,
,Chapter 01: Introduction to Health Assessment
km km km km km
Wilson: Health Assessment for Nursing Practice, 7th Edition
km km km km km km km
MULTIPLE CHOICE km
1. A patient comes to the emergency department and tells the triage nurse that he is ―hav
km km km km km km km km km km km km km km km
ing a heart attack.‖ What is the nurse‘s top priority at this time?
km km km km km km km km km km km km
a. Determine the patient‘s personal data and insurance coverage.
km km km km km km km
b. Ask the patient to take a seat in the waiting room until his name is called.
km km km km km km km km km km km km km km km
c. Request that a nurse collect data for a comprehensive history.
km km km km km km km km km
d. Ask a nurse to start a focused assessment of this patient now.
km km km km km km km km km km km
ANS: D k m
The nurse needs to begin an assessment as soon as possible that is focused on this patie
km km km km km km km km km km km km km km km km
nt‘s cardiovascular system. The type of health assessment performed by the nurse is also
km km km km km km km km km km km km km km
driven by patient need. Personal data and insurance information will be obtained, but in
km km km km km km km km km km km km km km
this situation, these data can wait until after the patient is assessed. Based also on Maslo
km km km km km km km km km km km km km km km
w‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the patien
km km km km km km km km km km km km
t to wait, the nurse needs to begin data collection, such as vital signs, immediately to de
km km km km km km km km km km km km km km km km
termine the patient‘s health status. Complications can be prevented if an immediate asses
km km km km km km km km km km km km
sment is made to analyze the patient‘s symptoms. A comprehensive history is not indicat
km km km km km km km km km km km km km
ed in this situation at this time. Some subjective data will be collected, such as allergies
km km km km km km km km km km km km km km km k
mand medical history related to cardiovascular disease. Eyes, ears, or a complete musculo
km km km km km km km km km km km km
skeletal or mental health assessment is not a priority at this time.
km km km km km km km km km km km
DIF:Cognitive Level: Apply REF: Box 1- km km k m km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
2. Which situation illustrates a screening assessment?
km km km km km
a. A patient visits an obstetric clinic for the first time and the nurse cond
km km km km km km km km km km km km km
ucts a detailed history and physical examination.
km km km km km km
b. A hospital sponsors a health fair at a local mall and provides cholesterol and
km km km km km km km km km km km km km km
blood pressure checks to mall patrons.
km km km km km
c. The nurse in an urgent care center checks the vital signs of a patient
km km km km km km km km km km km km km km
who is complaining of leg pain.km km km km km
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting b
km km km km km km km km km km km km
lood glucose level. km km
ANS: B k m
A health fair at a local mall that provides cholesterol and blood pressure checks is an e
km km km km km km km km km km km km km km km km
xample of a screening assessment focused on disease detection. A detailed history and p
km km km km km km km km km km km km km
hysical examination conducted during a first-
km km km km km
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing
km km km km km km km km km km km km km k
ma patient complaining of leg pain in the triage area of an urgent care center is an exa
km km km km km km km km km km k m km km km km km km
mple of a problem- km km km
based/focused assessment. A patient‘s return appointment 1 month after today‘s office vi
km km km km km km km km km km km
sit to report fasting blood glucose levels is an example of an episodic or follow-
km km km km km km km km km km km km km km
up assessment.
km
DIF:Cognitive Level: Understand km km REF: Box 1-3 km km
, TOP:Nursing Process: Assessment km km
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
km km km km km km km km
3. For which person is a screening assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: B km
A screening assessment is performed for the purpose of disease detection. In this case th
km km km km km km km km km km km km km km
is person may have diabetes mellitus. A shift assessment is most appropriate for the pers
km km km km km km km km km km km km km km
on who is recovering in the hospital from surgery. A comprehensive assessment is perfo
km km km km km km km km km km km km km
rmed during admission to a facility to obtain a detailed history and complete physical ex
km km km km km km km km km km km km km km
amination. An episodic or follow- km km km km
up assessment is performed after knee replacement to evaluate the outcome of the proced
km km km km km km km km km km km km km
ure.
DIF:Cognitive Level: Understand REF: Box 1- km km km km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
4. For which person is a shift assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: A km
A shift assessment is most appropriate for the person who is recovering in the hospital fr
km km km km km km km km km km km km km km km
om surgery. A screening assessment is performed for the purpose of disease detection, in
km km km km km km km km km km km km km km
this case diabetes mellitus. A comprehensive assessment is performed during admission to
km km km km km km km km km km km
a facility to obtain a detailed history and complete physical examination. An episodic or
km km km km km km km km km km km km km km
follow-
km
up assessment is performed after knee replacement to evaluate the outcome of the proced
km km km km km km km km km km km km km
ure.
DIF:Cognitive Level: Understand REF: Box 1- km km km km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
5. For which person is a comprehensive assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: C km
A comprehensive assessment is performed during admission to a facility to obtain a deta
km km km km km km km km km km km km km
iled history and complete physical examination. A shift assessment is most appropriate f
km km km km km km km km km km km km
or the person who is recovering in the hospital from surgery. A screening assessment is
km km km km km km km km km km km km km km k
mperformed for the purpose of disease detection, in this case diabetes mellitus. An episo
km km km km km km km km km km km km km
dic or follow-
km km
up assessment is performed after knee replacement to evaluate the outcome of the proce
km km km km km km km km km km km km km
dure.
,Chapter 01: Introduction to Health Assessment
km km km km km
Wilson: Health Assessment for Nursing Practice, 7th Edition
km km km km km km km
MULTIPLE CHOICE km
1. A patient comes to the emergency department and tells the triage nurse that he is ―hav
km km km km km km km km km km km km km km km
ing a heart attack.‖ What is the nurse‘s top priority at this time?
km km km km km km km km km km km km
a. Determine the patient‘s personal data and insurance coverage.
km km km km km km km
b. Ask the patient to take a seat in the waiting room until his name is called.
km km km km km km km km km km km km km km km
c. Request that a nurse collect data for a comprehensive history.
km km km km km km km km km
d. Ask a nurse to start a focused assessment of this patient now.
km km km km km km km km km km km
ANS: D k m
The nurse needs to begin an assessment as soon as possible that is focused on this patie
km km km km km km km km km km km km km km km km
nt‘s cardiovascular system. The type of health assessment performed by the nurse is also
km km km km km km km km km km km km km km
driven by patient need. Personal data and insurance information will be obtained, but in
km km km km km km km km km km km km km km
this situation, these data can wait until after the patient is assessed. Based also on Maslo
km km km km km km km km km km km km km km km
w‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the patien
km km km km km km km km km km km km
t to wait, the nurse needs to begin data collection, such as vital signs, immediately to de
km km km km km km km km km km km km km km km km
termine the patient‘s health status. Complications can be prevented if an immediate asses
km km km km km km km km km km km km
sment is made to analyze the patient‘s symptoms. A comprehensive history is not indicat
km km km km km km km km km km km km km
ed in this situation at this time. Some subjective data will be collected, such as allergies
km km km km km km km km km km km km km km km k
mand medical history related to cardiovascular disease. Eyes, ears, or a complete musculo
km km km km km km km km km km km km
skeletal or mental health assessment is not a priority at this time.
km km km km km km km km km km km
DIF:Cognitive Level: Apply REF: Box 1- km km k m km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
2. Which situation illustrates a screening assessment?
km km km km km
a. A patient visits an obstetric clinic for the first time and the nurse cond
km km km km km km km km km km km km km
ucts a detailed history and physical examination.
km km km km km km
b. A hospital sponsors a health fair at a local mall and provides cholesterol and
km km km km km km km km km km km km km km
blood pressure checks to mall patrons.
km km km km km
c. The nurse in an urgent care center checks the vital signs of a patient
km km km km km km km km km km km km km km
who is complaining of leg pain.km km km km km
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting b
km km km km km km km km km km km km
lood glucose level. km km
ANS: B k m
A health fair at a local mall that provides cholesterol and blood pressure checks is an e
km km km km km km km km km km km km km km km km
xample of a screening assessment focused on disease detection. A detailed history and p
km km km km km km km km km km km km km
hysical examination conducted during a first-
km km km km km
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing
km km km km km km km km km km km km km k
ma patient complaining of leg pain in the triage area of an urgent care center is an exa
km km km km km km km km km km k m km km km km km km
mple of a problem- km km km
based/focused assessment. A patient‘s return appointment 1 month after today‘s office vi
km km km km km km km km km km km
sit to report fasting blood glucose levels is an example of an episodic or follow-
km km km km km km km km km km km km km km
up assessment.
km
DIF:Cognitive Level: Understand km km REF: Box 1-3 km km
, TOP:Nursing Process: Assessment km km
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
km km km km km km km km
3. For which person is a screening assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: B km
A screening assessment is performed for the purpose of disease detection. In this case th
km km km km km km km km km km km km km km
is person may have diabetes mellitus. A shift assessment is most appropriate for the pers
km km km km km km km km km km km km km km
on who is recovering in the hospital from surgery. A comprehensive assessment is perfo
km km km km km km km km km km km km km
rmed during admission to a facility to obtain a detailed history and complete physical ex
km km km km km km km km km km km km km km
amination. An episodic or follow- km km km km
up assessment is performed after knee replacement to evaluate the outcome of the proced
km km km km km km km km km km km km km
ure.
DIF:Cognitive Level: Understand REF: Box 1- km km km km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
4. For which person is a shift assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: A km
A shift assessment is most appropriate for the person who is recovering in the hospital fr
km km km km km km km km km km km km km km km
om surgery. A screening assessment is performed for the purpose of disease detection, in
km km km km km km km km km km km km km km
this case diabetes mellitus. A comprehensive assessment is performed during admission to
km km km km km km km km km km km
a facility to obtain a detailed history and complete physical examination. An episodic or
km km km km km km km km km km km km km km
follow-
km
up assessment is performed after knee replacement to evaluate the outcome of the proced
km km km km km km km km km km km km km
ure.
DIF:Cognitive Level: Understand REF: Box 1- km km km km
3 TOP:Nursing Process: Assessment
km km km
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Estab
km km km km km km km km km km km
lishing Priorities km
5. For which person is a comprehensive assessment indicated?
km km km km km km km
a. The person who had abdominal surgery yesterday
km km km km km km
b. The person who is unaware of his high serum glucose levels
km km km km km km km km km km
c. The person who is being admitted to a long-term care facility
km km km km km km km km km km
d. The person who is beginning rehabilitation after a knee replacement
km km km km km km km km km
ANS: C km
A comprehensive assessment is performed during admission to a facility to obtain a deta
km km km km km km km km km km km km km
iled history and complete physical examination. A shift assessment is most appropriate f
km km km km km km km km km km km km
or the person who is recovering in the hospital from surgery. A screening assessment is
km km km km km km km km km km km km km km k
mperformed for the purpose of disease detection, in this case diabetes mellitus. An episo
km km km km km km km km km km km km km
dic or follow-
km km
up assessment is performed after knee replacement to evaluate the outcome of the proce
km km km km km km km km km km km km km
dure.
