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Test Bank for Health Assessment for
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g Nursing Practice 7th Edition by Wilson
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Chapter 1 - 24 g g g
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Chapter01:Introduction toHealth Assessment
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MULTIPLE CHOICE g
1. Apatientcomesto the emergencydepartment andtellsthe triage nursethat he is
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“having a heart attack.” What is the nurse’s top priorityat this time?
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a. Determinethepatient’spersonaldataand g g g g g
insurance coverage. g g
b. Ask the patient totake a seat inthe waiting
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room until his name is called.
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c. Requestthat a nurse collect data for a g g g g g g g
comprehensive history.
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d. Ask a nurseto start a focused assessment of
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this patient now.
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ANSWER: D g
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
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cardiovascular system. The type of health assessment performed by the nurse is also driven by
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patient need. Personal data and insurance information will be obtained, but in this situation,
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these data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of
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needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
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needs to begin data collection, such as vital signs, immediately to determine the patient’s health
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status. Complications can be prevented if an immediate assessment is made to analyze the
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patient’s symptoms. A comprehensive history is not indicated in this situation at this time.
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Some subjective data will be collected, such as allergies and medical history related to
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cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessment
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is not a priority at this time.
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DIF: Cognitive Level: Apply
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TOP: Nursing Process: Assessment
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MSC: NCLEXPatient Needs: Safe and Effective Care Environment: Management of Care:
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Establishing Priorities
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2. Which situationillustratesa screeningassessment?
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a. A patient visits an obstetric clinic for the g g g g g g g
firsttimeandthenurseconductsa detailed g g g g g g g g
history and physical examination. g g g g
b. Ahospital sponsorsa health fair ata local mall g g g g g g g g g
and provides cholesterol and blood pressure g g g g g g
checks to mall patrons. g g g g
c. The nurse inan urgent care centerchecks the g g g g g g g g
vital signs of a patient who is complaining g g g g g g g g
of leg pain. g g g
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d. Apatient newlydiagnosed withdiabetes
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mellitus comes to test his fasting blood
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glucose level.
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ANSWER: B g
A health fair at a local mall that provides cholesterol and blood
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pressure checks is an example of a screening assessment focused on
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disease g
detection. A detailed history and physical examination conducted during a g g g g g g g g g
gfirst-time visit to an obstetric clinic is an example of a comprehensive g g g g g g g g g g
assessment. Assessing a patient complaining of leg pain in the triage
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garea
of an urgent care center is an example of a problem-based/focused
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g assessment. A patient’s return appointment 1 month after today’s office g g g g g g g g g g g g g g g g g g
visit to report fasting blood glucose levels is an example of an episodic
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or follow-up assessment.
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DIF: Cognitive Level: UnderstandREF: Box 1-3 g g g g g g g g g
| p. 3 TOP: 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 g g
abdominal surgery yesterday g g g
b. The person who is unaware g g g g
of his high serum glucose g g g g g
levels g
c. The person who is being g g g g
admitted to a long-term care g g g g g
facility
d. The person who is beginning g g g g
rehabilitation after a knee g g g
replacement g
ANSWER: B
A screening assessment is performed for the purpose of disease detection.
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In this case this person may have diabetes mellitus. A shift assessment
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is most appropriate for the person who is recovering in the hospital
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from surgery. A comprehensive assessment is performed during admission
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to a facility to obtain a detailed history and complete physical
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examination. An episodic or follow-up assessment is performed after
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knee replacement to g g g g g
evaluate the outcome of the procedure. g g g g g g g g g g
DIF: Cognitive Level: UnderstandREF: Box 1-3 g g g g g g g g g
| p. 3 TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of
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Care: Establishing Priorities
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4. For which person is a shift assessment indicated?
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a. The person who had g g
abdominal surgery yesterday g g g
b. The person who is unaware g g g g
of his high serum glucose g g g g g
levels g
c. The person who is being g g g
admitted to a g g g
long-term care facility g g g
d. The person who is beginning g g g g
rehabilitation after a knee g g g