TestBankforHealthAssessmentfor
o o o o o
oNursingPractice7thEditionbyWilson
o o o o o
o Chapter1-24 o o o
,Chapter01:Introductionto Health Assessment o o o o o
MULTIPLE CHOICE o
1. Apatient comesto the emergencydepartment andtellsthe triage nursethat heis o o o o o o o o o o o o o o
“havinga heart attack.” What isthe nurse’stop priorityat thistime?
o o o o o o o o o o o o o
a. Determinethepatient’spersonaldataand o o o o o
insurance coverage. o o
b. Ask thepatient totakea seat inthewaitingroomo o o o o o o o o o
until hisname iscalled.
o o o o o
c. Requestthata nursecollectdata for a o o o o o o o
comprehensive history.
o o
d. Ask a nurseto startafocusedassessmentof o o o o o o o o
thispatient now.
o o o
ANSWER: D o
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
o o o o o o o o o o o o o o o o
cardiovascular system. The type of health assessment performed by the nurse is also drivenby
o o o o o o o o o o o o o o o
patient need. Personal data and insurance information will be obtained, but in this situation, these
o o o o o o o o o o o o o o o
data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of needs,
o o o o o o o o o o o o o o o o
physiologic needs take precedence. Rather than asking the patient to wait, the nurse needs to
o o o o o o o o o o o o o o o
begin data collection, such as vital signs, immediately to determinethe patient’s health status.
o o o o o o o o o o o o o o
Complications can be prevented if an immediate assessment is made to analyze the patient’s
o o o o o o o o o o o o o o
symptoms. A comprehensive history is not indicated in this situation at this time. Some
o o o o o o o o o o o o o o
subjective data will be collected, such as allergies and medical history related to cardiovascular
o o o o o o o o o o o o o o
disease. Eyes, ears, or a complete musculoskeletal or mental healthassessment is not a priorityat
o o o o o o o o o o o o o o o o
thistime.
o o
DIF: CognitiveLevel: Apply
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
2. Which situationillustratesa screeningassessment? o o o o o
a. A patient visits an obstetric clinic for the first o o o o o o o o
timeandthe nurseconductsadetailedhistory o o o o o o o o
and physical examination. o o o
b. Ahospital sponsorsahealth fair atalocal o o o o o o o o
mall and provides cholesterol and blood o o o o o o
pressure checksto mall patrons. o o o o o
c. Thenurseinan urgent carecenterchecksthe o o o o o o o o
vital signs of a patient who is complaining o o o o o o o o
oflegpain. o o o
, d. Apatient newlydiagnosed withdiabetes
o o o o o
mellitus comes to test his fasting blood
o o o o o o o
glucoselevel.
o o
ANSWER: B o
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a
o o o o o o o o o o o o o o o o o o
screening assessment focused on disease detection. A detailed history and physical examination
o o o o o o o o o o o o
conducted duringa first-time visit to anobstetricclinicisanexampleof a comprehensive
o o o o o o o o o o o o o o o
assessment. Assessing a patient complaining of leg pain in the triage area of an urgent care center
o o o o o o o o o o o o o o o o o
is an example of a problem-based/focused assessment. A patient’s return appointment 1 month
o o o o o o o o o o o o o
after today’s office visit to report fasting blood glucose levelsisanexample ofanepisodic or
o o o o o o o o o o o o o o o o o
follow-up assessment.
o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: HealthPromotionandMaintenance: HealthScreening
o o o o o o o o o
3. Forwhichpersonisa screeningassessmentindicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels
o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility
o o o
d. The personwho isbeginning rehabilitation o o o o o
after a knee replacement
o o o o
ANSWER: B o
A screening assessment is performed for the purpose of disease detection. In this case thisperson
o o o o o o o o o o o o o o o
may have diabetes mellitus. A shift assessment is most appropriate for the person who is
o o o o o o o o o o o o o o o
recovering in the hospital from surgery. A comprehensive assessment is performedduring
o o o o o o o o o o o o
admission to a facility to obtain a detailed history and complete physical examination. An
o o o o o o o o o o o o o o
episodic or follow-up assessment is performed after knee replacement toevaluate the outcome
o o o o o o o o o o o o o
ofthe procedure.
o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
4. Forwhichpersonisa shiftassessmentindicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o
d. The personwhoisbeginningrehabilitation o o o o o
after aknee replacement o o o o
ANSWER: A o
A shift assessment is most appropriate for the person who is recovering in the hospital from
o o o o o o o o o o o o o o o
surgery. A screening assessment is performed for the purpose of disease detection, in this case
o o o o o o o o o o o o o o o
diabetesmellitus. Acomprehensive assessmentisperformed duringadmissiontoa
o o o o o o o o o o o
, facility to obtain a detailed history and complete physical examination. An episodic or follow-
o o o o o o o o o o o o o
up assessment isperformed after kneereplacement to evaluatetheoutcomeoftheprocedure.
o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 4 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
5. Forwhichpersonisacomprehensive assessment indicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o o
d. The personwho isbeginningrehabilitation o o o o o
after a knee replacement o o o o
ANSWER: C o
Acomprehensive assessment isperformed duringadmissiontoa facilityto obtaina
o o o o o o o o o o o o
detailed history and complete physical examination. A shift assessment is most appropriatefor
o o o o o o o o o o o o
the person who is recovering in the hospital from surgery. A screening assessment is performed
o o o o o o o o o o o o o o o
for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-up
o o o o o o o o o o o o o o o
assessment is performed after knee replacement to evaluate the outcome of the procedure.
o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
6. Forwhichpersonisanepisodic orfollow-upassessment indicated?
o o o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwho isunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o
d. The personwho isbeginningrehabilitation o o o o o
after a knee replacement o o o o
ANSWER: D o
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
o o o o o o o o o o o o o
outcome of the procedure. A shift assessment is most appropriate for the person who is
o o o o o o o o o o o o o o o
recovering in the hospital from surgery. A screening assessment is performed for the purposeof
o o o o o o o o o o o o o o o
disease detection,inthiscasediabetesmellitus. Acomprehensive assessmentis performed
o o o o o o o o o o o o
during admission to a facility to obtain a detailed history and complete physicalexamination.
o o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o o o REF: Box 1-3 | p. 3 o o o o o
TOP: NursingProcess: Assessment
o o o o
o o o o o
oNursingPractice7thEditionbyWilson
o o o o o
o Chapter1-24 o o o
,Chapter01:Introductionto Health Assessment o o o o o
MULTIPLE CHOICE o
1. Apatient comesto the emergencydepartment andtellsthe triage nursethat heis o o o o o o o o o o o o o o
“havinga heart attack.” What isthe nurse’stop priorityat thistime?
o o o o o o o o o o o o o
a. Determinethepatient’spersonaldataand o o o o o
insurance coverage. o o
b. Ask thepatient totakea seat inthewaitingroomo o o o o o o o o o
until hisname iscalled.
o o o o o
c. Requestthata nursecollectdata for a o o o o o o o
comprehensive history.
o o
d. Ask a nurseto startafocusedassessmentof o o o o o o o o
thispatient now.
o o o
ANSWER: D o
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
o o o o o o o o o o o o o o o o
cardiovascular system. The type of health assessment performed by the nurse is also drivenby
o o o o o o o o o o o o o o o
patient need. Personal data and insurance information will be obtained, but in this situation, these
o o o o o o o o o o o o o o o
data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of needs,
o o o o o o o o o o o o o o o o
physiologic needs take precedence. Rather than asking the patient to wait, the nurse needs to
o o o o o o o o o o o o o o o
begin data collection, such as vital signs, immediately to determinethe patient’s health status.
o o o o o o o o o o o o o o
Complications can be prevented if an immediate assessment is made to analyze the patient’s
o o o o o o o o o o o o o o
symptoms. A comprehensive history is not indicated in this situation at this time. Some
o o o o o o o o o o o o o o
subjective data will be collected, such as allergies and medical history related to cardiovascular
o o o o o o o o o o o o o o
disease. Eyes, ears, or a complete musculoskeletal or mental healthassessment is not a priorityat
o o o o o o o o o o o o o o o o
thistime.
o o
DIF: CognitiveLevel: Apply
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
2. Which situationillustratesa screeningassessment? o o o o o
a. A patient visits an obstetric clinic for the first o o o o o o o o
timeandthe nurseconductsadetailedhistory o o o o o o o o
and physical examination. o o o
b. Ahospital sponsorsahealth fair atalocal o o o o o o o o
mall and provides cholesterol and blood o o o o o o
pressure checksto mall patrons. o o o o o
c. Thenurseinan urgent carecenterchecksthe o o o o o o o o
vital signs of a patient who is complaining o o o o o o o o
oflegpain. o o o
, d. Apatient newlydiagnosed withdiabetes
o o o o o
mellitus comes to test his fasting blood
o o o o o o o
glucoselevel.
o o
ANSWER: B o
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of a
o o o o o o o o o o o o o o o o o o
screening assessment focused on disease detection. A detailed history and physical examination
o o o o o o o o o o o o
conducted duringa first-time visit to anobstetricclinicisanexampleof a comprehensive
o o o o o o o o o o o o o o o
assessment. Assessing a patient complaining of leg pain in the triage area of an urgent care center
o o o o o o o o o o o o o o o o o
is an example of a problem-based/focused assessment. A patient’s return appointment 1 month
o o o o o o o o o o o o o
after today’s office visit to report fasting blood glucose levelsisanexample ofanepisodic or
o o o o o o o o o o o o o o o o o
follow-up assessment.
o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: HealthPromotionandMaintenance: HealthScreening
o o o o o o o o o
3. Forwhichpersonisa screeningassessmentindicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels
o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility
o o o
d. The personwho isbeginning rehabilitation o o o o o
after a knee replacement
o o o o
ANSWER: B o
A screening assessment is performed for the purpose of disease detection. In this case thisperson
o o o o o o o o o o o o o o o
may have diabetes mellitus. A shift assessment is most appropriate for the person who is
o o o o o o o o o o o o o o o
recovering in the hospital from surgery. A comprehensive assessment is performedduring
o o o o o o o o o o o o
admission to a facility to obtain a detailed history and complete physical examination. An
o o o o o o o o o o o o o o
episodic or follow-up assessment is performed after knee replacement toevaluate the outcome
o o o o o o o o o o o o o
ofthe procedure.
o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
4. Forwhichpersonisa shiftassessmentindicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o
d. The personwhoisbeginningrehabilitation o o o o o
after aknee replacement o o o o
ANSWER: A o
A shift assessment is most appropriate for the person who is recovering in the hospital from
o o o o o o o o o o o o o o o
surgery. A screening assessment is performed for the purpose of disease detection, in this case
o o o o o o o o o o o o o o o
diabetesmellitus. Acomprehensive assessmentisperformed duringadmissiontoa
o o o o o o o o o o o
, facility to obtain a detailed history and complete physical examination. An episodic or follow-
o o o o o o o o o o o o o
up assessment isperformed after kneereplacement to evaluatetheoutcomeoftheprocedure.
o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 4 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
5. Forwhichpersonisacomprehensive assessment indicated?
o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwhoisunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o o
d. The personwho isbeginningrehabilitation o o o o o
after a knee replacement o o o o
ANSWER: C o
Acomprehensive assessment isperformed duringadmissiontoa facilityto obtaina
o o o o o o o o o o o o
detailed history and complete physical examination. A shift assessment is most appropriatefor
o o o o o o o o o o o o
the person who is recovering in the hospital from surgery. A screening assessment is performed
o o o o o o o o o o o o o o o
for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-up
o o o o o o o o o o o o o o o
assessment is performed after knee replacement to evaluate the outcome of the procedure.
o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o REF: Box 1-3 | p. 3 o o o o o o o
TOP: NursingProcess: Assessment
o o o o
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:Managementof Care:Establishing
o o o o o o o o o o o o
Priorities
o
6. Forwhichpersonisanepisodic orfollow-upassessment indicated?
o o o o o o o o o
a. Thepersonwho hadabdominal surgery o o o o o
yesterday o
b. The personwho isunaware ofhishigh o o o o o o o
serum glucose levels o o o
c. The personwho isbeingadmitted to a o o o o o o o
long-termcare facility o o
d. The personwho isbeginningrehabilitation o o o o o
after a knee replacement o o o o
ANSWER: D o
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
o o o o o o o o o o o o o
outcome of the procedure. A shift assessment is most appropriate for the person who is
o o o o o o o o o o o o o o o
recovering in the hospital from surgery. A screening assessment is performed for the purposeof
o o o o o o o o o o o o o o o
disease detection,inthiscasediabetesmellitus. Acomprehensive assessmentis performed
o o o o o o o o o o o o
during admission to a facility to obtain a detailed history and complete physicalexamination.
o o o o o o o o o o o o o o
DIF: CognitiveLevel: Understand
oo o o o REF: Box 1-3 | p. 3 o o o o o
TOP: NursingProcess: Assessment
o o o o
