TEST BANK
Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,TABLE OF CONTENTS qw qw
Unit I: Foundations for Health Assessment
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1. Introduction to Health Assessment qw qw qw
2. Interviewing Patients to Obtain a Health History
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3. Techniques and Equipment for Physical Assessment
qw qw qw qw qw
4. General Inspection and Measurement of Vital Signs
qw qw qw qw qw qw
5. Ethnic, Cultural, and Spiritual Considerations
qw qw qw qw
6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
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8. Nutritional Assessment qw
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 qw qw qw
14. Musculoskeletal System qw
15. Neurologic System qw
16. Breasts and Axillae qw qw
17. Reproductive System and the Perineum qw qw qw qw
Unit III: Health Assessment Across the Life Span
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18. Developmental Assessment Throughout the Life Span qw qw qw qw qw
19. Assessment of the Infant, Child, and Adolescent qw qw qw qw qw qw
20. Assessment of the Pregnant Patient qw qw qw qw
21. Assessment of the Older Adult qw qw qw qw
Unit IV: Synthesis and Application of Health Assessment
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22. Conducting a Head-to-Toe Examination qw qw qw
23. Documenting the Head-to-Toe Health Assessment qw q w qw qw
24. Adapting Health Assessment qw qw
Chapter 01: Introduction to Health Assessment
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,MULTIPLE CHOICE qw
1. A patient comes to the emergency department and tells the triage nurse t
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hat heis “having 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 i qw qw qw qw qw qw
nsurance coverage. qw
b. Ask the patient to take a seat in the waiti qw qw qw qw qw qw qw qw qw
ng room until his name is called. qw qw qw qw qw qw
c. Request that a nurse collect data for qw qw qw qw qw qw
acomprehensive history. qw
d. Ask a nurse to start a focused assessment qw qw qw qw qw qw qw
of this patient now. qw qw qw
ANSWER: D qw
The nurse needs to begin an assessment as soon as possible that is focused on this patie
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
nt’s cardiovascular system. The type of health assessment performed by the nurse is als
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o driven by patient need. Personal data and insurance information will be obtained, b
qw qw qw qw qw qw qw qw qw qw qw qw qw
ut in this situation, these data can wait until after the patient is assessed. Based also
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather than askin
qw qw qw qw qw qw qw qw qw qw qw
g the patient to wait, the nurse needs to begin data collection, such as vital signs, imme
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
diately to determine the patient’s health status. Complications can be prevented if an im
qw qw qw qw qw qw qw qw qw qw qw qw qw
mediate assessment is made to analyze the patient’s symptoms. A comprehensive hist
qw qw qw qw qw qw qw qw qw qw qw
ory is not indicated in this situation at this time. Some subjective data will be collected,
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
such as allergies and medical history related to cardiovascular disease. Eyes, ears, or
qw qw qw qw qw qw qw qw qw qw qw qw qw
a complete musculoskeletal or mental health assessment is not a priority at this time.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
DIF: Cognitive Level: Apply
q w REF: Box 1- qw qw qw qw
3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establis
qw qw qw qw qw qw qw qw qw qw qw
hing Prioritiesq w
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the fir qw qw qw qw qw qw qw qw
st
time and the nurse conducts a detailedhistor qw qw qw qw qw qw
y and physical examination. qw qw qw
b. A hospital sponsors a health fair at a qw qw qw qw qw qw qw
localmall and provides cholesterol and bl qw qw qw qw qw
ood pressure checks to mall patrons. qw qw qw qw qw
c. The nurse in an urgent care center checks
qw qw qw qw qw qw qw
the vital signs of a patient who is complai
qw qw qw qw qw qw qw qw
ning of leg pain. qw qw qw
, d. A patient newly diagnosed with
qw qw qw qw
diabetesmellitus comes to test his fasting bl qw qw qw qw qw qw
ood glucose level. qw qw
ANSWER: B qw
A health fair at a local mall that provides cholesterol and blood pressure checks is an
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
example of a screening assessment focused on disease detection. A detailed history a
qw qw qw qw qw qw qw qw qw qw qw qw
nd physical examination conducted during a first-
qw qw qw qw qw qw
time visit to an obstetric clinic is an exampleof a comprehensive assessment. Assessing
qw qw qw qw qw qw qw qw qw qw qw qw q
wa patient complaining of leg pain in the triage area of an urgent care center is an exa
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
mple of a problem-
qw qw qw
based/focused assessment. A patient’s return appointment 1 month after today’s offic
qw qw qw qw qw qw qw qw qw qw
e visit to report fasting blood glucose levels is an example of an episodic or follow-
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
up assessment.
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DIF: Cognitive Level: Understand REF: Box 1-
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3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
qw qw qw qw qw qw qw qw qw
3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery qw qw qw qw qw
yesterday
b. The person who is unaware of his high
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serum glucose levels
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c. The person who is being admitted to a
qw qw qw qw qw qw qw
long-term care facility qw qw
d. The person who is beginning rehabilitation
qw qw qw qw qw
after a knee replacement
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ANSWER: B qw
A screening assessment is performed for the purpose of disease detection. In this case t
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
his person may have diabetes mellitus. A shift assessment is most appropriate for the
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person who is recovering in the hospital from surgery. A comprehensive assessment is p
qw qw qw qw qw qw qw qw qw qw qw qw qw
erformed during admission to a facility to obtain a detailed history and complete phy
qw qw qw qw qw qw qw qw qw qw qw qw qw
sical examination. An episodic or follow-
qw qw qw qw qw
up assessment is performed after knee replacement to evaluate the outcome of the pr
qw qw qw qw qw qw qw qw qw qw qw qw qw
ocedure.
DIF: Cognitive Level: Understand REF: Box 1-
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3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establis
qw qw qw qw qw qw qw qw qw qw qw
hing Priorities q w
4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery qw qw qw qw qw
yesterday
b. The person who is unaware of his high qw qw qw qw qw qw qw
serum glucose levels qw qw
c. The person who is being admitted to a
qw qw qw qw qw qw qw
long-term care facility qw qw
d. The person who is beginning rehabilitation
qw qw qw qw qw
after a knee replacement
qw qw qw
ANSWER: A qw
A shift assessment is most appropriate for the person who is recovering in the hospital fr
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
om surgery. A screening assessment is performed for the purpose of disease detection,
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in this case diabetes mellitus. A comprehensive assessment is performed during admissi
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on to a qw qw
Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,TABLE OF CONTENTS qw qw
Unit I: Foundations for Health Assessment
qw qw qw qw qw
1. Introduction to Health Assessment qw qw qw
2. Interviewing Patients to Obtain a Health History
qw qw qw qw qw qw
3. Techniques and Equipment for Physical Assessment
qw qw qw qw qw
4. General Inspection and Measurement of Vital Signs
qw qw qw qw qw qw
5. Ethnic, Cultural, and Spiritual Considerations
qw qw qw qw
6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
qw qw qw qw qw
8. Nutritional Assessment qw
Unit II: Health Assessment of the Adult
qw qw qw qw qw qw
9. Skin, Hair, and Nails
qw qw qw
10. Head, Eyes, Ears, Nose, and Throat
qw qw qw qw qw
11. Lungs and Respiratory System
qw qw qw
12. Heart and Peripheral Vascular System
qw qw qw qw
13. Abdomen and Gastrointestinal System qw qw qw
14. Musculoskeletal System qw
15. Neurologic System qw
16. Breasts and Axillae qw qw
17. Reproductive System and the Perineum qw qw qw qw
Unit III: Health Assessment Across the Life Span
qw qw qw qw qw qw qw
18. Developmental Assessment Throughout the Life Span qw qw qw qw qw
19. Assessment of the Infant, Child, and Adolescent qw qw qw qw qw qw
20. Assessment of the Pregnant Patient qw qw qw qw
21. Assessment of the Older Adult qw qw qw qw
Unit IV: Synthesis and Application of Health Assessment
qw qw qw qw qw qw qw
22. Conducting a Head-to-Toe Examination qw qw qw
23. Documenting the Head-to-Toe Health Assessment qw q w qw qw
24. Adapting Health Assessment qw qw
Chapter 01: Introduction to Health Assessment
qw qw qw qw qw
,MULTIPLE CHOICE qw
1. A patient comes to the emergency department and tells the triage nurse t
qw qw qw qw qw qw qw qw qw qw qw qw
hat heis “having a heart attack.” What is the nurse’s top priority at this time?
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
a. Determine the patient’s personal data and i qw qw qw qw qw qw
nsurance coverage. qw
b. Ask the patient to take a seat in the waiti qw qw qw qw qw qw qw qw qw
ng room until his name is called. qw qw qw qw qw qw
c. Request that a nurse collect data for qw qw qw qw qw qw
acomprehensive history. qw
d. Ask a nurse to start a focused assessment qw qw qw qw qw qw qw
of this patient now. qw qw qw
ANSWER: D qw
The nurse needs to begin an assessment as soon as possible that is focused on this patie
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
nt’s cardiovascular system. The type of health assessment performed by the nurse is als
qw qw qw qw qw qw qw qw qw qw qw qw qw
o driven by patient need. Personal data and insurance information will be obtained, b
qw qw qw qw qw qw qw qw qw qw qw qw qw
ut in this situation, these data can wait until after the patient is assessed. Based also
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
on Maslow’s hierarchy of needs, physiologic needs take precedence. Rather than askin
qw qw qw qw qw qw qw qw qw qw qw
g the patient to wait, the nurse needs to begin data collection, such as vital signs, imme
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
diately to determine the patient’s health status. Complications can be prevented if an im
qw qw qw qw qw qw qw qw qw qw qw qw qw
mediate assessment is made to analyze the patient’s symptoms. A comprehensive hist
qw qw qw qw qw qw qw qw qw qw qw
ory is not indicated in this situation at this time. Some subjective data will be collected,
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
such as allergies and medical history related to cardiovascular disease. Eyes, ears, or
qw qw qw qw qw qw qw qw qw qw qw qw qw
a complete musculoskeletal or mental health assessment is not a priority at this time.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
DIF: Cognitive Level: Apply
q w REF: Box 1- qw qw qw qw
3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establis
qw qw qw qw qw qw qw qw qw qw qw
hing Prioritiesq w
2. Which situation illustrates a screening assessment?
qw qw qw qw qw
a. A patient visits an obstetric clinic for the fir qw qw qw qw qw qw qw qw
st
time and the nurse conducts a detailedhistor qw qw qw qw qw qw
y and physical examination. qw qw qw
b. A hospital sponsors a health fair at a qw qw qw qw qw qw qw
localmall and provides cholesterol and bl qw qw qw qw qw
ood pressure checks to mall patrons. qw qw qw qw qw
c. The nurse in an urgent care center checks
qw qw qw qw qw qw qw
the vital signs of a patient who is complai
qw qw qw qw qw qw qw qw
ning of leg pain. qw qw qw
, d. A patient newly diagnosed with
qw qw qw qw
diabetesmellitus comes to test his fasting bl qw qw qw qw qw qw
ood glucose level. qw qw
ANSWER: B qw
A health fair at a local mall that provides cholesterol and blood pressure checks is an
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
example of a screening assessment focused on disease detection. A detailed history a
qw qw qw qw qw qw qw qw qw qw qw qw
nd physical examination conducted during a first-
qw qw qw qw qw qw
time visit to an obstetric clinic is an exampleof a comprehensive assessment. Assessing
qw qw qw qw qw qw qw qw qw qw qw qw q
wa patient complaining of leg pain in the triage area of an urgent care center is an exa
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
mple of a problem-
qw qw qw
based/focused assessment. A patient’s return appointment 1 month after today’s offic
qw qw qw qw qw qw qw qw qw qw
e visit to report fasting blood glucose levels is an example of an episodic or follow-
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
up assessment.
qw
DIF: Cognitive Level: Understand REF: Box 1-
q w qw qw qw qw
3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
qw qw qw qw qw qw qw qw qw
3. For which person is a screening assessment indicated?
qw qw qw qw qw qw qw
a. The person who had abdominal surgery qw qw qw qw qw
yesterday
b. The person who is unaware of his high
qw qw qw qw qw qw qw q
serum glucose levels
w qw qw
c. The person who is being admitted to a
qw qw qw qw qw qw qw
long-term care facility qw qw
d. The person who is beginning rehabilitation
qw qw qw qw qw
after a knee replacement
qw qw qw
ANSWER: B qw
A screening assessment is performed for the purpose of disease detection. In this case t
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
his person may have diabetes mellitus. A shift assessment is most appropriate for the
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
person who is recovering in the hospital from surgery. A comprehensive assessment is p
qw qw qw qw qw qw qw qw qw qw qw qw qw
erformed during admission to a facility to obtain a detailed history and complete phy
qw qw qw qw qw qw qw qw qw qw qw qw qw
sical examination. An episodic or follow-
qw qw qw qw qw
up assessment is performed after knee replacement to evaluate the outcome of the pr
qw qw qw qw qw qw qw qw qw qw qw qw qw
ocedure.
DIF: Cognitive Level: Understand REF: Box 1-
q w qw qw qw qw
3 | p. 3 TOP: Nursing Process: Assessment
qw qw qw qw qw qw qw
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establis
qw qw qw qw qw qw qw qw qw qw qw
hing Priorities q w
4. For which person is a shift assessment indicated?
qw qw qw qw qw qw qw
a. The person who had abdominal surgery qw qw qw qw qw
yesterday
b. The person who is unaware of his high qw qw qw qw qw qw qw
serum glucose levels qw qw
c. The person who is being admitted to a
qw qw qw qw qw qw qw
long-term care facility qw qw
d. The person who is beginning rehabilitation
qw qw qw qw qw
after a knee replacement
qw qw qw
ANSWER: A qw
A shift assessment is most appropriate for the person who is recovering in the hospital fr
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
om surgery. A screening assessment is performed for the purpose of disease detection,
qw qw qw qw qw qw qw qw qw qw qw qw
in this case diabetes mellitus. A comprehensive assessment is performed during admissi
qw qw qw qw qw qw qw qw qw qw qw qw
on to a qw qw
