,Chapter 01: Introduction to Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he
is “having a heart attack.” What is the nurse’s top priority at this time?
a. Determine the patient’s personal data and
insurance coverage.
b. Ask the patient to take a seat in the waiting
room until his name is called.
c. Request that a nurse collect data for a
comprehensive history.
d. Ask a nurse to start a focused assessment
of this patient now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
cardiovascular system. The type of health assessment performed by the nurse is also driven
by patient need. Personal data and insurance information will be obtained, but in this
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
the patient’s health status. Complications can be prevented if an immediate assessment is
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
situation at this time. Some subjective data will be collected, such as allergies and medical
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
mental health assessment is not a priority at this time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
2. Which situation illustrates a screening assessment?
a. A patient visits an obstetric clinic for the
first time and the nurse conducts a detailed
history and physical examination.
b. A hospital sponsors a health fair at a local
mall and provides cholesterol and blood
pressure checks to mall patrons.
c. The nurse in an urgent care center checks
the vital signs of a patient who is
complaining of leg pain.
, d. A patient newly diagnosed with diabetes
mellitus comes to test his fasting blood
glucose level.
ANSWER: B
A health fair at a local mall that provides cholesterol and blood pressure checks is an
example of a screening assessment focused on disease detection. A detailed history and
physical examination conducted during a first-time visit to an obstetric clinic is an example
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
area of an urgent care center is an example of a problem-based/focused assessment. A
patient’s return appointment 1 month after today’s office visit to report fasting blood
glucose levels is an example of an episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person may have diabetes mellitus. A shift assessment is most appropriate for the person
who is recovering in the hospital from surgery. A comprehensive assessment is performed
during admission to a facility to obtain a detailed history and complete physical
examination. An episodic or follow-up assessment is performed after knee replacement to
evaluate the outcome of the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery. A screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. A comprehensive assessment is performed during admission to a
, facility to obtain a detailed history and complete physical examination. An episodic or
follow-up assessment is performed after knee replacement to evaluate the outcome of the
procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For which person is a comprehensive assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: C
A comprehensive assessment is performed during admission to a facility to obtain a
detailed history and complete physical examination. A shift assessment is most appropriate
for the person who is recovering in the hospital from surgery. A screening assessment is
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
or follow-up assessment is performed after knee replacement to evaluate the outcome of
the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
6. For which person is an episodic or follow-up assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: D
An episodic or follow-up assessment is performed after the knee replacement to evaluate
the outcome of the procedure. A shift assessment is most appropriate for the person who is
recovering in the hospital from surgery. A screening assessment is performed for the
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
performed during admission to a facility to obtain a detailed history and complete physical
examination.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triage nurse that he
is “having a heart attack.” What is the nurse’s top priority at this time?
a. Determine the patient’s personal data and
insurance coverage.
b. Ask the patient to take a seat in the waiting
room until his name is called.
c. Request that a nurse collect data for a
comprehensive history.
d. Ask a nurse to start a focused assessment
of this patient now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
cardiovascular system. The type of health assessment performed by the nurse is also driven
by patient need. Personal data and insurance information will be obtained, but in this
situation, these data can wait until after the patient is assessed. Based also on Maslow’s
hierarchy of needs, physiologic needs take precedence. Rather than asking the patient to
wait, the nurse needs to begin data collection, such as vital signs, immediately to determine
the patient’s health status. Complications can be prevented if an immediate assessment is
made to analyze the patient’s symptoms. A comprehensive history is not indicated in this
situation at this time. Some subjective data will be collected, such as allergies and medical
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
mental health assessment is not a priority at this time.
DIF: Cognitive Level: Apply REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
2. Which situation illustrates a screening assessment?
a. A patient visits an obstetric clinic for the
first time and the nurse conducts a detailed
history and physical examination.
b. A hospital sponsors a health fair at a local
mall and provides cholesterol and blood
pressure checks to mall patrons.
c. The nurse in an urgent care center checks
the vital signs of a patient who is
complaining of leg pain.
, d. A patient newly diagnosed with diabetes
mellitus comes to test his fasting blood
glucose level.
ANSWER: B
A health fair at a local mall that provides cholesterol and blood pressure checks is an
example of a screening assessment focused on disease detection. A detailed history and
physical examination conducted during a first-time visit to an obstetric clinic is an example
of a comprehensive assessment. Assessing a patient complaining of leg pain in the triage
area of an urgent care center is an example of a problem-based/focused assessment. A
patient’s return appointment 1 month after today’s office visit to report fasting blood
glucose levels is an example of an episodic or follow-up assessment.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
3. For which person is a screening assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: B
A screening assessment is performed for the purpose of disease detection. In this case this
person may have diabetes mellitus. A shift assessment is most appropriate for the person
who is recovering in the hospital from surgery. A comprehensive assessment is performed
during admission to a facility to obtain a detailed history and complete physical
examination. An episodic or follow-up assessment is performed after knee replacement to
evaluate the outcome of the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
4. For which person is a shift assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: A
A shift assessment is most appropriate for the person who is recovering in the hospital from
surgery. A screening assessment is performed for the purpose of disease detection, in this
case diabetes mellitus. A comprehensive assessment is performed during admission to a
, facility to obtain a detailed history and complete physical examination. An episodic or
follow-up assessment is performed after knee replacement to evaluate the outcome of the
procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 4
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
5. For which person is a comprehensive assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: C
A comprehensive assessment is performed during admission to a facility to obtain a
detailed history and complete physical examination. A shift assessment is most appropriate
for the person who is recovering in the hospital from surgery. A screening assessment is
performed for the purpose of disease detection, in this case diabetes mellitus. An episodic
or follow-up assessment is performed after knee replacement to evaluate the outcome of
the procedure.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
Establishing Priorities
6. For which person is an episodic or follow-up assessment indicated?
a. The person who had abdominal surgery
yesterday
b. The person who is unaware of his high
serum glucose levels
c. The person who is being admitted to a
long-term care facility
d. The person who is beginning rehabilitation
after a knee replacement
ANSWER: D
An episodic or follow-up assessment is performed after the knee replacement to evaluate
the outcome of the procedure. A shift assessment is most appropriate for the person who is
recovering in the hospital from surgery. A screening assessment is performed for the
purpose of disease detection, in this case diabetes mellitus. A comprehensive assessment is
performed during admission to a facility to obtain a detailed history and complete physical
examination.
DIF: Cognitive Level: Understand REF: Box 1-3 | p. 3
TOP: Nursing Process: Assessment
