognitive Level: Apply REF: Box 1- v8 v8 v 8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
2. Which situation illustrates a screening assessment?
v8 v8 v8 v8 v8
a. A patient visits an obstetric clinic for the first time and the nurse conduct
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
s a detailed history and physical examination.
v8 v8 v8 v8 v8 v8
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
od pressure checks to mall patrons.
v8 v8 v8 v8 v8
c. The nurse in an urgent care center checks the vital signs of a patient who
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
is complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
od glucose level. v8 v8
ANS: B v 8
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ple of a screening assessment focused on disease detection. A detailed history and physical
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8examination conducted during a first- v8 v8 v8 v8
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
patient complaining of leg pain in the triage area of an urgent care center is an example of
v8 v8 v8 v8 v8 v8 v8 v8 v8 v 8 v8 v8 v8 v8 v8 v8 v8 v
8a problem-
v8
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
to report fasting blood glucose levels is an example of an episodic or follow-
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
up assessment.
v8
DIF:Cognitive Level: Understand v8 v8 REF: Box 1-3 v8 v8
, TOP:Nursing Process: Assessment v8 v8
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
v8 v8 v8 v8 v8 v8 v8 v8
3. For which person is a screening assessment indicated?
v8 v8 v8 v8 v8 v8 v8
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 v8
A screening assessment is performed for the purpose of disease detection. In this case this
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ring admission to a facility to obtain a detailed history and complete physical examination.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
An episodic or follow-
v8 v8 v8
up assessment is performed after knee replacement to evaluate the outcome of the procedur
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
e.
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
4. For which person is a shift assessment indicated?
v8 v8 v8 v8 v8 v8 v8
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
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
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ANS: A v8
A shift assessment is most appropriate for the person who is recovering in the hospital from
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
v8surgery. A screening assessment is performed for the purpose of disease detection, in this c
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ty to obtain a detailed history and complete physical examination. An episodic or follow-
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
up assessment is performed after knee replacement to evaluate the outcome of the procedure
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
.
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
5. For which person is a comprehensive assessment indicated?
v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: C v8
A comprehensive assessment is performed during admission to a facility to obtain a detaile
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d history and complete physical examination. A shift assessment is most appropriate for th
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
e person who is recovering in the hospital from surgery. A screening assessment is perfor
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
re.
, DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
6. For which person is an episodic or follow-up assessment indicated?
v8 v8 v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: D v8
An episodic or follow-
v8 v8 v8
up assessment is performed after the knee replacement to evaluate the outcome of the proc
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
edure. A shift assessment is most appropriate for the person who is recovering in the hospi
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
tal from surgery. A screening assessment is performed for the purpose of disease detection,
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8in this case diabetes mellitus. A comprehensive assessment is performed during admission
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
to a facility to obtain a detailed history and complete physical examination.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A v8
The lack of hair and shiny skin over both shins are objective data or signs that are part of
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
the physical examination. A patient‘s concerns about lack of money are subjective data an
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d are part of the health history. A patient‘s complaints of tingling sensations in the feet are
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
subjective data and are part of the health history. A patient‘s family statements are conside
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
red secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- v8 v8 v 8 v8
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
8
8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.v8 v8 v8 v8
ANS: D v8
v8 v8 v8 v8 v8
Wilson: Health Assessment for Nursing Practice, 8th Edition
v8 v8 v8 v8 v8 v8 v8
MULTIPLE CHOICE v8
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
a heart attack.‖ What is the nurse‘s top priority at this time?
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
a. Determine the patient‘s personal data and insurance coverage. v8 v8 v8 v8 v8 v8 v8
b. Ask the patient to take a seat in the waiting room until his name is called.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. Request that a nurse collect data for a comprehensive history.
v8 v8 v8 v8 v8 v8 v8 v8 v8
d. Ask a nurse to start a focused assessment of this patient now.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: D v 8
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
cardiovascular system. The type of health assessment performed by the nurse is also driven
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8by patient need. Personal data and insurance information will be obtained, but in this situat
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
urse needs to begin data collection, such as vital signs, immediately to determine the patien
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
t‘s health status. Complications can be prevented if an immediate assessment is made to an
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
his time. Some subjective data will be collected, such as allergies and medical history relat
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
essment is not a priority at this time. v8 v8 v8 v8 v8 v8 v8
DIF:Cognitive Level: Apply REF: Box 1- v8 v8 v 8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
2. Which situation illustrates a screening assessment?
v8 v8 v8 v8 v8
a. A patient visits an obstetric clinic for the first time and the nurse conduct
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
s a detailed history and physical examination.
v8 v8 v8 v8 v8 v8
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
od pressure checks to mall patrons.
v8 v8 v8 v8 v8
c. The nurse in an urgent care center checks the vital signs of a patient who
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
is complaining of leg pain.
v8 v8 v8 v8 v8
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
od glucose level. v8 v8
ANS: B v 8
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ple of a screening assessment focused on disease detection. A detailed history and physical
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8examination conducted during a first- v8 v8 v8 v8
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
patient complaining of leg pain in the triage area of an urgent care center is an example of
v8 v8 v8 v8 v8 v8 v8 v8 v8 v 8 v8 v8 v8 v8 v8 v8 v8 v
8a problem-
v8
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
to report fasting blood glucose levels is an example of an episodic or follow-
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
up assessment.
v8
DIF:Cognitive Level: Understand v8 v8 REF: Box 1-3 v8 v8
, TOP:Nursing Process: Assessment v8 v8
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
v8 v8 v8 v8 v8 v8 v8 v8
3. For which person is a screening assessment indicated?
v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: B v8
A screening assessment is performed for the purpose of disease detection. In this case this
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ring admission to a facility to obtain a detailed history and complete physical examination.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
An episodic or follow-
v8 v8 v8
up assessment is performed after knee replacement to evaluate the outcome of the procedur
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
e.
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
4. For which person is a shift assessment indicated?
v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: A v8
A shift assessment is most appropriate for the person who is recovering in the hospital from
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
v8surgery. A screening assessment is performed for the purpose of disease detection, in this c
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ty to obtain a detailed history and complete physical examination. An episodic or follow-
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
up assessment is performed after knee replacement to evaluate the outcome of the procedure
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
.
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
5. For which person is a comprehensive assessment indicated?
v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: C v8
A comprehensive assessment is performed during admission to a facility to obtain a detaile
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d history and complete physical examination. A shift assessment is most appropriate for th
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
e person who is recovering in the hospital from surgery. A screening assessment is perfor
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
re.
, DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
6. For which person is an episodic or follow-up assessment indicated?
v8 v8 v8 v8 v8 v8 v8 v8 v8
a. The person who had abdominal surgery yesterday
v8 v8 v8 v8 v8 v8
b. The person who is unaware of his high serum glucose levels
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
c. The person who is being admitted to a long-term care facility
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
d. The person who is beginning rehabilitation after a knee replacement
v8 v8 v8 v8 v8 v8 v8 v8 v8
ANS: D v8
An episodic or follow-
v8 v8 v8
up assessment is performed after the knee replacement to evaluate the outcome of the proc
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
edure. A shift assessment is most appropriate for the person who is recovering in the hospi
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
tal from surgery. A screening assessment is performed for the purpose of disease detection,
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v
8in this case diabetes mellitus. A comprehensive assessment is performed during admission
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
to a facility to obtain a detailed history and complete physical examination.
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
DIF:Cognitive Level: Understand REF: Box 1- v8 v8 v8 v8
3 TOP:Nursing Process: Assessment
v8 v8 v8
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
v8 v8 v8 v8 v8 v8 v8 v8 v8 v8 v8
hing Priorities v8
7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A v8
The lack of hair and shiny skin over both shins are objective data or signs that are part of
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the physical examination. A patient‘s concerns about lack of money are subjective data an
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d are part of the health history. A patient‘s complaints of tingling sensations in the feet are
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subjective data and are part of the health history. A patient‘s family statements are conside
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red secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- v8 v8 v 8 v8
3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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Assessments
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8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.v8 v8 v8 v8
ANS: D v8
