TEST BANK FOR
HEALTH ASSESSMENT FOR NURSING PRACTICE, 6TH EDITION
BY SUSAN FICKERTT WILSON PHD RN (AUTHOR),
JEAN FORET GIDDENS PHD RN FAAN ANEF (AUTHOR).
,Table Of Contents
Chapter 01: Introduction To Health Assessment ...................................................................................... 3
Chapter 02: Obtaining A Health History ................................................................................................. 10
Chapter 03: Techniques And Equipment For Physical Assessment ........................................................ 28
Chapter 04: General Inspection And Measurement Of Vital Signs ......................................................... 43
Chapter 5: Ethnic, Cultural, And Spiritual Considerations Test Bank ..................................................... 52
Chapter 06: Pain Assessment .................................................................................................................. 62
Chapter 07: Mental Health Assessment ................................................................................................. 71
Chapter 08: Nutritional Assessment ....................................................................................................... 81
Chapter 09: Skin, Hair, And Nails ............................................................................................................ 92
Chapter 10: Head, Eyes, Ears, Nose, And Throat .................................................................................. 107
Chapter 11: Lungs And Respiratory System .......................................................................................... 144
Chapter 12: Heart And Peripheral Vascular System ............................................................................. 160
Chapter 13: Abdomen And Gastrointestinal System ............................................................................ 177
Chapter 14: Musculoskeletal System .................................................................................................... 196
Chapter 15: Neurologic System ............................................................................................................ 211
Chapter 16: Breasts And Axillae ............................................................................................................ 228
Chapter 17: Reproductive System And The Perineum ......................................................................... 240
Chapter 18: Developmental Assessment Throughout The Life Span ................................................... 260
Chapter 19: Assessment Of The Infant, Child, And Adolescent ............................................................ 269
Chapter 20: Assessment Of The Pregnant Patient................................................................................ 291
Chapter 21: Assessment Of The Older Adult ........................................................................................ 305
Chapter 22: Conducting A Head-To-Toe Examination .......................................................................... 316
Chapter 23: Documenting The Comprehensive Health Assessment .................................................... 319
Chapter 24: Adapting Health Assessment To The Hospitalized Patient ............................................... 323
,Chapter 01: Introduction To Health Assessment
Wilson: Health Assessment For Nursing Practice, 6th 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.
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 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.
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 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
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
HEALTH ASSESSMENT FOR NURSING PRACTICE, 6TH EDITION
BY SUSAN FICKERTT WILSON PHD RN (AUTHOR),
JEAN FORET GIDDENS PHD RN FAAN ANEF (AUTHOR).
,Table Of Contents
Chapter 01: Introduction To Health Assessment ...................................................................................... 3
Chapter 02: Obtaining A Health History ................................................................................................. 10
Chapter 03: Techniques And Equipment For Physical Assessment ........................................................ 28
Chapter 04: General Inspection And Measurement Of Vital Signs ......................................................... 43
Chapter 5: Ethnic, Cultural, And Spiritual Considerations Test Bank ..................................................... 52
Chapter 06: Pain Assessment .................................................................................................................. 62
Chapter 07: Mental Health Assessment ................................................................................................. 71
Chapter 08: Nutritional Assessment ....................................................................................................... 81
Chapter 09: Skin, Hair, And Nails ............................................................................................................ 92
Chapter 10: Head, Eyes, Ears, Nose, And Throat .................................................................................. 107
Chapter 11: Lungs And Respiratory System .......................................................................................... 144
Chapter 12: Heart And Peripheral Vascular System ............................................................................. 160
Chapter 13: Abdomen And Gastrointestinal System ............................................................................ 177
Chapter 14: Musculoskeletal System .................................................................................................... 196
Chapter 15: Neurologic System ............................................................................................................ 211
Chapter 16: Breasts And Axillae ............................................................................................................ 228
Chapter 17: Reproductive System And The Perineum ......................................................................... 240
Chapter 18: Developmental Assessment Throughout The Life Span ................................................... 260
Chapter 19: Assessment Of The Infant, Child, And Adolescent ............................................................ 269
Chapter 20: Assessment Of The Pregnant Patient................................................................................ 291
Chapter 21: Assessment Of The Older Adult ........................................................................................ 305
Chapter 22: Conducting A Head-To-Toe Examination .......................................................................... 316
Chapter 23: Documenting The Comprehensive Health Assessment .................................................... 319
Chapter 24: Adapting Health Assessment To The Hospitalized Patient ............................................... 323
,Chapter 01: Introduction To Health Assessment
Wilson: Health Assessment For Nursing Practice, 6th 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.
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 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.
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 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
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
