Test6Bank6for6Health6Assessment6f
or6Nursing6Practice67th6Edition6by6
Wilson6Chapter616-624
,Chapter601:6Introduction6to6Health6Assessment
MULTIPLE6CHOICE
1. A6patient6comes6to6the6emergency6department6and6tells6the6triage6nurse
6that6he6is6“having6a6heart6attack.”6What6is6the6nurse’s6top6priority6at6this6time?
a. Determine6the6patient’s6personal6data6and
6insurance6coverage.
b. Ask6the6patient6to6take6a6seat6in6the6wa
iting6room6until6his6name6is6called.
c. Request6that6a6nurse6collect6data6f
or6a6comprehensive6history.
d. Ask6a6nurse6to6start6a6focused6assess
ment6of6this6patient6now.
ANSWER:6D
The6nurse6needs6to6begin6an6assessment6as6soon6as6possible6that6is6focused6on6this
6patient’s6cardiovascular6system.6The6type6of6health6assessment6performed6by6the6nu
rse6is6also6driven6by6patient6need.6Personal6data6and6insurance6information6will6be6
obtained,6but6in6this6situation,6these6data6can6wait6until6after6the6patient6is6assessed
.6Based6also6on6Maslow’s6hierarchy6of6needs,6physiologic6needs6take6precedence.6R
ather6than6asking6the6patient6to6wait,6the6nurse6needs6to6begin6data6collection,6such
6as6vital6signs,6immediately6to6determine6the6patient’s6health6status.6Complications6c
an6be6prevented6if6an6immediate6assessment6is6made6to6analyze6the6patient’s6sympt
oms.6A6comprehensive6history6is6not6indicated6in6this6situation6at6this6time.6Some6
subjective6data6will6be6collected,6such6as6allergies6and6medical6history6related6to6ca
rdiovascular6disease.6Eyes,6ears,6or6a6complete6musculoskeletal6or6mental6health6ass
essment6is6not6a6priority6at6this6time.
DIF:666Cognitive6Level:6Apply REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
2. Which6situation6illustrates6a6screening6assessment?
a. A6patient6visits6an6obstetric6clinic6for6th
e6first6time6and6the6nurse6conducts6a6det
ailed6history6and6physical6examination.
b. A6hospital6sponsors6a6health6fair6at6a6
local6mall6and6provides6cholesterol6an
d6blood6pressure6checks6to6mall6patro
ns.
c. The6nurse6in6an6urgent6care6center6ch
ecks6the6vital6signs6of6a6patient6who6
is6complaining6of6leg6pain.
, d. A6patient6newly6diagnosed6with6diab
etes6mellitus6comes6to6test6his6fasting
6blood6glucose6level.
ANSWER:6B
A6health6fair6at6a6local6mall6that6provides6cholesterol6and6blood6pressure6checks6is
6an6example6of6a6screening6assessment6focused6on6disease6detection.6A6detailed6his
tory6and6physical6examination6conducted6during6a6first-
time6visit6to6an6obstetric6clinic6is6an6example6of6a6comprehensive6assessment.6Asses
sing6a6patient6complaining6of6leg6pain6in6the6triage6area6of6an6urgent6care6center6i
s6an6example6of6a6problem-
based/focused6assessment.6A6patient’s6return6appointment616month6after6today’s6offi
ce6visit6to6report6fasting6blood6glucose6levels6is6an6example6of6an6episodic6or6follo
w-up6assessment.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Health6Promotion6and6Maintenance:6Health6Screening
3. For6which6person6is6a6screening6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6
to6a6long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6B
A6screening6assessment6is6performed6for6the6purpose6of6disease6detection.6In6this6
case6this6person6may6have6diabetes6mellitus.6A6shift6assessment6is6most6appropriat
e6for6the6person6who6is6recovering6in6the6hospital6from6surgery.6A6comprehensive
6assessment6is6performed6during6admission6to6a6facility6to6obtain6a6detailed6history
6and6complete6physical6examination.6An6episodic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the6
procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
4. For6which6person6is6a6shift6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6to6a
long-term6care6facility
d. The6person6who6is6beginning6rehabilitat
ion6after6a6knee6replacement
ANSWER:6A
A6shift6assessment6is6most6appropriate6for6the6person6who6is6recovering6in6the6hosp
ital6from6surgery.6A6screening6assessment6is6performed6for6the6purpose6of6disease6d
etection,6in6this6case6diabetes6mellitus.6A6comprehensive6assessment6is6performed6du
ring6admission6to6a
, facility6to6obtain6a6detailed6history6and6complete6physical6examination.6An6episod
ic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the
6procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.646TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
5. For6which6person6is6a6comprehensive6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6
to6a6long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6C
A6comprehensive6assessment6is6performed6during6admission6to6a6facility6to6obtain6a
detailed6history6and6complete6physical6examination.6A6shift6assessment6is6most6appr
opriate6for6the6person6who6is6recovering6in6the6hospital6from6surgery.6A6screening6
assessment6is6performed6for6the6purpose6of6disease6detection,6in6this6case6diabetes6
mellitus.6An6episodic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the6
procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
6. For6which6person6is6an6episodic6or6follow-up6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6to6a
long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6D
An6episodic6or6follow-
up6assessment6is6performed6after6the6knee6replacement6to6evaluate6the6outcome6of6
the6procedure.6A6shift6assessment6is6most6appropriate6for6the6person6who6is6recover
ing6in6the6hospital6from6surgery.6A6screening6assessment6is6performed6for6the6purp
ose6of6disease6detection,6in6this6case6diabetes6mellitus.6A6comprehensive6assessment
6is6performed6during6admission6to6a6facility6to6obtain6a6detailed6history6and6compl
ete6physical6examination.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
or6Nursing6Practice67th6Edition6by6
Wilson6Chapter616-624
,Chapter601:6Introduction6to6Health6Assessment
MULTIPLE6CHOICE
1. A6patient6comes6to6the6emergency6department6and6tells6the6triage6nurse
6that6he6is6“having6a6heart6attack.”6What6is6the6nurse’s6top6priority6at6this6time?
a. Determine6the6patient’s6personal6data6and
6insurance6coverage.
b. Ask6the6patient6to6take6a6seat6in6the6wa
iting6room6until6his6name6is6called.
c. Request6that6a6nurse6collect6data6f
or6a6comprehensive6history.
d. Ask6a6nurse6to6start6a6focused6assess
ment6of6this6patient6now.
ANSWER:6D
The6nurse6needs6to6begin6an6assessment6as6soon6as6possible6that6is6focused6on6this
6patient’s6cardiovascular6system.6The6type6of6health6assessment6performed6by6the6nu
rse6is6also6driven6by6patient6need.6Personal6data6and6insurance6information6will6be6
obtained,6but6in6this6situation,6these6data6can6wait6until6after6the6patient6is6assessed
.6Based6also6on6Maslow’s6hierarchy6of6needs,6physiologic6needs6take6precedence.6R
ather6than6asking6the6patient6to6wait,6the6nurse6needs6to6begin6data6collection,6such
6as6vital6signs,6immediately6to6determine6the6patient’s6health6status.6Complications6c
an6be6prevented6if6an6immediate6assessment6is6made6to6analyze6the6patient’s6sympt
oms.6A6comprehensive6history6is6not6indicated6in6this6situation6at6this6time.6Some6
subjective6data6will6be6collected,6such6as6allergies6and6medical6history6related6to6ca
rdiovascular6disease.6Eyes,6ears,6or6a6complete6musculoskeletal6or6mental6health6ass
essment6is6not6a6priority6at6this6time.
DIF:666Cognitive6Level:6Apply REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
2. Which6situation6illustrates6a6screening6assessment?
a. A6patient6visits6an6obstetric6clinic6for6th
e6first6time6and6the6nurse6conducts6a6det
ailed6history6and6physical6examination.
b. A6hospital6sponsors6a6health6fair6at6a6
local6mall6and6provides6cholesterol6an
d6blood6pressure6checks6to6mall6patro
ns.
c. The6nurse6in6an6urgent6care6center6ch
ecks6the6vital6signs6of6a6patient6who6
is6complaining6of6leg6pain.
, d. A6patient6newly6diagnosed6with6diab
etes6mellitus6comes6to6test6his6fasting
6blood6glucose6level.
ANSWER:6B
A6health6fair6at6a6local6mall6that6provides6cholesterol6and6blood6pressure6checks6is
6an6example6of6a6screening6assessment6focused6on6disease6detection.6A6detailed6his
tory6and6physical6examination6conducted6during6a6first-
time6visit6to6an6obstetric6clinic6is6an6example6of6a6comprehensive6assessment.6Asses
sing6a6patient6complaining6of6leg6pain6in6the6triage6area6of6an6urgent6care6center6i
s6an6example6of6a6problem-
based/focused6assessment.6A6patient’s6return6appointment616month6after6today’s6offi
ce6visit6to6report6fasting6blood6glucose6levels6is6an6example6of6an6episodic6or6follo
w-up6assessment.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Health6Promotion6and6Maintenance:6Health6Screening
3. For6which6person6is6a6screening6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6
to6a6long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6B
A6screening6assessment6is6performed6for6the6purpose6of6disease6detection.6In6this6
case6this6person6may6have6diabetes6mellitus.6A6shift6assessment6is6most6appropriat
e6for6the6person6who6is6recovering6in6the6hospital6from6surgery.6A6comprehensive
6assessment6is6performed6during6admission6to6a6facility6to6obtain6a6detailed6history
6and6complete6physical6examination.6An6episodic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the6
procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
4. For6which6person6is6a6shift6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6to6a
long-term6care6facility
d. The6person6who6is6beginning6rehabilitat
ion6after6a6knee6replacement
ANSWER:6A
A6shift6assessment6is6most6appropriate6for6the6person6who6is6recovering6in6the6hosp
ital6from6surgery.6A6screening6assessment6is6performed6for6the6purpose6of6disease6d
etection,6in6this6case6diabetes6mellitus.6A6comprehensive6assessment6is6performed6du
ring6admission6to6a
, facility6to6obtain6a6detailed6history6and6complete6physical6examination.6An6episod
ic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the
6procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.646TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
5. For6which6person6is6a6comprehensive6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6
to6a6long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6C
A6comprehensive6assessment6is6performed6during6admission6to6a6facility6to6obtain6a
detailed6history6and6complete6physical6examination.6A6shift6assessment6is6most6appr
opriate6for6the6person6who6is6recovering6in6the6hospital6from6surgery.6A6screening6
assessment6is6performed6for6the6purpose6of6disease6detection,6in6this6case6diabetes6
mellitus.6An6episodic6or6follow-
up6assessment6is6performed6after6knee6replacement6to6evaluate6the6outcome6of6the6
procedure.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
MSC:6NCLEX6Patient6Needs:6Safe6and6Effective6Care6Environment:6Management6of6Care:6E
stablishing6Priorities
6. For6which6person6is6an6episodic6or6follow-up6assessment6indicated?
a. The6person6who6had6abdominal6surg
ery6yesterday
b. The6person6who6is6unaware6of6his6
high6serum6glucose6levels
c. The6person6who6is6being6admitted6to6a
long-term6care6facility
d. The6person6who6is6beginning6rehabilitati
on6after6a6knee6replacement
ANSWER:6D
An6episodic6or6follow-
up6assessment6is6performed6after6the6knee6replacement6to6evaluate6the6outcome6of6
the6procedure.6A6shift6assessment6is6most6appropriate6for6the6person6who6is6recover
ing6in6the6hospital6from6surgery.6A6screening6assessment6is6performed6for6the6purp
ose6of6disease6detection,6in6this6case6diabetes6mellitus.6A6comprehensive6assessment
6is6performed6during6admission6to6a6facility6to6obtain6a6detailed6history6and6compl
ete6physical6examination.
DIF:666Cognitive6Level:6Understand REF:6Box61-
36|6p.636TOP:6Nursing6Process:6Assessment
