TEST BANK
x
Health Assessment for Nursing Practice
x x x x x
x 7th Edition by Wilson Chapter 1 - 24
x x x x x x x
,TABLE OF CONTENTS x x x
Unit I: Foundations for Health Assessment
x x x x x
1. Introduction to Health Assessment x x x
2. Interviewing Patients to Obtain a Health History x x x x x x
3. Techniques and Equipment for Physical Assessment x x x x x
4. General Inspection and Measurement of Vital Signs
x x x x x x
5. Ethnic, Cultural, and Spiritual Considerations
x x x x
6. Pain Assessment
x
7. Mental Health and Abusive Behavior Assessment
x x x x x
8. Nutritional Assessment x
Unit II: Health Assessment of the Adult
x x x x x x
9. Skin, Hair, and Nails
x x x
10. Head, Eyes, Ears, Nose, and Throat
x x x x x
11. Lungs and Respiratory Systemx x x
12. Heart and Peripheral Vascular System
x x x x
13. Abdomen and Gastrointestinal System x x x
14. Musculoskeletal System x
15. Neurologic System x
16. Breasts and Axillae x x
17. Reproductive System and the Perineum x x x x
Unit III: Health Assessment Across the Life Span
x x x x x x x
18. Developmental Assessment Throughout the Life Span x x x x x
19. Assessment of the Infant, Child, and Adolescent x x x x x x
20. Assessment of the Pregnant Patient x x x x
21. Assessment of the Older Adult x x x x
Unit IV: Synthesis and Application of Health Assessment
x x x x x x x
22. Conducting a Head-to-Toe Examination x x x
23. Documenting the Head-to-Toe Health Assessment x x x x
24. Adapting Health Assessment x x
Chapter 01: Introduction to Health Assessment
x x x x x
,MULTIPLE CHOICE x
1. A patient comes to the emergency department and tells the triage nurse that
x x x x x x x x x x x x
x heis “having a heart attack.” What is the nurse’s top priority at this time?
x x x x x x x x x x x x x
a. Determine the patient’s personal data and x x x x x
insurance coverage. x x
b. Ask the patient to take a seat in the waiting x x x x x x x x x
room until his name is called. x x x x x x
c. Request that a nurse collect data for x x x x x x
acomprehensive history. x
d. Ask a nurse to start a focused assessment x x x x x x x
of this patient now. x x x
ANSWER: D x
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
x x x x x x x x x x x x x x x x
cardiovascular system. The type of health assessment performed by the nurse is also driven
x x x x x x x x x x x x x x
by patient need. Personal data and insurance information will be obtained, but in this
x x x x x x x x x x x x x x
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
x x x x x x x x x x x x x x x
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
x x x x x x x x x x x x x
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
x x x x x x x x x x x x x x x
the patient’s health status. Complications can be prevented if an immediate assessment is
x x x x x x x x x x x x x
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
x x x x x x x x x x x x x x
situation at this time. Some subjective data will be collected, such as allergies and medical
x x x x x x x x x x x x x x x
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
x x x x x x x x x x x x
mental health assessment is not a priority at this time.
x x x x x x x x x x
DIF: Cognitive Level: Apply
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
x x x x x x x x x x x
xPriorities
2. Which situation illustrates a screening assessment?
x x x x x
a. A patient visits an obstetric clinic for the first x x x x x x x x
time and the nurse conducts a detailedhistory x x x x x x
and physical examination. x x x
b. A hospital sponsors a health fair at a
x x x x x x x
localmall and provides cholesterol and x x x x
xblood pressure checks to mall patrons. x x x x x
c. The nurse in an urgent care center checks
x x x x x x x
the vital signs of a patient who is
x x x x x x x
xcomplaining of leg pain. x x x
, d. A patient newly diagnosed with
x x x x
diabetesmellitus comes to test his fasting x x x x x
blood glucose level.
x x x
ANSWER: B x
A health fair at a local mall that provides cholesterol and blood pressure checks is an
x x x x x x x x x x x x x x x
example of a screening assessment focused on disease detection. A detailed history and
x x x x x x x x x x x x x
physical examination conducted during a first-time visit to an obstetric clinic is an exampleof
x x x x x x x x x x x x x x
a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
x x x x x x x x x x x x x x
of an urgent care center is an example of a problem-based/focused assessment. A
x x x x x x x x x x x x x
patient’s return appointment 1 month after today’s office visit to report fasting blood
x x x x x x x x x x x x x
glucose levels is an example of an episodic or follow-up assessment.
x x x x x x x x x x x
DIF: Cognitive Level: Understand
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x x x x x x x x x
3. For which person is a screening assessment indicated?
x x x x x x x
a. The person who had abdominal surgery x x x x x
yesterday
b. The person who is unaware of his high
x x x x x x x
xserum glucose levels x x
c. The person who is being admitted to a
x x x x x x x
long-term care facility x x
d. The person who is beginning rehabilitation
x x x x x
after a knee replacement x x x
ANSWER: B x
A screening assessment is performed for the purpose of disease detection. In this case this
x x x x x x x x x x x x x x
person may have diabetes mellitus. A shift assessment is most appropriate for the person
x x x x x x x x x x x x x x
who is recovering in the hospital from surgery. A comprehensive assessment is performed
x x x x x x x x x x x x x
during admission to a facility to obtain a detailed history and complete physical
x x x x x x x x x x x x x
examination. An episodic or follow-up assessment is performed after knee replacement to
x x x x x x x x x x x x
evaluate the outcome of the procedure.
x x x x x x
DIF: Cognitive Level: Understand
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
x x x x x x x x x x x
xPriorities
4. For which person is a shift assessment indicated?
x x x x x x x
a. The person who had abdominal surgery x x x x x
yesterday
b. The person who is unaware of his high
x x x x x x x
serum glucose levels x x
c. The person who is being admitted to a
x x x x x x x
long-term care facility x x
d. The person who is beginning rehabilitation
x x x x x
after a knee replacement x x x
ANSWER: A x
A shift assessment is most appropriate for the person who is recovering in the hospital from
x x x x x x x x x x x x x x x
surgery. A screening assessment is performed for the purpose of disease detection, in this
x x x x x x x x x x x x x x
case diabetes mellitus. A comprehensive assessment is performed during admission to a
x x x x x x x x x x x x
x
Health Assessment for Nursing Practice
x x x x x
x 7th Edition by Wilson Chapter 1 - 24
x x x x x x x
,TABLE OF CONTENTS x x x
Unit I: Foundations for Health Assessment
x x x x x
1. Introduction to Health Assessment x x x
2. Interviewing Patients to Obtain a Health History x x x x x x
3. Techniques and Equipment for Physical Assessment x x x x x
4. General Inspection and Measurement of Vital Signs
x x x x x x
5. Ethnic, Cultural, and Spiritual Considerations
x x x x
6. Pain Assessment
x
7. Mental Health and Abusive Behavior Assessment
x x x x x
8. Nutritional Assessment x
Unit II: Health Assessment of the Adult
x x x x x x
9. Skin, Hair, and Nails
x x x
10. Head, Eyes, Ears, Nose, and Throat
x x x x x
11. Lungs and Respiratory Systemx x x
12. Heart and Peripheral Vascular System
x x x x
13. Abdomen and Gastrointestinal System x x x
14. Musculoskeletal System x
15. Neurologic System x
16. Breasts and Axillae x x
17. Reproductive System and the Perineum x x x x
Unit III: Health Assessment Across the Life Span
x x x x x x x
18. Developmental Assessment Throughout the Life Span x x x x x
19. Assessment of the Infant, Child, and Adolescent x x x x x x
20. Assessment of the Pregnant Patient x x x x
21. Assessment of the Older Adult x x x x
Unit IV: Synthesis and Application of Health Assessment
x x x x x x x
22. Conducting a Head-to-Toe Examination x x x
23. Documenting the Head-to-Toe Health Assessment x x x x
24. Adapting Health Assessment x x
Chapter 01: Introduction to Health Assessment
x x x x x
,MULTIPLE CHOICE x
1. A patient comes to the emergency department and tells the triage nurse that
x x x x x x x x x x x x
x heis “having a heart attack.” What is the nurse’s top priority at this time?
x x x x x x x x x x x x x
a. Determine the patient’s personal data and x x x x x
insurance coverage. x x
b. Ask the patient to take a seat in the waiting x x x x x x x x x
room until his name is called. x x x x x x
c. Request that a nurse collect data for x x x x x x
acomprehensive history. x
d. Ask a nurse to start a focused assessment x x x x x x x
of this patient now. x x x
ANSWER: D x
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
x x x x x x x x x x x x x x x x
cardiovascular system. The type of health assessment performed by the nurse is also driven
x x x x x x x x x x x x x x
by patient need. Personal data and insurance information will be obtained, but in this
x x x x x x x x x x x x x x
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
x x x x x x x x x x x x x x x
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
x x x x x x x x x x x x x
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
x x x x x x x x x x x x x x x
the patient’s health status. Complications can be prevented if an immediate assessment is
x x x x x x x x x x x x x
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
x x x x x x x x x x x x x x
situation at this time. Some subjective data will be collected, such as allergies and medical
x x x x x x x x x x x x x x x
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
x x x x x x x x x x x x
mental health assessment is not a priority at this time.
x x x x x x x x x x
DIF: Cognitive Level: Apply
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
x x x x x x x x x x x
xPriorities
2. Which situation illustrates a screening assessment?
x x x x x
a. A patient visits an obstetric clinic for the first x x x x x x x x
time and the nurse conducts a detailedhistory x x x x x x
and physical examination. x x x
b. A hospital sponsors a health fair at a
x x x x x x x
localmall and provides cholesterol and x x x x
xblood pressure checks to mall patrons. x x x x x
c. The nurse in an urgent care center checks
x x x x x x x
the vital signs of a patient who is
x x x x x x x
xcomplaining of leg pain. x x x
, d. A patient newly diagnosed with
x x x x
diabetesmellitus comes to test his fasting x x x x x
blood glucose level.
x x x
ANSWER: B x
A health fair at a local mall that provides cholesterol and blood pressure checks is an
x x x x x x x x x x x x x x x
example of a screening assessment focused on disease detection. A detailed history and
x x x x x x x x x x x x x
physical examination conducted during a first-time visit to an obstetric clinic is an exampleof
x x x x x x x x x x x x x x
a comprehensive assessment. Assessing a patient complaining of leg pain in the triage area
x x x x x x x x x x x x x x
of an urgent care center is an example of a problem-based/focused assessment. A
x x x x x x x x x x x x x
patient’s return appointment 1 month after today’s office visit to report fasting blood
x x x x x x x x x x x x x
glucose levels is an example of an episodic or follow-up assessment.
x x x x x x x x x x x
DIF: Cognitive Level: Understand
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x x x x x x x x x
3. For which person is a screening assessment indicated?
x x x x x x x
a. The person who had abdominal surgery x x x x x
yesterday
b. The person who is unaware of his high
x x x x x x x
xserum glucose levels x x
c. The person who is being admitted to a
x x x x x x x
long-term care facility x x
d. The person who is beginning rehabilitation
x x x x x
after a knee replacement x x x
ANSWER: B x
A screening assessment is performed for the purpose of disease detection. In this case this
x x x x x x x x x x x x x x
person may have diabetes mellitus. A shift assessment is most appropriate for the person
x x x x x x x x x x x x x x
who is recovering in the hospital from surgery. A comprehensive assessment is performed
x x x x x x x x x x x x x
during admission to a facility to obtain a detailed history and complete physical
x x x x x x x x x x x x x
examination. An episodic or follow-up assessment is performed after knee replacement to
x x x x x x x x x x x x
evaluate the outcome of the procedure.
x x x x x x
DIF: Cognitive Level: Understand
x REF: Box 1-3 | p. 3 x x x x x x x
TOP: Nursing Process: Assessment
x x x x
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
x x x x x x x x x x x
xPriorities
4. For which person is a shift assessment indicated?
x x x x x x x
a. The person who had abdominal surgery x x x x x
yesterday
b. The person who is unaware of his high
x x x x x x x
serum glucose levels x x
c. The person who is being admitted to a
x x x x x x x
long-term care facility x x
d. The person who is beginning rehabilitation
x x x x x
after a knee replacement x x x
ANSWER: A x
A shift assessment is most appropriate for the person who is recovering in the hospital from
x x x x x x x x x x x x x x x
surgery. A screening assessment is performed for the purpose of disease detection, in this
x x x x x x x x x x x x x x
case diabetes mellitus. A comprehensive assessment is performed during admission to a
x x x x x x x x x x x x
