Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment
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MULTIPLE CHOICE Qg
1. A patient comes to the emergency department and tells the triage nurse
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Qg that heis “having a heart attack.” What is the nurse’s top priority at this time?
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a. Determine the patient’s personal data and Qg Qg Qg Qg Qg
insurance coverage. Q
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b. Ask the patient to take a seat in the
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waitingroom until his name is called.
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c. Request that a nurse collect data Qg Qg Qg Qg Qg
for acomprehensive history.
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d. Ask a nurse to start a focused
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assessmentof this patient now.
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ANSWER: D Qg
The nurse needs to begin an assessment as soon as possible that is focused on this
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patient’scardiovascular system. The type of health assessment performed by the
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nurse is also drivenby patient need. Personal data and insurance information will
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be obtained, but in this situation, these data can wait until after the patient is
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assessed. Based also on Maslow’s hierarchy of needs, physiologic needs take
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precedence. Rather than asking the patient to wait, the nurse needs to begin data
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collection, such as vital signs, immediately to determinethe patient’s health status.
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Complications can be prevented if an immediate assessment is made to analyze
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the patient’s symptoms. A comprehensive history is not indicated in this situation
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at this time. Some subjective data will be collected, such as allergies and medical
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history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
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or mental health assessment is not a priority at this time.
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DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
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Establishing Priorities
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2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for Qg Qg Qg Qg Qg Qg
the first time and the nurse conducts a Qg Qg Qg Qg Qg Qg Qg Qg
detailedhistory and physical examination. Qg Q
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b. A hospital sponsors a health fair at a Qg Qg Qg Qg Qg Qg Qg
localmall and provides cholesterol Qg Q
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and blood pressure checks to mall Qg Qg Qg Qg Qg Qg
patrons. Qg
c. The nurse in an urgent care center Qg Qg Qg Qg Qg Qg
checksthe vital signs of a patient Qg Q
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who is complaining of leg pain. Qg Qg Qg Qg Qg Qg
, d. A patient newly diagnosed with
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diabetesmellitus comes to test his
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fasting blood glucose level.
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ANSWER: B Qg
A health fair at a local mall that provides cholesterol and blood pressure checks is
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an example of a screening assessment focused on disease detection. A detailed
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history and physical examination conducted during a first-time visit to an obstetric
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clinic is an exampleof a comprehensive assessment. Assessing a patient
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complaining of leg pain in the triage area of an urgent care center is an example
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of a problem-based/focused assessment. A patient’s return appointment 1 month
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after today’s office visit to report fasting blood glucose levels is an example of an
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episodic or follow-up assessment.
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DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
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b. The person who is unaware of his
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highserum glucose levels
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c. The person who is being admitted
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to along-term care facility
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d. The person who is beginning
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rehabilitationafter a knee replacement
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ANSWER: B Qg
A screening assessment is performed for the purpose of disease detection. In this
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case thisperson may have diabetes mellitus. A shift assessment is most
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appropriate for the person who is recovering in the hospital from surgery. A
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comprehensive assessment is performedduring admission to a facility to obtain a
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detailed history and complete physical examination. An episodic or follow-up
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assessment is performed after knee replacement toevaluate the outcome of the
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procedure.
Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
4. For which person is a shift assessment indicated?
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a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted to a Qg Qg Qg Qg Qg Qg Qg
long-term care facility Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: A Qg
A shift assessment is most appropriate for the person who is recovering in the
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hospital fromsurgery. A screening assessment is performed for the purpose of
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disease detection, in this case diabetes mellitus. A comprehensive assessment is
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performed during admission to a
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,facility to obtain a detailed history and complete physical examination. An
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episodic or follow-up assessment is performed after knee replacement to evaluate
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the outcome of theprocedure.
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g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 4TOP: Nursing Process: Assessment
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g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
5. For which person is a comprehensive assessment indicated?
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a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted Qg Qg Qg Qg Qg
to along-term care facility Qg Qg Q
g Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: C Qg
A comprehensive assessment is performed during admission to a facility to obtain a
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detailed history and complete physical examination. A shift assessment is most
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appropriatefor the person who is recovering in the hospital from surgery. A
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
screening assessment is performed for the purpose of disease detection, in this
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case diabetes mellitus. An episodic or follow-up assessment is performed after
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knee replacement to evaluate the outcome of the procedure.
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DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
6. For which person is an episodic or follow-up assessment indicated?
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a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted to a Qg Qg Qg Qg Qg Qg Qg
long-term care facility Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: D Qg
An episodic or follow-up assessment is performed after the knee replacement to
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evaluate the outcome of the procedure. A shift assessment is most appropriate for
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the person who isrecovering in the hospital from surgery. A screening assessment
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is performed for the purpose of disease detection, in this case diabetes mellitus. A
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comprehensive assessment is performed during admission to a facility to obtain a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
detailed history and complete physicalexamination.
Qg Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
,MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
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Establishing Priorities
Q
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7. Which is an example of data a nurse collects during a Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
physicalexamination?
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a. The patient’s lack of hair and shiny Qg Qg Qg Qg Qg Qg
skinover both shins Qg Q
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b. The patient’s stated concern about lack Qg Qg Qg Qg Qg
ofmoney for prescriptions Qg Q
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c. The patient’s complaints of Qg Qg Qg
tinglingsensations in the feet Qg Q
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d. The patient’s mother’s statements that Qg Qg Qg Qg
thepatient is very nervous lately Qg Q
g Qg Qg Qg Qg
ANSWER: A Qg
The lack of hair and shiny skin over both shins are objective data or signs that
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are part of the physical examination. A patient’s concerns about lack of money are
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subjective data andare part of the health history. A patient’s complaints of tingling
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
sensations in the feet are subjective data and are part of the health history. A
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patient’s family statements are considered secondary data, are subjective data, and
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are part of the health history.
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DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
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Specific Assessments
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8. The nurse documents which information in the patient’s history?
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a. The patient’s skin feels warm to the Qg Qg Qg Qg Qg Qg
touch. Qg
b. The patient is scratching his arm. Qg Qg Qg Qg Qg
c. The patient’s temperature is 100° F.
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d. The patient complains of itching.
Qg Qg Qg Qg
ANSWER: D Qg
A patient’s complaint of itching is subjective information, which means it is a
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symptom and is documented in the history. The patient’s warm skin is objective
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information gathered by the nurse through palpation, is also a sign, and is
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documented in the physicalexamination. The patient’s scratching is objective
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g Qg Qg Qg Qg Qg
information gathered by the nurse through observation, is also a sign, and is
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documented in the physical examination. The patient’s elevated temperature is
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objective information gathered by the nurse through measurement, is also a sign,
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and is documented in the physical examination.
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DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. 1 | p. 2 and Qg Qg Qg Qg Qg Qg Qg Qg
Box 1-2TOP: Nursing Process: Assessment
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g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
9. Which patient information does the nurse document in the patient’s
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Qg physicalassessment? Q
g
a. Slurred speech Qg
b. Immunizations
c. Smoking habit Qg
d. Allergies
,ANSWER: A Qg
Slurred speech should be noticed by the nurse and documented as objective data in
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the physical assessment. Data on immunizations are collected from the patient, are
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subjective, and documented in the history. A smoking habit is information that
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comes from the patient,making it subjective data that is documented in the history.
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg
Allergies are information that come from the patient, making it subjective data that
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is documented in the history.
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DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. 1-2 and Box Qg Qg Qg Qg Qg Qg
1-2TOP: Nursing Process: Assessment
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g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
10. After collecting the data, the nurse begins data analysis with which action?
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a. Clustering data Qg
b. Documenting subjective data Qg Qg
c. Reporting information to other health Qg Qg Qg Qg
teammembers Qg Q
g
d. Documenting objective information Qg Qg
ANSWER: A Qg
After collecting data, the nurse organizes or clusters the data so that the problems
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appearmore clearly. To cluster data, the nurse interprets the assessment data
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
collected.
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Documenting subjective data is necessary for the medical record, but does not
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provide analysis. Before reporting data to health team members, the nurse clusters
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and interprets data. Documenting objective data is necessary for the medical record,
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but does not provideanalysis.
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g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: p. Qg Qg Qg
4TOP: Nursing Process: Assessment
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g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management
Qg Qg Qg Qg Qg Qg Qg Qg Qg
of Care:Establishing Priorities
Qg Qg Q
g Qg
11. Which activity illustrates the concept of primary prevention? Qg Qg Qg Qg Qg Qg Qg
a. Monthly breast self-examination Qg Qg
b. Annual cervical (Papanicolaou Qg Qg
test)examination
Qg Q
g
c. Education about living with asthma Qg Qg Qg Qg
d. Exercising three times a week Qg Qg Qg Qg
ANSWER: D Qg
Exercising is an example of primary prevention that prevents disease from
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developing by maintaining a healthy lifestyle. Monthly breast self-examination is
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an example of secondary prevention and screening efforts to promote early
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detection of disease. Annual cervical (Papanicolaou test) examination is an
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example of secondary prevention and screening efforts to promote early detection
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of disease. Teaching a patient how to live witha chronic disease such as asthma
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g Qg Qg Qg Qg Qg
is an example of tertiary prevention directed toward minimizing the disability
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from chronic disease and helping the patient maximize his or herhealth.
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
, 12. A nurse is teaching a patient how to manage chronic obstructive
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pulmonarydisease (COPD). This intervention is an example of which level of
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
health promotion?
Qg Qg
a. Primary prevention Qg
b. Secondary prevention Qg
c. Tertiary prevention Qg
d. Risk factor prevention Qg Qg
ANSWER: C Qg
Teaching a patient how to live with a chronic disease is an example of tertiary
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prevention directed toward minimizing the disability from chronic disease and
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helping the patient maximize his or her health. The focus of primary prevention is
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to prevent a disease from developing by promoting a healthy lifestyle. Secondary
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prevention consists of efforts to promote early detection of disease. Risk factor
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prevention is part of primary prevention thatfocuses on preventing disease by
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g Qg Qg Qg Qg
managing risk factors.
Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
13. Which activity illustrates the concept of secondary prevention?
Qg Qg Qg Qg Qg Qg Qg
a. Annual mammogram Qg
b. Nutrition classes on low-fat cooking Qg Qg Qg Qg
c. Education on living with diabetes mellitus
Qg Qg Qg Qg Qg
d. Cardiac rehabilitation after coronary
Qg Qg Qg
arterybypass surgery
Qg Q
g Qg
ANSWER: A Qg
A mammogram screens for breast cancer and is an example of secondary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention to promote early detection of disease. Nutrition classes are an example
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of primary preventionto prevent a disease from developing by promoting a
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g Qg Qg Qg Qg Qg Qg Qg Qg
healthy lifestyle. Education about diabetes mellitus is an example of tertiary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention directed toward minimizing the disability from chronic disease and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
helping the patient maximize his or her health. Cardiac rehabilitation after
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coronary artery bypass surgery is an example of tertiary prevention directed
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toward minimizing the disability from chronic disease and helping the patient
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
maximize his or her health.
Qg Qg Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
14. A community organization sponsors a health fair to increase awareness of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
coloncancer. At the health fair, colorectal cancer screening kits are distributed, and
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g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
health care professionals answer questions, take blood pressure, and distribute
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literature. What level ofhealth prevention is being implemented by this community
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g Qg Qg Qg Qg Qg Qg Qg
organization?
Qg
a. Primary
b. Secondary
c. Tertiary
d. Risk factor Qg
ANSWER: B Qg
Secondary prevention consists of screening efforts to promote early detection of
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disease —in this scenario, colorectal cancer and hypertension. Primary prevention
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g Qg Qg Qg Qg Qg Qg Qg Qg
is focused on preventing disease from developing through the promotion of a
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healthy lifestyle. Tertiary
Qg Qg Qg
, prevention is directed toward minimizing the disability from chronic disease and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
helping the patient maximize his or her health. Risk factor prevention is part of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
primary preventionthat focuses on preventing disease by managing risk factors.
Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Table 1-1 | p.
Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
P owered Qg Qg Qg Qg
by T CP DF (www. tpcd Qg Qg Qg Qg
f. o rg )
,Chapter 02: Obtaining a Health History
Qg Qg Qg Qg Qg
MULTIPLE CHOICE Qg
1. Which statement or question does the nurse use during the Qg Qg Qg Qg Qg Qg Qg Qg Qg
Qg introductionphase of the interview? Q
g Qg Qg Qg
a. “I’m here to learn more about the Qg Qg Qg Qg Qg Qg
painyou’re experiencing.” Qg Q
g Qg
b. “Can you describe the pain that Qg Qg Qg Qg Qg
you’reexperiencing?” Qg Q
g
c. “I heard you say that the pain is ‘all
Qg Qg Qg Qg Qg Qg Qg Qg
over’your body.”
Qg Q
g Qg
d. “What relieves the pain you are having?”
Qg Qg Qg Qg Qg Qg
ANSWER: A Q g
“I’m here to learn more about the pain you’re experiencing” is an example of the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
introduction phase a nurse may use to explain the purpose of the interview to a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient. “Can you describe the pain that you’re experiencing?” is an example of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
part of a symptomanalysis that occurs in the discussion phase. “I heard you say that
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the pain is ‘all over’ your body” is an example of a summary statement by the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
nurse that occurs in the summary phase. “What relieves the pain you are
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
having?” is an example of part of a symptom analysis that occurs in the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
discussion phase.
Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 2-1 | p. Qg Qg Qg Qg Qg Qg
8-9TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
2. Which statement is appropriate to use when beginning an interview Qg Qg Qg Qg Qg Qg Qg Qg Qg
with anew patient?
Qg Qg Q
g Qg
a. “Have you ever been a patient in this Qg Qg Qg Qg Qg Qg Qg
clinicbefore?” Qg Q
g
b. “What is your purpose for coming to Qg Qg Qg Qg Qg Qg
theclinic today?” Qg Q
g Qg
c. “Tell me a little about yourself and your Qg Qg Qg Qg Qg Qg Qg
family.” Q
g
d. “Did you have any difficulty finding Qg Qg Qg Qg Qg
theclinic?” Qg Q
g
ANSWER: B Qg
“What is your purpose for coming to the clinic today?” is an open-ended question
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
that focuses on the patient’s reason for seeking care. “Have you ever been a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient in this clinicbefore?” is a close-ended question that yields a “yes” or “no”
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
response. This question may be asked on the first visit, but not as an opening
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
question for a health interview. “Tell me a little about yourself and your family”
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
is an open-ended question, but it is too general, and itis at least two questions:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg
one about the patient and another about the family. “Did you have
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
, any difficulty finding the clinic?” is a social question and does not focus on the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient’spurpose for the visit.
Qg Q
g Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Q g REF: p. Qg Qg Qg
8TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
3. Which statement by the nurse demonstrates a patient-centered interview?
Qg Qg Qg Qg Qg Qg Qg Qg
a. “I need to complete this Qg Qg Qg Qg
questionnaire about your medical Qg Qg Qg Qg
and family history.” Qg Qg Qg
b. “The hospital requires me to complete Qg Qg Qg Qg Qg
thisassessment as soon as possible.” Qg Q
g Qg Qg Qg Qg
c. “Tell me about the symptoms you’ve Qg Qg Qg Qg Qg
beenhaving.” Qg Q
g
d. “I’ve had the same symptoms that Qg Qg Qg Qg Qg
you’vedescribed.” Qg Q
g
ANSWER: C Qg
“Tell me about the symptoms you’ve been having” focuses on the needs of the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient so that the patient is free to share concerns, beliefs, and values in his or
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
her own words. “I need to complete this questionnaire about your medical and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
family history” focuses on thenurse’s need to complete the assessment rather than
Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg
the needs of the patient. “The hospitalrequires me to complete this assessment as
Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg
soon as possible” focuses on the nurse’s need tomeet hospital requirements rather
Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg
than the needs of the patient. “I’ve had the same symptoms that you’ve
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
described” focuses on the nurse rather than on the patient.
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. Qg Qg Qg
8TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
4. Which question is an example of an open-ended question?
Qg Qg Qg Qg Qg Qg Qg Qg
a. “Have you experienced this pain before?” Qg Qg Qg Qg Qg
b. “Do you have someone to help Qg Qg Qg Qg Qg
you athome?” Qg Qg Q
g
c. “How many times a day do you use Qg Qg Qg Qg Qg Qg Qg
your Qg
inhaler?”
d. “What were you doing when you felt Qg Qg Qg Qg Qg Qg
thepain?” Qg Q
g
ANSWER: D Qg
“What were you doing when you felt the pain?” is a broadly stated question that
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
encourages a free-flowing, open response. “Have you experienced this pain
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
before?” is closed-ended, which can obtain a “yes” or “no” answer to the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
question without any additional data. “Do you have someone to help you at
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
home?” is closed-ended, which canobtain a “yes” or “no” answer to the question
Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
without any additional data. “How many times a day do you use your inhaler?”
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
is closed-ended, which can obtain an answer of a specific number without any
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
additional data.
Qg Qg
Nursing Practice 7th Edition by Wilson
Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment
Qg Qg Qg Qg Qg
MULTIPLE CHOICE Qg
1. A patient comes to the emergency department and tells the triage nurse
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Qg that heis “having a heart attack.” What is the nurse’s top priority at this time?
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
a. Determine the patient’s personal data and Qg Qg Qg Qg Qg
insurance coverage. Q
g Qg
b. Ask the patient to take a seat in the
Qg Qg Qg Qg Qg Qg Qg Qg
waitingroom until his name is called.
Qg Q
g Qg Qg Qg Qg Qg
c. Request that a nurse collect data Qg Qg Qg Qg Qg
for acomprehensive history.
Qg Qg Q
g Qg
d. Ask a nurse to start a focused
Qg Qg Qg Qg Qg Qg
assessmentof this patient now.
Qg Q
g Qg Qg Qg
ANSWER: D Qg
The nurse needs to begin an assessment as soon as possible that is focused on this
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient’scardiovascular system. The type of health assessment performed by the
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg
nurse is also drivenby patient need. Personal data and insurance information will
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
be obtained, but in this situation, these data can wait until after the patient is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
assessed. Based also on Maslow’s hierarchy of needs, physiologic needs take
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
precedence. Rather than asking the patient to wait, the nurse needs to begin data
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
collection, such as vital signs, immediately to determinethe patient’s health status.
Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg
Complications can be prevented if an immediate assessment is made to analyze
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the patient’s symptoms. A comprehensive history is not indicated in this situation
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
at this time. Some subjective data will be collected, such as allergies and medical
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
or mental health assessment is not a priority at this time.
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
2. Which situation illustrates a screening assessment?
Qg Qg Qg Qg Qg
a. A patient visits an obstetric clinic for Qg Qg Qg Qg Qg Qg
the first time and the nurse conducts a Qg Qg Qg Qg Qg Qg Qg Qg
detailedhistory and physical examination. Qg Q
g Qg Qg Qg
b. A hospital sponsors a health fair at a Qg Qg Qg Qg Qg Qg Qg
localmall and provides cholesterol Qg Q
g Qg Qg Qg
and blood pressure checks to mall Qg Qg Qg Qg Qg Qg
patrons. Qg
c. The nurse in an urgent care center Qg Qg Qg Qg Qg Qg
checksthe vital signs of a patient Qg Q
g Qg Qg Qg Qg Qg
who is complaining of leg pain. Qg Qg Qg Qg Qg Qg
, d. A patient newly diagnosed with
Qg Qg Qg Qg
diabetesmellitus comes to test his
Qg Q
g Qg Qg Qg Qg
fasting blood glucose level.
Qg Qg Qg Qg
ANSWER: B Qg
A health fair at a local mall that provides cholesterol and blood pressure checks is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
an example of a screening assessment focused on disease detection. A detailed
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
history and physical examination conducted during a first-time visit to an obstetric
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
clinic is an exampleof a comprehensive assessment. Assessing a patient
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg
complaining of leg pain in the triage area of an urgent care center is an example
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
of a problem-based/focused assessment. A patient’s return appointment 1 month
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
after today’s office visit to report fasting blood glucose levels is an example of an
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
episodic or follow-up assessment.
Qg Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
Qg Qg Qg Qg Qg Qg Qg Qg Qg
3. For which person is a screening assessment indicated?
Qg Qg Qg Qg Qg Qg Qg
a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his
Qg Qg Qg Qg Qg Qg
highserum glucose levels
Qg Q
g Qg Qg
c. The person who is being admitted
Qg Qg Qg Qg Qg
to along-term care facility
Qg Qg Q
g Qg Qg
d. The person who is beginning
Qg Qg Qg Qg
rehabilitationafter a knee replacement
Qg Q
g Qg Qg Qg
ANSWER: B Qg
A screening assessment is performed for the purpose of disease detection. In this
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
case thisperson may have diabetes mellitus. A shift assessment is most
Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg
appropriate for the person who is recovering in the hospital from surgery. A
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
comprehensive assessment is performedduring admission to a facility to obtain a
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg
detailed history and complete physical examination. An episodic or follow-up
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
assessment is performed after knee replacement toevaluate the outcome of the
Qg Qg Qg Qg Qg Qg Qg gQ Qg Qg Qg Qg
procedure.
Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
4. For which person is a shift assessment indicated?
Qg Qg Qg Qg Qg Qg Qg
a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted to a Qg Qg Qg Qg Qg Qg Qg
long-term care facility Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: A Qg
A shift assessment is most appropriate for the person who is recovering in the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
hospital fromsurgery. A screening assessment is performed for the purpose of
Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg
disease detection, in this case diabetes mellitus. A comprehensive assessment is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
performed during admission to a
Qg Qg Qg Qg Qg
,facility to obtain a detailed history and complete physical examination. An
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
episodic or follow-up assessment is performed after knee replacement to evaluate
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the outcome of theprocedure.
Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 4TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
5. For which person is a comprehensive assessment indicated?
Qg Qg Qg Qg Qg Qg Qg
a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted Qg Qg Qg Qg Qg
to along-term care facility Qg Qg Q
g Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: C Qg
A comprehensive assessment is performed during admission to a facility to obtain a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
detailed history and complete physical examination. A shift assessment is most
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
appropriatefor the person who is recovering in the hospital from surgery. A
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
screening assessment is performed for the purpose of disease detection, in this
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
case diabetes mellitus. An episodic or follow-up assessment is performed after
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
knee replacement to evaluate the outcome of the procedure.
Qg Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
6. For which person is an episodic or follow-up assessment indicated?
Qg Qg Qg Qg Qg Qg Qg Qg Qg
a. The person who had abdominal Qg Qg Qg Qg
surgeryyesterday Qg Q
g
b. The person who is unaware of his Qg Qg Qg Qg Qg Qg
highserum glucose levels Qg Q
g Qg Qg
c. The person who is being admitted to a Qg Qg Qg Qg Qg Qg Qg
long-term care facility Qg Qg
d. The person who is beginning Qg Qg Qg Qg
rehabilitationafter a knee replacement Qg Q
g Qg Qg Qg
ANSWER: D Qg
An episodic or follow-up assessment is performed after the knee replacement to
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
evaluate the outcome of the procedure. A shift assessment is most appropriate for
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the person who isrecovering in the hospital from surgery. A screening assessment
Qg Qg Qg Qg gQ Qg Qg Qg Qg Qg Qg Qg Qg
is performed for the purpose of disease detection, in this case diabetes mellitus. A
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
comprehensive assessment is performed during admission to a facility to obtain a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
detailed history and complete physicalexamination.
Qg Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
,MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
7. Which is an example of data a nurse collects during a Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
physicalexamination?
Qg Q
g
a. The patient’s lack of hair and shiny Qg Qg Qg Qg Qg Qg
skinover both shins Qg Q
g Qg Qg
b. The patient’s stated concern about lack Qg Qg Qg Qg Qg
ofmoney for prescriptions Qg Q
g Qg Qg
c. The patient’s complaints of Qg Qg Qg
tinglingsensations in the feet Qg Q
g Qg Qg Qg
d. The patient’s mother’s statements that Qg Qg Qg Qg
thepatient is very nervous lately Qg Q
g Qg Qg Qg Qg
ANSWER: A Qg
The lack of hair and shiny skin over both shins are objective data or signs that
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
are part of the physical examination. A patient’s concerns about lack of money are
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
subjective data andare part of the health history. A patient’s complaints of tingling
Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
sensations in the feet are subjective data and are part of the health history. A
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient’s family statements are considered secondary data, are subjective data, and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
are part of the health history.
Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 1-3 | Qg Qg Qg Qg Qg
p. 3TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Specific Assessments
Q
g Qg
8. The nurse documents which information in the patient’s history?
Qg Qg Qg Qg Qg Qg Qg Qg
a. The patient’s skin feels warm to the Qg Qg Qg Qg Qg Qg
touch. Qg
b. The patient is scratching his arm. Qg Qg Qg Qg Qg
c. The patient’s temperature is 100° F.
Qg Qg Qg Qg Qg
d. The patient complains of itching.
Qg Qg Qg Qg
ANSWER: D Qg
A patient’s complaint of itching is subjective information, which means it is a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
symptom and is documented in the history. The patient’s warm skin is objective
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
information gathered by the nurse through palpation, is also a sign, and is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
documented in the physicalexamination. The patient’s scratching is objective
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg
information gathered by the nurse through observation, is also a sign, and is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
documented in the physical examination. The patient’s elevated temperature is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
objective information gathered by the nurse through measurement, is also a sign,
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
and is documented in the physical examination.
Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. 1 | p. 2 and Qg Qg Qg Qg Qg Qg Qg Qg
Box 1-2TOP: Nursing Process: Assessment
Qg Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
9. Which patient information does the nurse document in the patient’s
Qg Qg Qg Qg Qg Qg Qg Qg Qg
Qg physicalassessment? Q
g
a. Slurred speech Qg
b. Immunizations
c. Smoking habit Qg
d. Allergies
,ANSWER: A Qg
Slurred speech should be noticed by the nurse and documented as objective data in
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the physical assessment. Data on immunizations are collected from the patient, are
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
subjective, and documented in the history. A smoking habit is information that
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
comes from the patient,making it subjective data that is documented in the history.
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg
Allergies are information that come from the patient, making it subjective data that
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
is documented in the history.
Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. 1-2 and Box Qg Qg Qg Qg Qg Qg
1-2TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
Establishing Priorities
Q
g Qg
10. After collecting the data, the nurse begins data analysis with which action?
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
a. Clustering data Qg
b. Documenting subjective data Qg Qg
c. Reporting information to other health Qg Qg Qg Qg
teammembers Qg Q
g
d. Documenting objective information Qg Qg
ANSWER: A Qg
After collecting data, the nurse organizes or clusters the data so that the problems
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
appearmore clearly. To cluster data, the nurse interprets the assessment data
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
collected.
Qg
Documenting subjective data is necessary for the medical record, but does not
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
provide analysis. Before reporting data to health team members, the nurse clusters
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
and interprets data. Documenting objective data is necessary for the medical record,
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
but does not provideanalysis.
Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: p. Qg Qg Qg
4TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management
Qg Qg Qg Qg Qg Qg Qg Qg Qg
of Care:Establishing Priorities
Qg Qg Q
g Qg
11. Which activity illustrates the concept of primary prevention? Qg Qg Qg Qg Qg Qg Qg
a. Monthly breast self-examination Qg Qg
b. Annual cervical (Papanicolaou Qg Qg
test)examination
Qg Q
g
c. Education about living with asthma Qg Qg Qg Qg
d. Exercising three times a week Qg Qg Qg Qg
ANSWER: D Qg
Exercising is an example of primary prevention that prevents disease from
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
developing by maintaining a healthy lifestyle. Monthly breast self-examination is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
an example of secondary prevention and screening efforts to promote early
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
detection of disease. Annual cervical (Papanicolaou test) examination is an
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
example of secondary prevention and screening efforts to promote early detection
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
of disease. Teaching a patient how to live witha chronic disease such as asthma
Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg
is an example of tertiary prevention directed toward minimizing the disability
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
from chronic disease and helping the patient maximize his or herhealth.
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
, 12. A nurse is teaching a patient how to manage chronic obstructive
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
pulmonarydisease (COPD). This intervention is an example of which level of
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
health promotion?
Qg Qg
a. Primary prevention Qg
b. Secondary prevention Qg
c. Tertiary prevention Qg
d. Risk factor prevention Qg Qg
ANSWER: C Qg
Teaching a patient how to live with a chronic disease is an example of tertiary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention directed toward minimizing the disability from chronic disease and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
helping the patient maximize his or her health. The focus of primary prevention is
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
to prevent a disease from developing by promoting a healthy lifestyle. Secondary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention consists of efforts to promote early detection of disease. Risk factor
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention is part of primary prevention thatfocuses on preventing disease by
Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg
managing risk factors.
Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
13. Which activity illustrates the concept of secondary prevention?
Qg Qg Qg Qg Qg Qg Qg
a. Annual mammogram Qg
b. Nutrition classes on low-fat cooking Qg Qg Qg Qg
c. Education on living with diabetes mellitus
Qg Qg Qg Qg Qg
d. Cardiac rehabilitation after coronary
Qg Qg Qg
arterybypass surgery
Qg Q
g Qg
ANSWER: A Qg
A mammogram screens for breast cancer and is an example of secondary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention to promote early detection of disease. Nutrition classes are an example
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
of primary preventionto prevent a disease from developing by promoting a
Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
healthy lifestyle. Education about diabetes mellitus is an example of tertiary
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
prevention directed toward minimizing the disability from chronic disease and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
helping the patient maximize his or her health. Cardiac rehabilitation after
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
coronary artery bypass surgery is an example of tertiary prevention directed
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
toward minimizing the disability from chronic disease and helping the patient
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
maximize his or her health.
Qg Qg Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Qg REF: Table 1-1 | p. Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
14. A community organization sponsors a health fair to increase awareness of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
coloncancer. At the health fair, colorectal cancer screening kits are distributed, and
Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
health care professionals answer questions, take blood pressure, and distribute
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
literature. What level ofhealth prevention is being implemented by this community
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg
organization?
Qg
a. Primary
b. Secondary
c. Tertiary
d. Risk factor Qg
ANSWER: B Qg
Secondary prevention consists of screening efforts to promote early detection of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
disease —in this scenario, colorectal cancer and hypertension. Primary prevention
Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
is focused on preventing disease from developing through the promotion of a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
healthy lifestyle. Tertiary
Qg Qg Qg
, prevention is directed toward minimizing the disability from chronic disease and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
helping the patient maximize his or her health. Risk factor prevention is part of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
primary preventionthat focuses on preventing disease by managing risk factors.
Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Table 1-1 | p.
Qg Qg Qg Qg Qg Qg
5-6TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
P owered Qg Qg Qg Qg
by T CP DF (www. tpcd Qg Qg Qg Qg
f. o rg )
,Chapter 02: Obtaining a Health History
Qg Qg Qg Qg Qg
MULTIPLE CHOICE Qg
1. Which statement or question does the nurse use during the Qg Qg Qg Qg Qg Qg Qg Qg Qg
Qg introductionphase of the interview? Q
g Qg Qg Qg
a. “I’m here to learn more about the Qg Qg Qg Qg Qg Qg
painyou’re experiencing.” Qg Q
g Qg
b. “Can you describe the pain that Qg Qg Qg Qg Qg
you’reexperiencing?” Qg Q
g
c. “I heard you say that the pain is ‘all
Qg Qg Qg Qg Qg Qg Qg Qg
over’your body.”
Qg Q
g Qg
d. “What relieves the pain you are having?”
Qg Qg Qg Qg Qg Qg
ANSWER: A Q g
“I’m here to learn more about the pain you’re experiencing” is an example of the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
introduction phase a nurse may use to explain the purpose of the interview to a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient. “Can you describe the pain that you’re experiencing?” is an example of
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
part of a symptomanalysis that occurs in the discussion phase. “I heard you say that
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
the pain is ‘all over’ your body” is an example of a summary statement by the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
nurse that occurs in the summary phase. “What relieves the pain you are
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
having?” is an example of part of a symptom analysis that occurs in the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
discussion phase.
Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: Box 2-1 | p. Qg Qg Qg Qg Qg Qg
8-9TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
2. Which statement is appropriate to use when beginning an interview Qg Qg Qg Qg Qg Qg Qg Qg Qg
with anew patient?
Qg Qg Q
g Qg
a. “Have you ever been a patient in this Qg Qg Qg Qg Qg Qg Qg
clinicbefore?” Qg Q
g
b. “What is your purpose for coming to Qg Qg Qg Qg Qg Qg
theclinic today?” Qg Q
g Qg
c. “Tell me a little about yourself and your Qg Qg Qg Qg Qg Qg Qg
family.” Q
g
d. “Did you have any difficulty finding Qg Qg Qg Qg Qg
theclinic?” Qg Q
g
ANSWER: B Qg
“What is your purpose for coming to the clinic today?” is an open-ended question
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
that focuses on the patient’s reason for seeking care. “Have you ever been a
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient in this clinicbefore?” is a close-ended question that yields a “yes” or “no”
Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
response. This question may be asked on the first visit, but not as an opening
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
question for a health interview. “Tell me a little about yourself and your family”
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
is an open-ended question, but it is too general, and itis at least two questions:
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg
one about the patient and another about the family. “Did you have
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
, any difficulty finding the clinic?” is a social question and does not focus on the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient’spurpose for the visit.
Qg Q
g Qg Qg Qg
DIF: Cognitive Level: Understand
Qg Qg Q g REF: p. Qg Qg Qg
8TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
3. Which statement by the nurse demonstrates a patient-centered interview?
Qg Qg Qg Qg Qg Qg Qg Qg
a. “I need to complete this Qg Qg Qg Qg
questionnaire about your medical Qg Qg Qg Qg
and family history.” Qg Qg Qg
b. “The hospital requires me to complete Qg Qg Qg Qg Qg
thisassessment as soon as possible.” Qg Q
g Qg Qg Qg Qg
c. “Tell me about the symptoms you’ve Qg Qg Qg Qg Qg
beenhaving.” Qg Q
g
d. “I’ve had the same symptoms that Qg Qg Qg Qg Qg
you’vedescribed.” Qg Q
g
ANSWER: C Qg
“Tell me about the symptoms you’ve been having” focuses on the needs of the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
patient so that the patient is free to share concerns, beliefs, and values in his or
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
her own words. “I need to complete this questionnaire about your medical and
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
family history” focuses on thenurse’s need to complete the assessment rather than
Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg
the needs of the patient. “The hospitalrequires me to complete this assessment as
Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg
soon as possible” focuses on the nurse’s need tomeet hospital requirements rather
Qg Qg Qg Qg Qg Qg Qg Qg Qg Q
g Qg Qg Qg
than the needs of the patient. “I’ve had the same symptoms that you’ve
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
described” focuses on the nurse rather than on the patient.
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
DIF: Cognitive Level: Apply
Qg Qg Q g REF: p. Qg Qg Qg
8TOP: Nursing Process: Assessment
Qg Q
g Qg Qg Qg
MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications
Qg Qg Qg Qg Qg Qg Qg
4. Which question is an example of an open-ended question?
Qg Qg Qg Qg Qg Qg Qg Qg
a. “Have you experienced this pain before?” Qg Qg Qg Qg Qg
b. “Do you have someone to help Qg Qg Qg Qg Qg
you athome?” Qg Qg Q
g
c. “How many times a day do you use Qg Qg Qg Qg Qg Qg Qg
your Qg
inhaler?”
d. “What were you doing when you felt Qg Qg Qg Qg Qg Qg
thepain?” Qg Q
g
ANSWER: D Qg
“What were you doing when you felt the pain?” is a broadly stated question that
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
encourages a free-flowing, open response. “Have you experienced this pain
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
before?” is closed-ended, which can obtain a “yes” or “no” answer to the
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
question without any additional data. “Do you have someone to help you at
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
home?” is closed-ended, which canobtain a “yes” or “no” answer to the question
Qg Qg Qg Qg Qg Q
g Qg Qg Qg Qg Qg Qg Qg Qg
without any additional data. “How many times a day do you use your inhaler?”
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
is closed-ended, which can obtain an answer of a specific number without any
Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg Qg
additional data.
Qg Qg
