TEST BANK
sd
Health Assessment for Nursing Practice
sd sd sd sd sdsd
7th Edition by Wilson Chapter 1 - 24
sd sd sd sd sd sd sd
,TABLE OF CONTENTS
sd sd sd
Unit I: Foundations for Health Assessment
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1. Introduction to Health Assessment
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2. Interviewing Patients to Obtain a Health History
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3. Techniques and Equipment for Physical Assessment
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4. General Inspection and Measurement of Vital Signs
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5. Ethnic, Cultural, and Spiritual Considerations
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6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
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8. Nutritional Assessment sd
Unit II: Health Assessment of the Adult
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9. Skin, Hair, and Nails
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10. Head, Eyes, Ears, Nose, and Throat
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11. Lungs and Respiratory System
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12. Heart and Peripheral Vascular System
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13. Abdomen and Gastrointestinal System
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14. Musculoskeletal System sd
15. Neurologic System sd
16. Breasts and Axillae sd sd
17. Reproductive System and the Perineum sd sd sd sd
Unit III: Health Assessment Across the Life Span
sd sd sd sd sd sd sd
18. Developmental Assessment Throughout the Life Span
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19. Assessment of the Infant, Child, and Adolescent
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20. Assessment of the Pregnant Patient sd sd sd sd
21. Assessment of the Older Adult sd sd sd sd
Unit IV: Synthesis and Application of Health Assessment
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22. Conducting a Head-to-Toe Examination
sd sd sd
23. Documenting the Head-to-Toe Health Assessment
sd sd sd sd
24. Adapting Health Assessment
sd sd
Chaptersd01:sdIntroductionsdtosdHealthsdAssessment
,MULTIPLEsdCHOICE
1. Asdpatientsdcomessdtosdthesdemergencysddepartmentsdandsdtellssdthesdtriagesdnurs
esdthatsdheissd“havingsdasdheartsdattack.”sdWhatsdissdthesdnurse’ssdtopsdprioritysdatsdthissdtime?
a. Determinesdthesdpatient’ssdpersonalsddatasdand
sdinsurancesdcoverage.
b. Asksdthesdpatientsdtosdtakesdasdseatsdinsdthesdwai
tingsdroomsduntilsdhissdnamesdissdcalled.
c. Requestsdthatsd asd nursesd collectsddatasd for
acomprehensives d history.
d. Asksdasdnursesdtosd startsdasdfocusedsdassessme
nt
ofsdthissdpatientsdnow.
ANSWER:sdD
Thesdnursesdneedssdtosdbeginsdansdassessmentsdassdsoonsdassdpossiblesdthatsdissdfocusedsdonsdthissdp
atient’ssdcardiovascularsdsystem.sdThesdtypesdofsdhealthsdassessmentsdperformedsdbysdthesdnurses
dissdalsosddrivensdbysdpatientsdneed.sdPersonalsddatasdandsdinsurancesdinformationsdwillsdbesdob
tained,sdbutsdinsdthissdsituation,sdthesesddatasdcansdwaitsduntilsdaftersdthesdpatientsdissdassessed.sd
BasedsdalsosdonsdMaslow’ssdhierarchysdofsdneeds,sdphysiologicsdneedssdtakesdprecedence.sdRa
thersdthansdaskingsdthesdpatientsdtosdwait,sdthesdnursesdneedssdtosdbeginsddatasdcollection,sdsuchsda
ssdvitalsdsigns,sdimmediatelysdtosddeterminesdthesdpatient’ssdhealthsdstatus.sdComplicationssdcansd
besdpreventedsdifsdansdimmediatesdassessmentsdissdmadesdtosdanalyzesdthesdpatient’ssdsymptom
s.sdAsdcomprehensivesdhistorysdissdnotsdindicatedsdinsdthissdsituationsdatsdthissdtime.sdSomesdsubj
ectivesddatasdwillsdbesdcollected,sdsuchsdassdallergiessdandsdmedicalsdhistorysdrelatedsdtosdcardio
vascularsddisease.sdEyes,sdears,sdorsdasdcompletesdmusculoskeletalsdorsdmentalsdhealthsdasses
smentsdissdnotsdasdprioritysdatsdthissdtime.
DIF:s d CognitivesdLevel:sdApply REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsdNeeds:sdSafesdandsdEffectivesdCaresdEnvironment:sdManagementsdofsdCare:Esta
blishings d Priorities
2. Whichsd situationsdillustratessdas d screeningsdassessment?
a. Asdpatientsdvisitssdansdobstetricsdclinicsdforsdthes
dfirst
timesdandsdthesdnursesdconductssdasddetailedhist
orysdandsdphysicalsdexamination.
b. Asdhospitalsdsponsorssdasdhealthsdfairsdatsda
localmallsdandsdprovidessdcholesterolsdandsd
bloodsdpressuresdcheckssdtosdmallsdpatrons.
c. Thesdnursesdinsdansdurgentsdcaresdcentersdcheck
s
thesdvitalsdsignssdofsdasdpatientsdwhosdissdcompl
ainingsdofsdlegsdpain.
, d. Asdpatientsd newlysddiagnosedsdwith
diabetesmellitussdcomessdtosdtestsdhissdfastingsdb
loodsdglucosesdlevel.
ANSWER:sdB
Asdhealthsdfairsdatsdasdlocalsdmallsdthatsdprovidessdcholesterolsdandsdbloodsdpressuresdcheckssdissd
ansdexamplesdofsdasdscreeningsdassessmentsdfocusedsdonsddiseasesddetection.sdAsddetailedsdhis
torysdandsdphysicalsdexaminationsdconductedsdduringsdasdfirst-
timesdvisitsdtosdansdobstetricsdclinicsdissdansdexampleofsdasdcomprehensivesdassessment.sdAssessi
ngsdasdpatientsdcomplainingsdofsdlegsdpainsdinsdthesdtriagesdareasdofsdansdurgentsdcaresdcentersdissda
nsdexamplesdofsdasdproblem-
based/focusedsdassessment.sdAsdpatient’ssdreturnsdappointmentsd1sdmonthsdaftersdtoday’ssdof
ficesdvisitsdtosdreportsdfastingsdbloodsdglucosesdlevelssdissdansdexamplesdofsdansdepisodicsdorsdfoll
ow-upsdassessment.
DIF:s d CognitivesdLevel:sdUnderstand REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsd Needs:sd HealthsdPromotionsdandsdMaintenance:sd HealthsdScreening
3. Forsd whichsdpersonsdissdas d screeningsdassessments d indicated?
a. Thesdpersonsdwhosdhadsdabdominalsdsurgery
yesterday
b. Thesdpersonsdwhosdissdunawaresdofsdhissdhig
hsdserumsdglucosesdlevels
c. Thesdpersonsdwhosdissdbeingsdadmittedsdtosda
long-termsdcaresdfacility
d. Thesdpersonsdwhosdissdbeginningsdrehabilitation
aftersdasdkneesdreplacement
ANSWER:sdB
Asdscreeningsdassessmentsdissdperformedsdforsdthesdpurposesdofsddiseasesddetection.sdInsdthissdcas
esdthissdpersonsdmaysdhavesddiabetessdmellitus.sdAsdshiftsdassessmentsdissdmostsdappropriatesdfor
sdthesdpersonsdwhosdissdrecoveringsdinsdthesdhospital sdfromsdsurgery.sdAsdcomprehensive sdassess
mentsdissdperformedsdduringsdadmissionsdtosdasdfacilitysdtosdobtainsdasddetailedsdhistorysdandsdc
ompletesdphysicalsdexamination.sdAnsdepisodicsdorsdfollow-
upsdassessmentsdissdperformedsdaftersdkneesdreplacementsdtosdevaluatesdthesdoutcomesdofsdthes
dprocedure.
DIF:s d CognitivesdLevel:sdUnderstand REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsdNeeds:sdSafesdandsdEffectivesdCaresdEnvironment:sdManagementsdofsdCare:Esta
blishings d Priorities
4. Forsd whichsdpersonsdissdas d shiftsd assessmentsd indicated?
a. Thesdpersonsdwhosdhadsdabdominalsdsurgery
yesterday
b. Thesdpersonsdwhosdissdunawaresdofsdhissdhigh
serums d glucoses d levels
c. Thesdpersonsdwhosdissdbeingsdadmittedsdtosda
long-termsdcaresdfacility
d. Thesdpersonsdwhosdissdbeginningsdrehabilitation
aftersdasdkneesdreplacement
ANSWER:sdA
Asdshiftsdassessmentsdissdmostsdappropriatesdforsdthesdpersonsdwhosdissdrecoveringsdinsdthesdhospit
alsdfromsdsurgery.sdAsdscreeningsdassessmentsdissdperformedsdforsdthesdpurposesdofsddiseasesdde
tection,sdinsdthissdcasesddiabetessdmellitus.sdAsdcomprehensivesdassessmentsdissdperformedsdduri
ngsdadmissionsdtosda
sd
Health Assessment for Nursing Practice
sd sd sd sd sdsd
7th Edition by Wilson Chapter 1 - 24
sd sd sd sd sd sd sd
,TABLE OF CONTENTS
sd sd sd
Unit I: Foundations for Health Assessment
sd sd sd sd sd
1. Introduction to Health Assessment
sd sd sd
2. Interviewing Patients to Obtain a Health History
sd sd sd sd sd sd
3. Techniques and Equipment for Physical Assessment
sd sd sd sd sd
4. General Inspection and Measurement of Vital Signs
sd sd sd sd sd sd
5. Ethnic, Cultural, and Spiritual Considerations
sd sd sd sd
6. Pain Assessment
sd
7. Mental Health and Abusive Behavior Assessment
sd sd sd sd sd
8. Nutritional Assessment sd
Unit II: Health Assessment of the Adult
sd sd sd sd sd sd
9. Skin, Hair, and Nails
sd sd sd
10. Head, Eyes, Ears, Nose, and Throat
sd sd sd sd sd
11. Lungs and Respiratory System
sd sd sd
12. Heart and Peripheral Vascular System
sd sd sd sd
13. Abdomen and Gastrointestinal System
sd sd sd
14. Musculoskeletal System sd
15. Neurologic System sd
16. Breasts and Axillae sd sd
17. Reproductive System and the Perineum sd sd sd sd
Unit III: Health Assessment Across the Life Span
sd sd sd sd sd sd sd
18. Developmental Assessment Throughout the Life Span
sd sd sd sd sd
19. Assessment of the Infant, Child, and Adolescent
sd sd sd sd sd sd
20. Assessment of the Pregnant Patient sd sd sd sd
21. Assessment of the Older Adult sd sd sd sd
Unit IV: Synthesis and Application of Health Assessment
sd sd sd sd sd sd sd
22. Conducting a Head-to-Toe Examination
sd sd sd
23. Documenting the Head-to-Toe Health Assessment
sd sd sd sd
24. Adapting Health Assessment
sd sd
Chaptersd01:sdIntroductionsdtosdHealthsdAssessment
,MULTIPLEsdCHOICE
1. Asdpatientsdcomessdtosdthesdemergencysddepartmentsdandsdtellssdthesdtriagesdnurs
esdthatsdheissd“havingsdasdheartsdattack.”sdWhatsdissdthesdnurse’ssdtopsdprioritysdatsdthissdtime?
a. Determinesdthesdpatient’ssdpersonalsddatasdand
sdinsurancesdcoverage.
b. Asksdthesdpatientsdtosdtakesdasdseatsdinsdthesdwai
tingsdroomsduntilsdhissdnamesdissdcalled.
c. Requestsdthatsd asd nursesd collectsddatasd for
acomprehensives d history.
d. Asksdasdnursesdtosd startsdasdfocusedsdassessme
nt
ofsdthissdpatientsdnow.
ANSWER:sdD
Thesdnursesdneedssdtosdbeginsdansdassessmentsdassdsoonsdassdpossiblesdthatsdissdfocusedsdonsdthissdp
atient’ssdcardiovascularsdsystem.sdThesdtypesdofsdhealthsdassessmentsdperformedsdbysdthesdnurses
dissdalsosddrivensdbysdpatientsdneed.sdPersonalsddatasdandsdinsurancesdinformationsdwillsdbesdob
tained,sdbutsdinsdthissdsituation,sdthesesddatasdcansdwaitsduntilsdaftersdthesdpatientsdissdassessed.sd
BasedsdalsosdonsdMaslow’ssdhierarchysdofsdneeds,sdphysiologicsdneedssdtakesdprecedence.sdRa
thersdthansdaskingsdthesdpatientsdtosdwait,sdthesdnursesdneedssdtosdbeginsddatasdcollection,sdsuchsda
ssdvitalsdsigns,sdimmediatelysdtosddeterminesdthesdpatient’ssdhealthsdstatus.sdComplicationssdcansd
besdpreventedsdifsdansdimmediatesdassessmentsdissdmadesdtosdanalyzesdthesdpatient’ssdsymptom
s.sdAsdcomprehensivesdhistorysdissdnotsdindicatedsdinsdthissdsituationsdatsdthissdtime.sdSomesdsubj
ectivesddatasdwillsdbesdcollected,sdsuchsdassdallergiessdandsdmedicalsdhistorysdrelatedsdtosdcardio
vascularsddisease.sdEyes,sdears,sdorsdasdcompletesdmusculoskeletalsdorsdmentalsdhealthsdasses
smentsdissdnotsdasdprioritysdatsdthissdtime.
DIF:s d CognitivesdLevel:sdApply REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsdNeeds:sdSafesdandsdEffectivesdCaresdEnvironment:sdManagementsdofsdCare:Esta
blishings d Priorities
2. Whichsd situationsdillustratessdas d screeningsdassessment?
a. Asdpatientsdvisitssdansdobstetricsdclinicsdforsdthes
dfirst
timesdandsdthesdnursesdconductssdasddetailedhist
orysdandsdphysicalsdexamination.
b. Asdhospitalsdsponsorssdasdhealthsdfairsdatsda
localmallsdandsdprovidessdcholesterolsdandsd
bloodsdpressuresdcheckssdtosdmallsdpatrons.
c. Thesdnursesdinsdansdurgentsdcaresdcentersdcheck
s
thesdvitalsdsignssdofsdasdpatientsdwhosdissdcompl
ainingsdofsdlegsdpain.
, d. Asdpatientsd newlysddiagnosedsdwith
diabetesmellitussdcomessdtosdtestsdhissdfastingsdb
loodsdglucosesdlevel.
ANSWER:sdB
Asdhealthsdfairsdatsdasdlocalsdmallsdthatsdprovidessdcholesterolsdandsdbloodsdpressuresdcheckssdissd
ansdexamplesdofsdasdscreeningsdassessmentsdfocusedsdonsddiseasesddetection.sdAsddetailedsdhis
torysdandsdphysicalsdexaminationsdconductedsdduringsdasdfirst-
timesdvisitsdtosdansdobstetricsdclinicsdissdansdexampleofsdasdcomprehensivesdassessment.sdAssessi
ngsdasdpatientsdcomplainingsdofsdlegsdpainsdinsdthesdtriagesdareasdofsdansdurgentsdcaresdcentersdissda
nsdexamplesdofsdasdproblem-
based/focusedsdassessment.sdAsdpatient’ssdreturnsdappointmentsd1sdmonthsdaftersdtoday’ssdof
ficesdvisitsdtosdreportsdfastingsdbloodsdglucosesdlevelssdissdansdexamplesdofsdansdepisodicsdorsdfoll
ow-upsdassessment.
DIF:s d CognitivesdLevel:sdUnderstand REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsd Needs:sd HealthsdPromotionsdandsdMaintenance:sd HealthsdScreening
3. Forsd whichsdpersonsdissdas d screeningsdassessments d indicated?
a. Thesdpersonsdwhosdhadsdabdominalsdsurgery
yesterday
b. Thesdpersonsdwhosdissdunawaresdofsdhissdhig
hsdserumsdglucosesdlevels
c. Thesdpersonsdwhosdissdbeingsdadmittedsdtosda
long-termsdcaresdfacility
d. Thesdpersonsdwhosdissdbeginningsdrehabilitation
aftersdasdkneesdreplacement
ANSWER:sdB
Asdscreeningsdassessmentsdissdperformedsdforsdthesdpurposesdofsddiseasesddetection.sdInsdthissdcas
esdthissdpersonsdmaysdhavesddiabetessdmellitus.sdAsdshiftsdassessmentsdissdmostsdappropriatesdfor
sdthesdpersonsdwhosdissdrecoveringsdinsdthesdhospital sdfromsdsurgery.sdAsdcomprehensive sdassess
mentsdissdperformedsdduringsdadmissionsdtosdasdfacilitysdtosdobtainsdasddetailedsdhistorysdandsdc
ompletesdphysicalsdexamination.sdAnsdepisodicsdorsdfollow-
upsdassessmentsdissdperformedsdaftersdkneesdreplacementsdtosdevaluatesdthesdoutcomesdofsdthes
dprocedure.
DIF:s d CognitivesdLevel:sdUnderstand REF:sdBoxsd1-
3sd|sdp.sd3sdTOP:sdNursingsdProcess:sdAssessment
MSC:sdNCLEXsdPatientsdNeeds:sdSafesdandsdEffectivesdCaresdEnvironment:sdManagementsdofsdCare:Esta
blishings d Priorities
4. Forsd whichsdpersonsdissdas d shiftsd assessmentsd indicated?
a. Thesdpersonsdwhosdhadsdabdominalsdsurgery
yesterday
b. Thesdpersonsdwhosdissdunawaresdofsdhissdhigh
serums d glucoses d levels
c. Thesdpersonsdwhosdissdbeingsdadmittedsdtosda
long-termsdcaresdfacility
d. Thesdpersonsdwhosdissdbeginningsdrehabilitation
aftersdasdkneesdreplacement
ANSWER:sdA
Asdshiftsdassessmentsdissdmostsdappropriatesdforsdthesdpersonsdwhosdissdrecoveringsdinsdthesdhospit
alsdfromsdsurgery.sdAsdscreeningsdassessmentsdissdperformedsdforsdthesdpurposesdofsddiseasesdde
tection,sdinsdthissdcasesddiabetessdmellitus.sdAsdcomprehensivesdassessmentsdissdperformedsdduri
ngsdadmissionsdtosda
