Test Bank For Health Assessment for Nursing Practice, 7th Edition by Susan F Wilson, Jean Foret Giddens All Chapters 1-24

Chapter 01: Introduction to Health Assessment
x@ x@ x@ x@ x@


Wilson: Health Assessment for Nursing Practice, 7th Edition
x@ x@ x@ x@ x@ x@ x@

,MULTIPLE CHOICE x@




1. A patient comes to the emergency department and tells the triage nurse that he is ―h
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


aving a heart attack.‖ What is the nurse‘s top priority at this time?
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


a. Determine the patient‘s personal data and insurance coverage.
x@ x@ x@ x@ x@ x@ x@


b. Ask the patient to take a seat in the waiting room until his name is called.
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


c. Request that a nurse collect data for a comprehensive history.
x@ x@ x@ x@ x@ x@ x@ x@ x@


d. Ask a nurse to start a focused assessment of this patient now.
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: D x @


The nurse needs to begin an assessment as soon as possible that is focused on this pat
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ient‘s cardiovascular system. The type of health assessment performed by the nurse is a
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


lso driven by patient need. Personal data and insurance information will be obtained, b
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ut in this situation, these data can wait until after the patient is assessed. Based also o
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


n Maslow‘s hierarchy of needs, physiologic needs take precedence. Rather than asking
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


the patient to wait, the nurse needs to begin data collection, such as vital signs, immed
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


iately to determine the patient‘s health status. Complications can be prevented if an im
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


mediate assessment is made to analyze the patient‘s symptoms. A comprehensive histor
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


y is not indicated in this situation at this time. Some subjective data will be collected,
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@such as allergies and medical history related to cardiovascular disease. Eyes, ears, or a
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@complete musculoskeletal or mental health assessment is not a priority at this time.
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@




DIF:Cognitive Level: Apply REF: Box 1- x@ x@ x @ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Esta
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


blishing Priorities x@




2. Which situation illustrates a screening assessment?
x@ x@ x@ x@ x@


a. A patient visits an obstetric clinic for the first time and the nurse con
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ducts a detailed history and physical examination.
x@ x@ x@ x@ x@ x@


b. A hospital sponsors a health fair at a local mall and provides cholesterol an
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


d blood pressure checks to mall patrons.
x@ x@ x@ x@ x@ x@


c. The nurse in an urgent care center checks the vital signs of a patient
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@who is complaining of leg pain.
x@ x@ x@ x@ x@


d. A patient newly diagnosed with diabetes mellitus comes to test his fasting
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


blood glucose level.
@ x@ x@




ANS: B x @


A health fair at a local mall that provides cholesterol and blood pressure checks is an
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


example of a screening assessment focused on disease detection. A detailed history and
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


x@physical examination conducted during a first-
x@ x@ x@ x@ x@


time visit to an obstetric clinic is an example of a comprehensive assessment. Assessin
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


g a patient complaining of leg pain in the triage area of an urgent care center is an e
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x @ x@ x@ x@ x@ x@ x@


xample of a problem- x@ x@ x@


based/focused assessment. A patient‘s return appointment 1 month after today‘s office v
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


isit to report fasting blood glucose levels is an example of an episodic or follow-
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


up assessment.
x@




DIF:Cognitive Level: Understand x@ x@ REF: Box 1-3 x@ x@

, TOP:Nursing Process: Assessment x@ x@


MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x@ x@ x@ x@ x@ x@ x@ x@




3. For which person is a screening assessment indicated?
x@ x@ x@ x@ x@ x@ x@


a. The person who had abdominal surgery yesterday
x@ x@ x@ x@ x@ x@


b. The person who is unaware of his high serum glucose levels
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


c. The person who is being admitted to a long-term care facility
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


d. The person who is beginning rehabilitation after a knee replacement
x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: B x@


A screening assessment is performed for the purpose of disease detection. In this case
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


this person may have diabetes mellitus. A shift assessment is most appropriate for the
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


person who is recovering in the hospital from surgery. A comprehensive assessment is
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


performed during admission to a facility to obtain a detailed history and complete phys
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ical examination. An episodic or follow-
x@ x@ x@ x@ x@


up assessment is performed after knee replacement to evaluate the outcome of the proc
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


edure.

DIF:Cognitive Level: Understand REF: Box 1-
x@ x@ x@ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Esta
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


blishing Priorities x@




4. For which person is a shift assessment indicated?
x@ x@ x@ x@ x@ x@ x@


a. The person who had abdominal surgery yesterday
x@ x@ x@ x@ x@ x@


b. The person who is unaware of his high serum glucose levels
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


c. The person who is being admitted to a long-term care facility
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


d. The person who is beginning rehabilitation after a knee replacement
x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: A x@


A shift assessment is most appropriate for the person who is recovering in the hospital
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@from surgery. A screening assessment is performed for the purpose of disease detection,
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


in this case diabetes mellitus. A comprehensive assessment is performed during admissi
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


on to a facility to obtain a detailed history and complete physical examination. An epis
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


odic or follow-x@ x@


up assessment is performed after knee replacement to evaluate the outcome of the proce
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


dure.

DIF:Cognitive Level: Understand REF: Box 1-
x@ x@ x@ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Esta
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


blishing Priorities x@




5. For which person is a comprehensive assessment indicated?
x@ x@ x@ x@ x@ x@ x@


a. The person who had abdominal surgery yesterday
x@ x@ x@ x@ x@ x@


b. The person who is unaware of his high serum glucose levels
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


c. The person who is being admitted to a long-term care facility
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


d. The person who is beginning rehabilitation after a knee replacement
x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: C x@


A comprehensive assessment is performed during admission to a facility to obtain a det
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ailed history and complete physical examination. A shift assessment is most appropriat
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


e for the person who is recovering in the hospital from surgery. A screening assessme
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


nt is performed for the purpose of disease detection, in this case diabetes mellitus. An
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@episodic or follow- x@ x@


up assessment is performed after knee replacement to evaluate the outcome of the pro
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


cedure.

, DIF:Cognitive Level: Understand REF: Box 1-
x@ x@ x@ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Esta
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


blishing Priorities x@




6. For which person is an episodic or follow-up assessment indicated?
x@ x@ x@ x@ x@ x@ x@ x@ x@


a. The person who had abdominal surgery yesterday
x@ x@ x@ x@ x@ x@


b. The person who is unaware of his high serum glucose levels
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


c. The person who is being admitted to a long-term care facility
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


d. The person who is beginning rehabilitation after a knee replacement
x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: D x@


An episodic or follow-
x@ x@ x@


up assessment is performed after the knee replacement to evaluate the outcome of the
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@procedure. A shift assessment is most appropriate for the person who is recovering in
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@the hospital from surgery. A screening assessment is performed for the purpose of dis
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ease detection, in this case diabetes mellitus. A comprehensive assessment is performed
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x


@during admission to a facility to obtain a detailed history and complete physical exam
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ination.

DIF:Cognitive Level: Understand REF: Box 1-
x@ x@ x@ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Esta
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


blishing Priorities x@




7. Which is an example of data a nurse collects during a physical examination?
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


a. The patient‘s lack of hair and shiny skin over both shins
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


b. The patient‘s stated concern about lack of money for prescriptions
x@ x@ x@ x@ x@ x@ x@ x@ x@


c. The patient‘s complaints of tingling sensations in the feet
x@ x@ x@ x@ x@ x@ x@ x@


d. The patient‘s mother‘s statements that the patient is very nervous lately
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@




ANS: A x@


The lack of hair and shiny skin over both shins are objective data or signs that are p
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


art of the physical examination. A patient‘s concerns about lack of money are subjecti
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ve data and are part of the health history. A patient‘s complaints of tingling sensation
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


s in the feet are subjective data and are part of the health history. A patient‘s family s
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


tatements are considered secondary data, are subjective data, and are part of the health
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


history.
x@




DIF:Cognitive Level: Apply REF: Box 1- x@ x@ x @ x@


3 TOP:Nursing Process: Assessment
x@ x@ x@


MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Spec
x@ x@ x@ x@ x@ x@ x@ x@ x@ x@


ific Assessments
x@




8. The nurse documents which information in the patient‘s history?
x@ x@ x@ x@ x@ x@ x@ x@


a. The patient‘s skin feels warm to the touch.
x@ x@ x@ x@ x@ x@ x@


b. The patient is scratching his arm.
x@ x@ x@ x@ x@


c. The patient‘s temperature is 100 F.
x@ x@ x@ x@ x@


d. The patient complains of itching.
x@ x@ x@ x@




ANS: D x@