Nursing Practice 8th Edition by Susan
Fickertt Wilson & Jean Foret Giddens
Complete Chapters 1-24 With Expert Approved Q&As & Explanations
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, Chapter 1: Importance of Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he is ―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 a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
CORRECT ANSWER: D
Feedback
A Personal data and insurance information will be obtained, but in this situation, these data can wait
until after the patient is assessed.
B 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.
C 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.
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.
DIF: Cognitive Level: Apply REF: 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 detailed history and
physical examination.
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood 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 is complaining of leg
pain.
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood glucose level.
CORRECT ANSWER: B
Feedback
A A detailed history and physical examination conducted during a first-time visit to an obstetric
clinic is an example of a comprehensive assessment.
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.
C 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.
D 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.
DIF: Cognitive Level: Understand REF: 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
CORRECT ANSWER: B
Feedback
A A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery.
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, B A screening assessment is performed for the purpose of disease detection. In this case this person
may have diabetes mellitus.
C A comprehensive assessment is performed during admission to a facility to obtain a detailed
history and complete physical examination.
D An episodic or follow-up assessment is performed after knee replacement to evaluate the outcome
of the procedure.
DIF: Cognitive Level: Understand REF: 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.
CORRECT ANSWER: A
Feedback
A A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery.
B A screening assessment is performed for the purpose of disease detection, in this case diabetes
mellitus.
C A comprehensive assessment is performed during admission to a facility to obtain a detailed
history and complete physical examination.
D An episodic or follow-up assessment is performed after knee replacement to evaluate the outcome
of the procedure.
DIF: Cognitive Level: Understand REF: 3 TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
Priorities
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