COMPLETE TEST BANK FOR
Health Assessment for Nursing Practice 8th Edition
by Susan Fickertt Wilson PhD RN Jean Foret Giddens PhD RN FAAN
8TH EDITION
,TABLE OF CONTENTS
UNIT I. FOUNDATIONS FOR HEALTH ASSESSMENT....................................................................................... 3
CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT ......................................................................... 3
CHAPTER 02: OBTAINING A HEALTH HISTORY ........................................................................................ 11
CHAPTER 03: TECHNIQUES AND EQUIPMENT FOR PHYSICAL ASSESSMENT .......................................... 30
CHAPTER 04: GENERAL INSPECTION AND MEASUREMENT OF VITAL SIGNS ......................................... 46
CHAPTER 5: ETHNIC, CULTURAL, AND SPIRITUAL CONSIDERATIONS ..................................................... 56
CHAPTER 06: PAIN ASSESSMENT ............................................................................................................ 67
CHAPTER 07: MENTAL HEALTH ASSESSMENT......................................................................................... 76
CHAPTER 08: NUTRITIONAL ASSESSMENT .............................................................................................. 87
UNIT II. HEALTH ASSESSMENT OF THE ADULT ............................................................................................ 98
CHAPTER 09: SKIN, HAIR, AND NAILS...................................................................................................... 98
CHAPTER 10: HEAD, EYES, EARS, NOSE, AND THROAT ......................................................................... 115
CHAPTER 11: LUNGS AND RESPIRATORY SYSTEM ................................................................................ 155
CHAPTER 12: HEART AND PERIPHERAL VASCULAR SYSTEM ................................................................. 173
CHAPTER 13: ABDOMEN AND GASTROINTESTINAL SYSTEM ................................................................ 191
CHAPTER 14: MUSCULOSKELETAL SYSTEM .......................................................................................... 213
CHAPTER 15: NEUROLOGIC SYSTEM ..................................................................................................... 228
CHAPTER 16: BREASTS AND AXILLAE .................................................................................................... 247
CHAPTER 17: REPRODUCTIVE SYSTEM AND THE PERINEUM ............................................................... 260
UNIT III. HEALTH ASSESSMENT ACROSS THE LIFE SPAN ........................................................................... 282
CHAPTER 18: DEVELOPMENTAL ASSESSMENT THROUGHOUT THE LIFE SPAN .................................... 282
CHAPTER 19: ASSESSMENT OF THE INFANT, CHILD, AND ADOLESCENT .............................................. 292
CHAPTER 20: ASSESSMENT OF THE PREGNANT PATIENT ..................................................................... 316
CHAPTER 21: ASSESSMENT OF THE OLDER ADULT ............................................................................... 331
UNIT IV. SYNTHESIS AND APPLICATION OF HEALTH ASSESSMENT........................................................... 342
CHAPTER 22: CONDUCTING A HEAD-TO-TOE EXAMINATION .............................................................. 342
CHAPTER 23: DOCUMENTING THE COMPREHENSIVE HEALTH ASSESSMENT ...................................... 346
CHAPTER 24: ADAPTING HEALTH ASSESSMENT TO THE HOSPITALIZED PATIENT ................................ 350
,UNIT I. FOUNDATIONS FOR HEALTH ASSESSMENT
CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT
WILSON: HEALTH ASSESSMENT FOR NURSING PRACTICE, 8TH EDITION
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 ANS>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
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.
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 ANS>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
EXAMPLE OF 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
CORRECT ANS>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
Health Assessment for Nursing Practice 8th Edition
by Susan Fickertt Wilson PhD RN Jean Foret Giddens PhD RN FAAN
8TH EDITION
,TABLE OF CONTENTS
UNIT I. FOUNDATIONS FOR HEALTH ASSESSMENT....................................................................................... 3
CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT ......................................................................... 3
CHAPTER 02: OBTAINING A HEALTH HISTORY ........................................................................................ 11
CHAPTER 03: TECHNIQUES AND EQUIPMENT FOR PHYSICAL ASSESSMENT .......................................... 30
CHAPTER 04: GENERAL INSPECTION AND MEASUREMENT OF VITAL SIGNS ......................................... 46
CHAPTER 5: ETHNIC, CULTURAL, AND SPIRITUAL CONSIDERATIONS ..................................................... 56
CHAPTER 06: PAIN ASSESSMENT ............................................................................................................ 67
CHAPTER 07: MENTAL HEALTH ASSESSMENT......................................................................................... 76
CHAPTER 08: NUTRITIONAL ASSESSMENT .............................................................................................. 87
UNIT II. HEALTH ASSESSMENT OF THE ADULT ............................................................................................ 98
CHAPTER 09: SKIN, HAIR, AND NAILS...................................................................................................... 98
CHAPTER 10: HEAD, EYES, EARS, NOSE, AND THROAT ......................................................................... 115
CHAPTER 11: LUNGS AND RESPIRATORY SYSTEM ................................................................................ 155
CHAPTER 12: HEART AND PERIPHERAL VASCULAR SYSTEM ................................................................. 173
CHAPTER 13: ABDOMEN AND GASTROINTESTINAL SYSTEM ................................................................ 191
CHAPTER 14: MUSCULOSKELETAL SYSTEM .......................................................................................... 213
CHAPTER 15: NEUROLOGIC SYSTEM ..................................................................................................... 228
CHAPTER 16: BREASTS AND AXILLAE .................................................................................................... 247
CHAPTER 17: REPRODUCTIVE SYSTEM AND THE PERINEUM ............................................................... 260
UNIT III. HEALTH ASSESSMENT ACROSS THE LIFE SPAN ........................................................................... 282
CHAPTER 18: DEVELOPMENTAL ASSESSMENT THROUGHOUT THE LIFE SPAN .................................... 282
CHAPTER 19: ASSESSMENT OF THE INFANT, CHILD, AND ADOLESCENT .............................................. 292
CHAPTER 20: ASSESSMENT OF THE PREGNANT PATIENT ..................................................................... 316
CHAPTER 21: ASSESSMENT OF THE OLDER ADULT ............................................................................... 331
UNIT IV. SYNTHESIS AND APPLICATION OF HEALTH ASSESSMENT........................................................... 342
CHAPTER 22: CONDUCTING A HEAD-TO-TOE EXAMINATION .............................................................. 342
CHAPTER 23: DOCUMENTING THE COMPREHENSIVE HEALTH ASSESSMENT ...................................... 346
CHAPTER 24: ADAPTING HEALTH ASSESSMENT TO THE HOSPITALIZED PATIENT ................................ 350
,UNIT I. FOUNDATIONS FOR HEALTH ASSESSMENT
CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT
WILSON: HEALTH ASSESSMENT FOR NURSING PRACTICE, 8TH EDITION
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 ANS>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
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.
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 ANS>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
EXAMPLE OF 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
CORRECT ANS>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
