TEST BANK
|
Health Assessment for Nursing Practice
| | | | |
| 7th Edition by Wilson Chapter 1 - 24
| | | | | | |
,TABLE OF CONTENTS | | |
Unit I: Foundations for Health Assessment
| | | | |
1. Introduction to Health Assessment | | |
2. Interviewing Patients to Obtain a Health History | | | | | |
3. Techniques and Equipment for Physical Assessment | | | | |
4. General Inspection and Measurement of Vital Signs
| | | | | |
5. Ethnic, Cultural, and Spiritual Considerations
| | | |
6. Pain Assessment
|
7. Mental Health and Abusive Behavior Assessment
| | | | |
8. Nutritional Assessment |
Unit II: Health Assessment of the Adult
| | | | | |
9. Skin, Hair, and Nails
| | |
10. Head, Eyes, Ears, Nose, and Throat
| | | | |
11. Lungs and Respiratory System | | |
12. Heart and Peripheral Vascular System
| | | |
13. Abdomen and Gastrointestinal System | | |
14. Musculoskeletal System |
15. Neurologic System |
16. Breasts and Axillae | |
17. Reproductive System and the Perineum | | | |
Unit III: Health Assessment Across the Life Span
| | | | | | |
18. Developmental Assessment Throughout the Life Span | | | | |
19. Assessment of the Infant, Child, and Adolescent | | | | | |
20. Assessment of the Pregnant Patient | | | |
21. Assessment of the Older Adult | | | |
Unit IV: Synthesis and Application of Health Assessment
| | | | | | |
22. Conducting a Head-to-Toe Examination | | |
23. Documenting the Head-to-Toe Health Assessment | | | |
24. Adapting Health Assessment | |
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.
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
|
Health Assessment for Nursing Practice
| | | | |
| 7th Edition by Wilson Chapter 1 - 24
| | | | | | |
,TABLE OF CONTENTS | | |
Unit I: Foundations for Health Assessment
| | | | |
1. Introduction to Health Assessment | | |
2. Interviewing Patients to Obtain a Health History | | | | | |
3. Techniques and Equipment for Physical Assessment | | | | |
4. General Inspection and Measurement of Vital Signs
| | | | | |
5. Ethnic, Cultural, and Spiritual Considerations
| | | |
6. Pain Assessment
|
7. Mental Health and Abusive Behavior Assessment
| | | | |
8. Nutritional Assessment |
Unit II: Health Assessment of the Adult
| | | | | |
9. Skin, Hair, and Nails
| | |
10. Head, Eyes, Ears, Nose, and Throat
| | | | |
11. Lungs and Respiratory System | | |
12. Heart and Peripheral Vascular System
| | | |
13. Abdomen and Gastrointestinal System | | |
14. Musculoskeletal System |
15. Neurologic System |
16. Breasts and Axillae | |
17. Reproductive System and the Perineum | | | |
Unit III: Health Assessment Across the Life Span
| | | | | | |
18. Developmental Assessment Throughout the Life Span | | | | |
19. Assessment of the Infant, Child, and Adolescent | | | | | |
20. Assessment of the Pregnant Patient | | | |
21. Assessment of the Older Adult | | | |
Unit IV: Synthesis and Application of Health Assessment
| | | | | | |
22. Conducting a Head-to-Toe Examination | | |
23. Documenting the Head-to-Toe Health Assessment | | | |
24. Adapting Health Assessment | |
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.
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
