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PRACTICE7THEDITIONBYSUSAN FICKERTTWILSON,
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JEAN FORET GIDDENS| 9780323661195| ALL CHAPTERS
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1-24| LATEST
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•
Chapter 01: Introduction to Health Assessment
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Wilson:HealthAssessmentforNursingPractice,7thEdition
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MULTIPLE CHOICE d
1. Apatientcomestothe emergencydepartment andtellsthetriage nursethat heis―havinga heart
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attack.‖ What is the nurse’s toppriorityat thistime?
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a. Determine the patient’spersonal data and insurance coverage.
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b. Askthe patienttotakea seat inthe waiting roomuntilhisname iscalled.
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c. Request that anursecollect data foracomprehensive history.
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d. Askanursetostartafocusedassessmentofthispatientnow.
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ANS:D
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,Thenurseneedstobeginanassessmentassoonaspossiblethatisfocusedonthispatient’s cardiovascular
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system.Thetypeofhealthassessmentperformedbythenurseisalsodrivenbypatient need. Personal data
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andinsurance information will be obtained, but inthis situation, thesedatacan waituntilafterthepatientis
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assessed.BasedalsoonMaslow’shierarchyofneeds,physiologicneeds takeprecedence.Ratherthan
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askingthepatientto wait, the nurse needstobegin data collection, such as vital signs,
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immediatelyto determine the patient’s health status.
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Complicationscanbepreventedifanimmediateassessment is madetoanalyzethepatient’s symptoms.A
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comprehensivehistoryisnotindicatedinthissituationatthistime.Somesubjective datawillbecollected,
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suchasallergiesandmedicalhistoryrelated tocardiovasculardisease.Eyes, ears,oracomplete
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musculoskeletalormentalhealthassessmentisnotapriorityatthistime.
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DIF: Cognitive Level: Apply
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
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EstablishingPriorities
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2. Which situation illustratesa screening assessment? d d d d d
a. Apatient visitsanobstetric clinic forthe firsttime andthenurseconductsa detailed
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historyand physical examination.
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b. Ahospitalsponsorsahealthfairatalocalmallandprovidescholesterolandblood
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pressure checks to mall patrons.
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c. Thenurseinanurgentcarecenterchecksthevitalsignsofapatientwhoiscomplainingof leg
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pain.
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d. Apatient newly diagnosed with diabetes mellitus comestotest his fasting blood
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glucoselevel.
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ANS:B
,Ahealth fairat a local mallthat providescholesteroland blood pressure checks isan example ofa screening
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assessment focused ondisease detection. Adetailed historyand physical
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, examinationconductedduringafirst-timevisittoanobstetricclinicisanexampleofa comprehensive
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assessment.Assessingapatientcomplainingoflegpaininthetriageareaofan urgent care center is an
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example of a problem-based/focused assessment. A patient’s return appointment1monthafter
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today’sofficevisit toreportfastingbloodglucoselevelsisanexample ofan episodic or follow-up
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assessment.
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DIF: Cognitive Level: UnderstandREF: Box 1-3 |p.3 TOP: Nursing Process: Assessment d d d d d d d d d d d d
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which personisa screeningassessment indicated? d d d d d d d
a. The person who hadabdominal surgery yesterday d d d d d d
b. The personwho isunaware ofhis high serumglucose levels d d d d d d d d d d
c. The personwho isbeing admittedto along-termcare facility d d d d d d d d d d
d. Thepersonwhoisbeginningrehabilitationafterakneereplacement d d d d d d d
ANS: B
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Ascreeningassessmentisperformedforthepurposeofdiseasedetection.Inthiscasethispersonmay have
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diabetesmellitus. A shiftassessment ismost appropriate for the person who isrecoveringin thehospital
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fromsurgery.Acomprehensiveassessmentisperformedduringadmissiontoafacilityto obtainadetailed
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historyandcompletephysicalexamination. Anepisodicorfollow-upassessment isperformedafter
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kneereplacementtoevaluatetheoutcomeofthe procedure.
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DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3 TOP: Nursing Process: Assessment MSC:
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NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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4. For whichpersonisa shiftassessment indicated? d d d d d d d
a. The person who hadabdominal surgery yesterday d d d d d d
b. The personwho isunaware ofhis high serumglucose levels d d d d d d d d d d
c. The personwho isbeingadmittedto along-termcare facility d d d d d d d d d d
d. Thepersonwhoisbeginningrehabilitationafterakneereplacement d d d d d d d
ANS: A
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Ashiftassessmentismostappropriateforthepersonwhoisrecoveringinthehospitalfromsurgery. A
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screeningassessmentisperformedforthepurposeofdiseasedetection,inthiscasediabetes mellitus. A
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comprehensive assessment is performed during admission to a facility toobtaina detailedhistoryand
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completephysicalexamination.Anepisodicorfollow-upassessment is performed after knee
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replacement toevaluate the outcome ofthe procedure.
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DIF: Cognitive Level: Understand REF: Box 1-3 | p. 4 TOP: Nursing Process: Assessment MSC:
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NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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5. For which personisa comprehensive assessment indicated?
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a. The person who hadabdominal surgery yesterday d d d d d d
b. The personwho isunaware ofhis high serumglucose levels d d d d d d d d d d
c. The personwho isbeingadmittedto along-termcare facility d d d d d d d d d d
d. Thepersonwhoisbeginningrehabilitationafterakneereplacement d d d d d d d
ANS: C
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