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