Test Bank — Health Assessment for Nursing Practice, 8th Edition — Susan Fickertt Wilson & Jean Foret Giddens — ISBN 9780443124433

Test Bank For Health Assessment for Nursing Practice
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7th Edition by Susan Fickertt Wilson, Jean Foret
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Giddens Chapter 1-24
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,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 7th Edition
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MULTIPLE CHOICE rb




1. Apatient comes to the emergencydepartment and tells the triagenursethat he is ―havinga heart
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rb 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. rb rb rb rb rb rb rb




b. Ask the patient to take a seat in the waiting room until his name is called.
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c. Request that a nurse collect data for a comprehensivehistory. rb rb rb rb rb rb rb rb rb




d. Ask a nurse to start a focused assessment of this patient now.
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ANS: D r b




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. Some
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subjective data will be collected, such as allergies and medical history related to cardiovascular
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disease. Eyes, ears, or a complete musculoskeletal or mental health assessment is not a priority
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at this time.
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DIF:Cognitive Level: Apply REF: Box1-3 rb rb r b rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing rb rb rb rb rb rb rb rb rb rb rb




Priorities
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2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse conducts a
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detailed history and physical examination.
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b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood
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pressure checks to mall patrons.
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c. The nurse in an urgent care center checks the vital signs of a patient who is
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complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood
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glucose level. rb rb




ANS: B r b




A health fair at a local mall that provides cholesterol and blood pressure checks is an example of
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a screening assessment focused on disease detection. A detailed history and physical
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examination conducted during a first-time visit to an obstetric clinic is an example of a
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comprehensive assessment. Assessing a patient complaining of leg pain in the triage area of an
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urgent care center is an example of a problem-based/focused assessment. A patient‘s return
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appointment 1 month after today‘s office visit to report fasting blood glucose levels is an
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example of an episodic or follow-up assessment.
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DIF:Cognitive Level: Understand rb rb REF: Box 1-3 rb rb

, TOP:Nursing Process: Assessment rb rb




MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening rb rb rb rb rb rb rb rb




3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: B rb




A screening assessment is performed for the purpose of disease detection. In this case this
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person may have diabetes mellitus. A shift assessment is most appropriate for the person who is
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recovering in the hospital from surgery. A comprehensive assessment is performed during
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admission to a 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 the outcome of
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the procedure.
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DIF:Cognitive Level: Understand REF:Box1-3 rb rb rb rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: A rb




A shift assessment is most appropriate for the person who is recovering in the hospital from
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surgery. A screening assessment is performed for the purpose of disease detection, in this case
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diabetes mellitus. A comprehensive assessment is performed during admission to a facility to
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obtain a detailed history and complete physical examination. An episodic or follow-up
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assessment is performed after knee replacement to evaluate the outcome of the procedure.
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DIF:Cognitive Level: Understand REF:Box1-3 rb rb rb rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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5. For which person is a comprehensive assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: C rb




A comprehensive assessment is performed during admission to a facility to obtain a detailed
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history and complete physical examination. A shift assessment is most appropriate for the
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person who is recovering in the hospital from surgery. A screening assessment is performed for
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the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-up
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assessment is performed after knee replacement to evaluate the outcome of the procedure.
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, DIF:Cognitive Level: Understand REF:Box1-3 rb rb rb rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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6. For which person is an episodic or follow-up assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: D rb




An episodic or follow-up assessment is performed after the knee replacement to evaluate the
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outcome of the procedure. A shift assessment is most appropriate for the person who is
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recovering in the hospital from surgery. A screening assessment is performed for the purpose of
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disease detection, in this case diabetes mellitus. A comprehensive assessment is performed
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during admission to a facility to obtain a detailed history and complete physical examination.
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DIF:Cognitive Level: Understand REF:Box1-3 rb rb rb rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
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Priorities
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7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A rb




The lack of hair and shiny skin over both shins are objective data or signs that are part of the
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physical examination. A patient‘s concerns about lack of money are subjective data and are part
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of the health history. A patient‘s complaints of tingling sensations in the feet are subjective data
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and are part of the health history. A patient‘s family statements are considered secondary data,
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are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box1-3 rb rb r b rb




TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific
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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 touch.
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b. The patient is scratching his arm. rb rb rb rb rb




c. The patient‘s temperature is 100 F. rb rb rb rb rb




d. The patient complains of itching. rb rb rb rb




ANS: D rb