Test Bank for Health Assessment for
Nursing Practice 7th Edition by Wilson
Cha
pter
1-
24
,Chapter1501:15Introduction15to15Health15Assessment
MULTIPLE15CHOICE
1. A15patient15comes15to15the15emergency15department15and15tells15the15triage15 n
urse15that15 he15is15“having15a15heart15attack.”15What15is15the15nurse’s15top15priority15at15th
is15time?
a. Determine15the15patient’s15personal15data15a
nd15insurance15coverage.
b. Ask15the15patient15to15take15a15seat15in15the1
5waiting15room15until15 his15name15is15called.
c. Request15that15a15nurse15collect15data
15for15a15comprehensive15 history.
d. Ask15a15nurse15to15start15a15focused15ass
essment15of15this15patient15now.
ANSWER:15 D
The15nurse15needs15to15begin15an15assessment15as15soon15as15possible15that15is15focused15
on15this15patient’s15cardiovascular15system.15The15type15of15health15assessment15performed
15by15the15nurse15is15also15driven15by15patient15need.15Personal15data15and15insurance15info
rmation15will15be15obtained,15but15in15this15situation,15these15data15can15wait15until15after1
5the15patient15is15assessed.15Based15also15on15Maslow’s15hierarchy15of15needs,15physiolog
ic15needs15take15precedence.15Rather15than15asking15the15patient15to15wait,15the15nurse15ne
eds15to15begin15data15collection,15such15as15vital15signs,15immediately15to15determine15the15
patient’s15health15status.15Complications15can15be15prevented15if15an15immediate15assessm
ent15is15made15to15analyze15the15patient’s15symptoms.15A15comprehensive15history15is15no
t15indicated15in15this15situation15at15this15time.15Some15subjective15data15will15be15collecte
d,15such15as15allergies15and15medical15history15related15to15cardiovascular15disease.15Eyes,
15ears,15or15a15complete15musculoskeletal15or15mental15 health15assessment15is15not15a15pri
ority15at15this15time.
DIF:151515 Cognitive15Level:15Apply REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
2. Which15situation15illustrates15a15 screening15assessment?
a. A15patient15visits15an15obstetric15clinic15for
15the15first15time15and15the15nurse15conducts
15a15detailed15history15and15physical15examin
ation.
b. A15hospital15sponsors15a15health15fair15at1
5a15local15mall15and15provides15cholestero
l15and15blood15pressure15checks15to15mall
15patrons.
c. The15nurse15in15an15urgent15care15center1
5checks15the15vital15signs15of15a15patient15
who15is15complaining15of15leg15pain.
, d. A15patient15 newly15diagnosed15with15dia
betes15mellitus15comes15to15test15his15fast
ing15blood15glucose15level.
ANSWER:15B
A15health15fair15at15a15local15mall15that15provides15cholesterol15and15blood15pressure15che
cks15is15an15example15of15a15screening15assessment15focused15on15disease15detection.15A15
detailed15history15and15physical15examination15conducted15during15a15first-
time15visit15to15an15obstetric15clinic15is15an15example15of15a15comprehensive15assessment.15
Assessing15a15patient15complaining15of15leg15pain15in15the15triage15area15of15an15urgent15c
are15center15is15an15example15of15a15problem-
based/focused15assessment.15A15patient’s15return15appointment15115month15after15today’s1
5office15visit15to15report15fasting15blood15glucose15levels15is15an15example15of15an15episodi
c15or15follow-up15assessment.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Health15Promotion15and15Maintenance:15Health15Screening
3. For15which15person15is15a15screening15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitte
d15to15a15long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15B
A15screening15assessment15is15performed15for15the15purpose15of15disease15detection.15In1
5this15case15this15person15may15have15diabetes15mellitus.15A15shift15assessment15is15most1
5appropriate15for15the15person15who15is15recovering15in15the15hospital15from15surgery.15A
15comprehensive15assessment15is15performed15during15admission15to15a15facility15to15obtai
n15a15detailed15history15and15complete15physical15examination.15An15episodic15or15follo
w-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15of1
5the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
4. For15which15person15is15a15shift15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitted15to1
5a
long-term15care15facility
d. The15person15who15is15beginning15rehabilit
ation15after15a15knee15replacement
ANSWER:15 A
A15shift15assessment15is15most15appropriate15for15the15person15who15is15recovering15in15th
e15hospital15from15surgery.15A15screening15assessment15is15performed15for15the15purpose15o
f15disease15detection,15in15this15case15diabetes15mellitus.15 A15comprehensive15assessment15
is15performed15during15admission15to15a
, facility15to15obtain15a15detailed15history15and15complete15physical15examination.15An15e
pisodic15or15follow-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15o
f15the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15415TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
5. For15which15person15is15a15comprehensive15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitte
d15to15a15long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15C
A15comprehensive15assessment15is15performed15during15admission15to15a15facility15to15obtain15a
detailed15history15and15complete15physical15examination.15A15shift15assessment15is15most1
5appropriate15for15the15person15who15is15recovering15in15the15hospital15from15surgery.15A1
5screening15assessment15is15performed15for15the15purpose15of15disease15detection,15in15thi
s15case15diabetes15mellitus.15An15episodic15or15follow-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15of
15the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
6. For15which15person15is15an15episodic15or15follow-up15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitted15to15
a
long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15 D
An15episodic15or15follow-
up15assessment15is15performed15after15the15knee15replacement15to15evaluate15the15outcom
e15of15the15procedure.15A15shift15assessment15is15most15appropriate15for15the15person15wh
o15is15recovering15in15the15hospital15from15surgery.15A15screening15assessment15is15perfor
med15for15the15purpose15of15disease15detection,15in15this15case15diabetes15mellitus.15A15com
prehensive15assessment15is15performed15during15admission15to15a15facility15to15obtain15a1
5detailed15history15and15complete15physical15examination.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
Nursing Practice 7th Edition by Wilson
Cha
pter
1-
24
,Chapter1501:15Introduction15to15Health15Assessment
MULTIPLE15CHOICE
1. A15patient15comes15to15the15emergency15department15and15tells15the15triage15 n
urse15that15 he15is15“having15a15heart15attack.”15What15is15the15nurse’s15top15priority15at15th
is15time?
a. Determine15the15patient’s15personal15data15a
nd15insurance15coverage.
b. Ask15the15patient15to15take15a15seat15in15the1
5waiting15room15until15 his15name15is15called.
c. Request15that15a15nurse15collect15data
15for15a15comprehensive15 history.
d. Ask15a15nurse15to15start15a15focused15ass
essment15of15this15patient15now.
ANSWER:15 D
The15nurse15needs15to15begin15an15assessment15as15soon15as15possible15that15is15focused15
on15this15patient’s15cardiovascular15system.15The15type15of15health15assessment15performed
15by15the15nurse15is15also15driven15by15patient15need.15Personal15data15and15insurance15info
rmation15will15be15obtained,15but15in15this15situation,15these15data15can15wait15until15after1
5the15patient15is15assessed.15Based15also15on15Maslow’s15hierarchy15of15needs,15physiolog
ic15needs15take15precedence.15Rather15than15asking15the15patient15to15wait,15the15nurse15ne
eds15to15begin15data15collection,15such15as15vital15signs,15immediately15to15determine15the15
patient’s15health15status.15Complications15can15be15prevented15if15an15immediate15assessm
ent15is15made15to15analyze15the15patient’s15symptoms.15A15comprehensive15history15is15no
t15indicated15in15this15situation15at15this15time.15Some15subjective15data15will15be15collecte
d,15such15as15allergies15and15medical15history15related15to15cardiovascular15disease.15Eyes,
15ears,15or15a15complete15musculoskeletal15or15mental15 health15assessment15is15not15a15pri
ority15at15this15time.
DIF:151515 Cognitive15Level:15Apply REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
2. Which15situation15illustrates15a15 screening15assessment?
a. A15patient15visits15an15obstetric15clinic15for
15the15first15time15and15the15nurse15conducts
15a15detailed15history15and15physical15examin
ation.
b. A15hospital15sponsors15a15health15fair15at1
5a15local15mall15and15provides15cholestero
l15and15blood15pressure15checks15to15mall
15patrons.
c. The15nurse15in15an15urgent15care15center1
5checks15the15vital15signs15of15a15patient15
who15is15complaining15of15leg15pain.
, d. A15patient15 newly15diagnosed15with15dia
betes15mellitus15comes15to15test15his15fast
ing15blood15glucose15level.
ANSWER:15B
A15health15fair15at15a15local15mall15that15provides15cholesterol15and15blood15pressure15che
cks15is15an15example15of15a15screening15assessment15focused15on15disease15detection.15A15
detailed15history15and15physical15examination15conducted15during15a15first-
time15visit15to15an15obstetric15clinic15is15an15example15of15a15comprehensive15assessment.15
Assessing15a15patient15complaining15of15leg15pain15in15the15triage15area15of15an15urgent15c
are15center15is15an15example15of15a15problem-
based/focused15assessment.15A15patient’s15return15appointment15115month15after15today’s1
5office15visit15to15report15fasting15blood15glucose15levels15is15an15example15of15an15episodi
c15or15follow-up15assessment.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Health15Promotion15and15Maintenance:15Health15Screening
3. For15which15person15is15a15screening15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitte
d15to15a15long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15B
A15screening15assessment15is15performed15for15the15purpose15of15disease15detection.15In1
5this15case15this15person15may15have15diabetes15mellitus.15A15shift15assessment15is15most1
5appropriate15for15the15person15who15is15recovering15in15the15hospital15from15surgery.15A
15comprehensive15assessment15is15performed15during15admission15to15a15facility15to15obtai
n15a15detailed15history15and15complete15physical15examination.15An15episodic15or15follo
w-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15of1
5the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
4. For15which15person15is15a15shift15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitted15to1
5a
long-term15care15facility
d. The15person15who15is15beginning15rehabilit
ation15after15a15knee15replacement
ANSWER:15 A
A15shift15assessment15is15most15appropriate15for15the15person15who15is15recovering15in15th
e15hospital15from15surgery.15A15screening15assessment15is15performed15for15the15purpose15o
f15disease15detection,15in15this15case15diabetes15mellitus.15 A15comprehensive15assessment15
is15performed15during15admission15to15a
, facility15to15obtain15a15detailed15history15and15complete15physical15examination.15An15e
pisodic15or15follow-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15o
f15the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15415TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
5. For15which15person15is15a15comprehensive15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitte
d15to15a15long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15C
A15comprehensive15assessment15is15performed15during15admission15to15a15facility15to15obtain15a
detailed15history15and15complete15physical15examination.15A15shift15assessment15is15most1
5appropriate15for15the15person15who15is15recovering15in15the15hospital15from15surgery.15A1
5screening15assessment15is15performed15for15the15purpose15of15disease15detection,15in15thi
s15case15diabetes15mellitus.15An15episodic15or15follow-
up15assessment15is15performed15after15knee15replacement15to15evaluate15the15outcome15of
15the15procedure.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
MSC:15NCLEX15Patient15Needs:15Safe15and15Effective15Care15Environment:15Management15of15C
are:15Establishing15Priorities
6. For15which15person15is15an15episodic15or15follow-up15assessment15indicated?
a. The15person15who15had15abdominal15su
rgery15yesterday
b. The15person15who15is15unaware15of15h
is15high15serum15glucose15levels
c. The15person15who15is15being15admitted15to15
a
long-term15care15facility
d. The15person15who15is15beginning15rehabilita
tion15after15a15knee15replacement
ANSWER:15 D
An15episodic15or15follow-
up15assessment15is15performed15after15the15knee15replacement15to15evaluate15the15outcom
e15of15the15procedure.15A15shift15assessment15is15most15appropriate15for15the15person15wh
o15is15recovering15in15the15hospital15from15surgery.15A15screening15assessment15is15perfor
med15for15the15purpose15of15disease15detection,15in15this15case15diabetes15mellitus.15A15com
prehensive15assessment15is15performed15during15admission15to15a15facility15to15obtain15a1
5detailed15history15and15complete15physical15examination.
DIF:151515 Cognitive15Level:15Understand REF:15Box151-
315|15p.15315TOP:15Nursing15Process:15Assessment
