,
,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 7th Edition
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MULTIPLE CHOICE vg
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
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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 insurance coverage. vg vg vg vg vg vg vg
b. Ask the patient to take a seat in the waiting room until his name is called.
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
c. Request that a nurse collect data for a comprehensive history.
vg vg vg vg vg vg vg vg vg
d. Ask a nurse to start a focused assessment of this patient now.
vg vg vg vg vg vg vg vg vg vg vg
ANS: D v g
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
cardiovascular system. The type of health assessment performed by the nurse is also driven
vg vg vg vg vg vg vg vg vg vg vg vg vg vg v
gby patient need. Personal data and insurance information will be obtained, but in this situat
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
urse needs to begin data collection, such as vital signs, immediately to determine the patien
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
t‘s health status. Complications can be prevented if an immediate assessment is made to an
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
his time. Some subjective data will be collected, such as allergies and medical history relat
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
vg vg vg vg vg vg vg vg vg vg vg vg vg
essment is not a priority at this time. vg vg vg vg vg vg vg
DIF:Cognitive Level: Apply REF: Box 1- vg vg v g vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
2. Which situation illustrates a screening assessment?
vg vg vg vg vg
a. A patient visits an obstetric clinic for the first time and the nurse conduct
vg vg vg vg vg vg vg vg vg vg vg vg vg
s a detailed history and physical examination.
vg vg vg vg vg vg
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
od pressure checks to mall patrons.
vg vg vg vg vg
c. The nurse in an urgent care center checks the vital signs of a patient who
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
is complaining of leg pain.
vg vg vg vg vg
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
vg vg vg vg vg vg vg vg vg vg vg vg
od glucose level. vg vg
ANS: B v g
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ple of a screening assessment focused on disease detection. A detailed history and physical
vg vg vg vg vg vg vg vg vg vg vg vg vg v
gexamination conducted during a first- vg vg vg vg
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
patient complaining of leg pain in the triage area of an urgent care center is an example of
vg vg vg vg vg vg vg vg vg v g vg vg vg vg vg vg vg v
ga problem-
vg
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
vg vg vg vg vg vg vg vg vg vg vg vg
to report fasting blood glucose levels is an example of an episodic or follow-
vg vg vg vg vg vg vg vg vg vg vg vg vg
up assessment.
vg
DIF:Cognitive Level: Understand vg vg REF: Box 1-3 vg vg
, TOP:Nursing Process: Assessment vg vg
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
vg vg vg vg vg vg vg vg
3. For which person is a screening assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: B vg
A screening assessment is performed for the purpose of disease detection. In this case this
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
vg vg vg vg vg vg vg vg vg vg vg vg vg
ring admission to a facility to obtain a detailed history and complete physical examination.
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
An episodic or follow-
vg vg vg
up assessment is performed after knee replacement to evaluate the outcome of the procedur
vg vg vg vg vg vg vg vg vg vg vg vg vg
e.
DIF:Cognitive Level: Understand REF: Box 1- vg vg vg vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
4. For which person is a shift assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: A vg
A shift assessment is most appropriate for the person who is recovering in the hospital from
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
vgsurgery. A screening assessment is performed for the purpose of disease detection, in this c
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
vg vg vg vg vg vg vg vg vg vg vg vg
ty to obtain a detailed history and complete physical examination. An episodic or follow-
vg vg vg vg vg vg vg vg vg vg vg vg vg
up assessment is performed after knee replacement to evaluate the outcome of the procedure
vg vg vg vg vg vg vg vg vg vg vg vg vg
.
DIF:Cognitive Level: Understand REF: Box 1- vg vg vg vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
5. For which person is a comprehensive assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: C vg
A comprehensive assessment is performed during admission to a facility to obtain a detaile
vg vg vg vg vg vg vg vg vg vg vg vg vg
d history and complete physical examination. A shift assessment is most appropriate for th
vg vg vg vg vg vg vg vg vg vg vg vg vg
e person who is recovering in the hospital from surgery. A screening assessment is perfor
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
vg vg vg vg vg vg vg vg vg vg vg vg vg
re.
,Chapter 01: Introduction to Health Assessment
vg vg vg vg vg
Wilson: Health Assessment for Nursing Practice, 7th Edition
vg vg vg vg vg vg vg
MULTIPLE CHOICE vg
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
a heart attack.‖ What is the nurse‘s top priority at this time?
vg vg vg vg vg vg vg vg vg vg vg
a. Determine the patient‘s personal data and insurance coverage. vg vg vg vg vg vg vg
b. Ask the patient to take a seat in the waiting room until his name is called.
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
c. Request that a nurse collect data for a comprehensive history.
vg vg vg vg vg vg vg vg vg
d. Ask a nurse to start a focused assessment of this patient now.
vg vg vg vg vg vg vg vg vg vg vg
ANS: D v g
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
cardiovascular system. The type of health assessment performed by the nurse is also driven
vg vg vg vg vg vg vg vg vg vg vg vg vg vg v
gby patient need. Personal data and insurance information will be obtained, but in this situat
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ion, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarch
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
y of needs, physiologic needs take precedence. Rather than asking the patient to wait, the n
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
urse needs to begin data collection, such as vital signs, immediately to determine the patien
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
t‘s health status. Complications can be prevented if an immediate assessment is made to an
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
alyze the patient‘s symptoms. A comprehensive history is not indicated in this situation at t
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
his time. Some subjective data will be collected, such as allergies and medical history relat
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ed to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health ass
vg vg vg vg vg vg vg vg vg vg vg vg vg
essment is not a priority at this time. vg vg vg vg vg vg vg
DIF:Cognitive Level: Apply REF: Box 1- vg vg v g vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
2. Which situation illustrates a screening assessment?
vg vg vg vg vg
a. A patient visits an obstetric clinic for the first time and the nurse conduct
vg vg vg vg vg vg vg vg vg vg vg vg vg
s a detailed history and physical examination.
vg vg vg vg vg vg
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
od pressure checks to mall patrons.
vg vg vg vg vg
c. The nurse in an urgent care center checks the vital signs of a patient who
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
is complaining of leg pain.
vg vg vg vg vg
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blo
vg vg vg vg vg vg vg vg vg vg vg vg
od glucose level. vg vg
ANS: B v g
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ple of a screening assessment focused on disease detection. A detailed history and physical
vg vg vg vg vg vg vg vg vg vg vg vg vg v
gexamination conducted during a first- vg vg vg vg
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
patient complaining of leg pain in the triage area of an urgent care center is an example of
vg vg vg vg vg vg vg vg vg v g vg vg vg vg vg vg vg v
ga problem-
vg
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
vg vg vg vg vg vg vg vg vg vg vg vg
to report fasting blood glucose levels is an example of an episodic or follow-
vg vg vg vg vg vg vg vg vg vg vg vg vg
up assessment.
vg
DIF:Cognitive Level: Understand vg vg REF: Box 1-3 vg vg
, TOP:Nursing Process: Assessment vg vg
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
vg vg vg vg vg vg vg vg
3. For which person is a screening assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: B vg
A screening assessment is performed for the purpose of disease detection. In this case this
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
person may have diabetes mellitus. A shift assessment is most appropriate for the person w
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ho is recovering in the hospital from surgery. A comprehensive assessment is performed du
vg vg vg vg vg vg vg vg vg vg vg vg vg
ring admission to a facility to obtain a detailed history and complete physical examination.
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
An episodic or follow-
vg vg vg
up assessment is performed after knee replacement to evaluate the outcome of the procedur
vg vg vg vg vg vg vg vg vg vg vg vg vg
e.
DIF:Cognitive Level: Understand REF: Box 1- vg vg vg vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
4. For which person is a shift assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: A vg
A shift assessment is most appropriate for the person who is recovering in the hospital from
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
vgsurgery. A screening assessment is performed for the purpose of disease detection, in this c
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ase diabetes mellitus. A comprehensive assessment is performed during admission to a facili
vg vg vg vg vg vg vg vg vg vg vg vg
ty to obtain a detailed history and complete physical examination. An episodic or follow-
vg vg vg vg vg vg vg vg vg vg vg vg vg
up assessment is performed after knee replacement to evaluate the outcome of the procedure
vg vg vg vg vg vg vg vg vg vg vg vg vg
.
DIF:Cognitive Level: Understand REF: Box 1- vg vg vg vg
3 TOP:Nursing Process: Assessment
vg vg vg
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establis
vg vg vg vg vg vg vg vg vg vg vg
hing Priorities vg
5. For which person is a comprehensive assessment indicated?
vg vg vg vg vg vg vg
a. The person who had abdominal surgery yesterday
vg vg vg vg vg vg
b. The person who is unaware of his high serum glucose levels
vg vg vg vg vg vg vg vg vg vg
c. The person who is being admitted to a long-term care facility
vg vg vg vg vg vg vg vg vg vg
d. The person who is beginning rehabilitation after a knee replacement
vg vg vg vg vg vg vg vg vg
ANS: C vg
A comprehensive assessment is performed during admission to a facility to obtain a detaile
vg vg vg vg vg vg vg vg vg vg vg vg vg
d history and complete physical examination. A shift assessment is most appropriate for th
vg vg vg vg vg vg vg vg vg vg vg vg vg
e person who is recovering in the hospital from surgery. A screening assessment is perfor
vg vg vg vg vg vg vg vg vg vg vg vg vg vg
med for the purpose of disease detection, in this case diabetes mellitus. An episodic or foll
vg vg vg vg vg vg vg vg vg vg vg vg vg vg vg
ow-
up assessment is performed after knee replacement to evaluate the outcome of the procedu
vg vg vg vg vg vg vg vg vg vg vg vg vg
re.
