TestBankforHealthAssessmentfor
. . . . . .
NursingPractice7thEditionbyWilson
. . . . . .
Chapter1-24 . . .
,Chapter01:IntroductiontoHealth Assessment . . . . .
MULTIPLECHOICE .
1. Apatient comesto the emergencydepartment andtellsthe triage nursethat heis . . . . . . . . . . . . . . .
“havinga heart attack.” What isthe nurse’stop priorityat thistime?
. . . . . . . . . . . .
a. Determinethepatient’spersonaldataand . . . . . .
insurance coverage. .
b. Ask thepatient totakea seat inthewaitingroom . . . . . . . . . . .
until hisname iscalled. . . . .
c. Requestthata nursecollectdata for a . . . . . . . .
comprehensive history. .
d. Ask a nurseto startafocusedassessmentof . . . . . . . . .
thispatient 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 drivenby . . . . . . . . . . . . . . .
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 determinethe 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 healthassessment isnot a priorityat
. . . . . . . . . . . . . . . .
thistime.
.
DIF: CognitiveLevel: Apply
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
2. Which situationillustratesa screeningassessment? . . . . .
a. A patient visits an obstetric clinic for the first . . . . . . . . .
timeandthe nurseconductsadetailedhistory . . . . . . . .
and physical examination. . .
b. Ahospital sponsorsahealthfair atalocal . . . . . . . . .
mall and provides cholesterol and blood . . . . . .
pressure checksto mall patrons. . . . .
c. Thenurseinan urgent carecenterchecksthe . . . . . . . . .
vital signs of a patient who is complainingof . . . . . . . . .
legpain. .
, d. Apatient newlydiagnosed withdiabetes
. . . . . .
mellitus comes to test his fasting blood . . . . . . .
glucoselevel. .
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 duringa first-time visit to anobstetricclinicisanexampleof 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 levelsisanexample ofanepisodic or
. . . . . . . . . . . . . . . . .
follow-up assessment. .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment . . .
MSC: NCLEXPatient Needs: HealthPromotionandMaintenance: HealthScreening
. . . . . . . . .
3. Forwhichpersonisa screeningassessmentindicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: B .
A screening assessment is performed for the purpose of disease detection. In this case thisperson
. . . . . . . . . . . . . . .
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 performedduring
. . . . . . . . . . . .
admission to a facility to obtain a detailed history and complete physical examination. An
. . . . . . . . . . . . . .
episodic or follow-up assessment is performed after knee replacement toevaluate the outcome
. . . . . . . . . . . . .
ofthe procedure.
. .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment . . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
4. Forwhichpersonisa shiftassessmentindicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . .
long-termcare facility . .
d. The personwhoisbeginningrehabilitation . . . . . .
after aknee 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
. . . . . . . . . . . . . . .
diabetesmellitus. Acomprehensive assessmentisperformed duringadmissiontoa
. . . . . . . . . .
, facility to obtain a detailed history and complete physical examination. An episodic or follow-
. . . . . . . . . . . . .
up assessment isperformed after kneereplacement to evaluatetheoutcomeoftheprocedure.
. . . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 4 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
5. Forwhichpersonisacomprehensive assessment indicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: C .
Acomprehensive assessment isperformed duringadmissiontoa facilityto obtaina
. . . . . . . . . . . .
detailed history and complete physical examination. A shift assessment is most appropriatefor
. . . . . . . . . . . . .
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. An episodic or follow-up
. . . . . . . . . . . . . . .
assessment is performed after knee replacement to evaluate the outcome of the procedure.
. . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
6. Forwhichpersonisanepisodic orfollow-upassessment indicated?
. . . . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. Thepersonwho isunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: D .
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
. . . . . . . . . . . . . .
outcome of the procedure. A shift assessment is most appropriate for the person who is
. . . . . . . . . . . . . . .
recovering in the hospital from surgery. A screening assessment is performed for the purposeof
. . . . . . . . . . . . . . .
disease detection,inthiscasediabetesmellitus. Acomprehensive assessmentis performed
. . . . . . . . . . . .
during admission to a facility to obtain a detailed history and complete physicalexamination.
. . . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . . . REF: Box 1-3 | p. 3 . . . . . .
TOP:NursingProcess: Assessment
. . .
. . . . . .
NursingPractice7thEditionbyWilson
. . . . . .
Chapter1-24 . . .
,Chapter01:IntroductiontoHealth Assessment . . . . .
MULTIPLECHOICE .
1. Apatient comesto the emergencydepartment andtellsthe triage nursethat heis . . . . . . . . . . . . . . .
“havinga heart attack.” What isthe nurse’stop priorityat thistime?
. . . . . . . . . . . .
a. Determinethepatient’spersonaldataand . . . . . .
insurance coverage. .
b. Ask thepatient totakea seat inthewaitingroom . . . . . . . . . . .
until hisname iscalled. . . . .
c. Requestthata nursecollectdata for a . . . . . . . .
comprehensive history. .
d. Ask a nurseto startafocusedassessmentof . . . . . . . . .
thispatient 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 drivenby . . . . . . . . . . . . . . .
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 determinethe 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 healthassessment isnot a priorityat
. . . . . . . . . . . . . . . .
thistime.
.
DIF: CognitiveLevel: Apply
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
2. Which situationillustratesa screeningassessment? . . . . .
a. A patient visits an obstetric clinic for the first . . . . . . . . .
timeandthe nurseconductsadetailedhistory . . . . . . . .
and physical examination. . .
b. Ahospital sponsorsahealthfair atalocal . . . . . . . . .
mall and provides cholesterol and blood . . . . . .
pressure checksto mall patrons. . . . .
c. Thenurseinan urgent carecenterchecksthe . . . . . . . . .
vital signs of a patient who is complainingof . . . . . . . . .
legpain. .
, d. Apatient newlydiagnosed withdiabetes
. . . . . .
mellitus comes to test his fasting blood . . . . . . .
glucoselevel. .
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 duringa first-time visit to anobstetricclinicisanexampleof 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 levelsisanexample ofanepisodic or
. . . . . . . . . . . . . . . . .
follow-up assessment. .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment . . .
MSC: NCLEXPatient Needs: HealthPromotionandMaintenance: HealthScreening
. . . . . . . . .
3. Forwhichpersonisa screeningassessmentindicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: B .
A screening assessment is performed for the purpose of disease detection. In this case thisperson
. . . . . . . . . . . . . . .
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 performedduring
. . . . . . . . . . . .
admission to a facility to obtain a detailed history and complete physical examination. An
. . . . . . . . . . . . . .
episodic or follow-up assessment is performed after knee replacement toevaluate the outcome
. . . . . . . . . . . . .
ofthe procedure.
. .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment . . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
4. Forwhichpersonisa shiftassessmentindicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . .
long-termcare facility . .
d. The personwhoisbeginningrehabilitation . . . . . .
after aknee 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
. . . . . . . . . . . . . . .
diabetesmellitus. Acomprehensive assessmentisperformed duringadmissiontoa
. . . . . . . . . .
, facility to obtain a detailed history and complete physical examination. An episodic or follow-
. . . . . . . . . . . . .
up assessment isperformed after kneereplacement to evaluatetheoutcomeoftheprocedure.
. . . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 4 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
5. Forwhichpersonisacomprehensive assessment indicated?
. . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. The personwhoisunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: C .
Acomprehensive assessment isperformed duringadmissiontoa facilityto obtaina
. . . . . . . . . . . .
detailed history and complete physical examination. A shift assessment is most appropriatefor
. . . . . . . . . . . . .
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. An episodic or follow-up
. . . . . . . . . . . . . . .
assessment is performed after knee replacement to evaluate the outcome of the procedure.
. . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . REF: Box 1-3 | p. 3 . . . . . . . .
TOP:NursingProcess: Assessment
. . .
MSC: NCLEXPatient Needs: Safe andEffectiveCareEnvironment:ManagementofCare:Establishing
. . . . . . . . . . . . .
Priorities
6. Forwhichpersonisanepisodic orfollow-upassessment indicated?
. . . . . . . . .
a. Thepersonwho hadabdominal surgery . . . . . .
yesterday
b. Thepersonwho isunaware ofhishigh . . . . . . . .
serum glucose levels . .
c. The personwho isbeingadmitted to a . . . . . . .
long-termcare facility . .
d. The personwho isbeginningrehabilitation . . . . . .
after aknee replacement . . .
ANSWER: D .
An episodic or follow-up assessment is performed after the knee replacement to evaluate the
. . . . . . . . . . . . . .
outcome of the procedure. A shift assessment is most appropriate for the person who is
. . . . . . . . . . . . . . .
recovering in the hospital from surgery. A screening assessment is performed for the purposeof
. . . . . . . . . . . . . . .
disease detection,inthiscasediabetesmellitus. Acomprehensive assessmentis performed
. . . . . . . . . . . .
during admission to a facility to obtain a detailed history and complete physicalexamination.
. . . . . . . . . . . . .
DIF: CognitiveLevel: Understand
. . . . . REF: Box 1-3 | p. 3 . . . . . .
TOP:NursingProcess: Assessment
. . .
