TEST BANK
n
Health Assessment for Nursing Practice
n n n n n
7th Edition by Wilson Chapter 1 - 24
n n n n n n n
,TABLE OF CONTENTS n n n
Unit I: Foundations for Health Assessment
n n n n n
1. Introduction to Health Assessment
n n n n
2. Interviewing Patients to Obtain a Health History
n n n n n n n
3. Techniques and Equipment for Physical Assessment
n n n n n n
4. General Inspection and Measurement of Vital Signs
n n n n n n n
5. Ethnic, Cultural, and Spiritual Considerations
n n n n n
6. Pain Assessment
n n
7. Mental Health and Abusive Behavior Assessment
n n n n n n
8. Nutritional Assessment
n n
Unit II: Health Assessment of the Adult
n n n n n n
9. Skin, Hair, and Nails
n n n n
10. Head, Eyes, Ears, Nose, and Throat
n n n n n n
11. Lungs and Respiratory System
n n n n
12. Heart and Peripheral Vascular System
n n n n n
13. Abdomen and Gastrointestinal System
n n n n
14. Musculoskeletal System
n n
15. Neurologic System
n n
16. Breasts and Axillae
n n n
17. Reproductive System and the Perineum
n n n n n
Unit III: Health Assessment Across the Life Span
n n n n n n n
18. Developmental Assessment Throughout the Life Span
n n n n n n
19. Assessment of the Infant, Child, and Adolescent
n n n n n n n
20. Assessment of the Pregnant Patient
n n n n n
21. Assessment of the Older Adult
n n n n n
Unit IV: Synthesis and Application of Health Assessment
n n n n n n n
22. Conducting a Head-to-Toe Examination
n n n n
23. Documenting the Head-to-Toe Health Assessment
n n n n n
24. Adapting Health Assessment
n n n
Chaptern01:nIntroductionntonHealthnAssessment
,MULTIPLEnCHOICE
1. Anpatientncomesnto nthe nemergency ndepartmentnandntellsnthe ntriage nnurse nthatn he nisn
“havingnanheartnattack.”nWhatnisnthe nnurse’sntopnpriority natnthisntime?
a. Determine nthe npatient’snpersonalndatanandninsu
rance ncoverage.
b. Ask nthe npatientnto ntake nanseatnin nthe nwaitingnro
omnuntiln hisnname nisncalled.
c. Requestnthatnannurse ncollectndatanfornanc
omprehensive nhistory.
d. Ask nannurse nto nstartnanfocusednassessmentno f
nthisnpatientnnow.
ANSWER:n D
The nnurse nneedsnto nbegin nan nassessmentnasnsoon nasnpossible nthatnisnfocusednon nthisnpatient’sncardi
ovascularnsystem.nThe ntype nofnhealth nassessmentnperformednby nthe nnurse nisnalso ndriven nby npatie
ntnneed.nPersonalndatanandninsurance ninformation nwillnbe nobtained,nbutnin nthisnsituation,nthese nd
atancan nwaitnuntilnafternthe npatientnisnassessed.nBasednalso nonnMaslow’snhierarchy nofnneeds,nphy
siologicnneedsntake nprecedence.nRathernthan naskingnthe npatientnto nwait,nthe nnurse nneedsnto nbegi
nndatancollection,nsuch nasnvitalnsigns,nimmediately nto ndetermine nthe npatient’snhealth nstatus.n Compl
icationsncannbe npreventednifnan nimmediate nassessmentnisnmade nto nanalyze nthe npatient’snsympto
ms.nAncomprehensive nhistory nisnnotnindicatedninnthisnsituation natnthisntime.nSome nsubjective ndatanw
illnbe ncollected,nsuch nasnallergiesnandnmedicalnhistory nrelatednto ncardiovascularndisease.nEyes,ne
ars,nornancomplete nmusculoskeletalnornmentalnhealth nassessmentnisnnotnanpriority natnthisntime.
DIF:nnn Cognitive nLevel:nApply REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffective nCarenEnvironment:nManagementnofnCare:nEstablishingnPri
orities
2. Which nsituation nillustratesnanscreeningnassessment?
a. Anpatientnvisitsnan nobstetricnclinicnfornthe nfirstnti
me nandnthe nnurse nconductsnandetailednhistory nan
dnphysicalnexamination.
b. Anhospitalnsponsorsnanhealth nfairnatnanlocalnm
allnandnprovidesncholesterolnandnbloodnpre
ssure nchecksnto nmallnpatrons.
c. The nnurse ninnannurgentncare ncenternchecksnth
e nvitalnsignsnofnanpatientnwho nisncomplainin
gnofnlegnpain.
, d. Anpatientnnewly ndiagnosednwith ndiabetesn
mellitusncomesnto ntestnhisnfastingnbloodnglu
cose nlevel.
ANSWER:nB
Anhealth nfairnatnanlocalnmallnthatnprovidesncholesterolnandnbloodnpressure nchecksnisnannexample n
ofnanscreeningnassessmentnfocusednon ndisease ndetection.nAndetailednhistory nandnphysicalnexami
nation nconductednduringnanfirst-
time nvisitnto nan nobstetricnclinicnisnannexample no fnancomprehensive nassessment.nAssessingnanpatientn
complainingnofnlegnpain ninnthe ntriage nareanofnannurgentncare ncenternisnan nexample nofnanproblem
-
based/focusednassessment.nAnpatient’snreturn nappointmentn1nmonth nafterntoday’snoffice nvisitnto n
reportnfastingnbloodnglucose nlevelsnisnannexample nofnan nepisodicnornfollow-upn assessment.
DIF:nnnCognitive nLevel:nUnderstand REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nHealth nPromotion nandnMaintenance:nHealth nScreening
3. Fornwhich nperson nisnanscreeningnassessmentnindicated?
a. The nperson nwho nhadnabdominalnsurgery ny
esterday
b. The nperson nwho nisnunaware nofnhisnhigh nse
rumnglucose nlevels
c. The nperson nwho nisnbeingnadmittednto nanl
ong-termncare nfacility
d. The nperson nwho nisnbeginningnrehabilitation naft
ernanknee nreplacement
ANSWER:nB
Anscreeningnassessmentnisnperformednfornthe npurpose nofndisease ndetection.nIn nthisncase nthisnpers
onnmay nhave ndiabetesnmellitus.nAnshiftnassessmentnisnmostnappropriate nfornthe nperson nwho nisnre
coveringninnthe nhospitalnfromnsurgery.nAncomprehensive nassessmentnisnperformednduringnadmiss
ionnto nanfacility nto nobtain nandetailednhistory nandncomplete nphysicalnexamination.nAn nepisodicn
ornfollow-
upnassessmentnisnperformednafternknee nreplacementnto ne valuate nthe noutcome nofnthe nprocedure
.
DIF:nnnCognitive nLevel:nUnderstand REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffective nCarenEnvironment:nManagementnofnCare:nEstablishingnPri
orities
4. Fornwhich nperson nisnanshiftnassessmentnindicated?
a. The nperson nwho nhadnabdominalnsurgery ny
esterday
b. The nperson nwho nisnunaware nofnhisnhigh nse
rumnglucose nlevels
c. The nperson nwho nisnbeingnadmittednto na
long-termncare nfacility
d. The nperson nwho nisnbeginningnrehabilitation naf
ternanknee nreplacement
ANSWER:n A
Anshiftnassessmentnisnmostnappropriate nfornthe nperson nwho nisnrecoveringninnthe nhospitalnfromnsurg
ery.nAnscreeningnassessmentnisnperformednfornthe npurpose nofndisease ndetection,nin nthisncase ndiab
etesnmellitus.nAncomprehensive nassessmentnisnperformednduringnadmission nto na
n
Health Assessment for Nursing Practice
n n n n n
7th Edition by Wilson Chapter 1 - 24
n n n n n n n
,TABLE OF CONTENTS n n n
Unit I: Foundations for Health Assessment
n n n n n
1. Introduction to Health Assessment
n n n n
2. Interviewing Patients to Obtain a Health History
n n n n n n n
3. Techniques and Equipment for Physical Assessment
n n n n n n
4. General Inspection and Measurement of Vital Signs
n n n n n n n
5. Ethnic, Cultural, and Spiritual Considerations
n n n n n
6. Pain Assessment
n n
7. Mental Health and Abusive Behavior Assessment
n n n n n n
8. Nutritional Assessment
n n
Unit II: Health Assessment of the Adult
n n n n n n
9. Skin, Hair, and Nails
n n n n
10. Head, Eyes, Ears, Nose, and Throat
n n n n n n
11. Lungs and Respiratory System
n n n n
12. Heart and Peripheral Vascular System
n n n n n
13. Abdomen and Gastrointestinal System
n n n n
14. Musculoskeletal System
n n
15. Neurologic System
n n
16. Breasts and Axillae
n n n
17. Reproductive System and the Perineum
n n n n n
Unit III: Health Assessment Across the Life Span
n n n n n n n
18. Developmental Assessment Throughout the Life Span
n n n n n n
19. Assessment of the Infant, Child, and Adolescent
n n n n n n n
20. Assessment of the Pregnant Patient
n n n n n
21. Assessment of the Older Adult
n n n n n
Unit IV: Synthesis and Application of Health Assessment
n n n n n n n
22. Conducting a Head-to-Toe Examination
n n n n
23. Documenting the Head-to-Toe Health Assessment
n n n n n
24. Adapting Health Assessment
n n n
Chaptern01:nIntroductionntonHealthnAssessment
,MULTIPLEnCHOICE
1. Anpatientncomesnto nthe nemergency ndepartmentnandntellsnthe ntriage nnurse nthatn he nisn
“havingnanheartnattack.”nWhatnisnthe nnurse’sntopnpriority natnthisntime?
a. Determine nthe npatient’snpersonalndatanandninsu
rance ncoverage.
b. Ask nthe npatientnto ntake nanseatnin nthe nwaitingnro
omnuntiln hisnname nisncalled.
c. Requestnthatnannurse ncollectndatanfornanc
omprehensive nhistory.
d. Ask nannurse nto nstartnanfocusednassessmentno f
nthisnpatientnnow.
ANSWER:n D
The nnurse nneedsnto nbegin nan nassessmentnasnsoon nasnpossible nthatnisnfocusednon nthisnpatient’sncardi
ovascularnsystem.nThe ntype nofnhealth nassessmentnperformednby nthe nnurse nisnalso ndriven nby npatie
ntnneed.nPersonalndatanandninsurance ninformation nwillnbe nobtained,nbutnin nthisnsituation,nthese nd
atancan nwaitnuntilnafternthe npatientnisnassessed.nBasednalso nonnMaslow’snhierarchy nofnneeds,nphy
siologicnneedsntake nprecedence.nRathernthan naskingnthe npatientnto nwait,nthe nnurse nneedsnto nbegi
nndatancollection,nsuch nasnvitalnsigns,nimmediately nto ndetermine nthe npatient’snhealth nstatus.n Compl
icationsncannbe npreventednifnan nimmediate nassessmentnisnmade nto nanalyze nthe npatient’snsympto
ms.nAncomprehensive nhistory nisnnotnindicatedninnthisnsituation natnthisntime.nSome nsubjective ndatanw
illnbe ncollected,nsuch nasnallergiesnandnmedicalnhistory nrelatednto ncardiovascularndisease.nEyes,ne
ars,nornancomplete nmusculoskeletalnornmentalnhealth nassessmentnisnnotnanpriority natnthisntime.
DIF:nnn Cognitive nLevel:nApply REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffective nCarenEnvironment:nManagementnofnCare:nEstablishingnPri
orities
2. Which nsituation nillustratesnanscreeningnassessment?
a. Anpatientnvisitsnan nobstetricnclinicnfornthe nfirstnti
me nandnthe nnurse nconductsnandetailednhistory nan
dnphysicalnexamination.
b. Anhospitalnsponsorsnanhealth nfairnatnanlocalnm
allnandnprovidesncholesterolnandnbloodnpre
ssure nchecksnto nmallnpatrons.
c. The nnurse ninnannurgentncare ncenternchecksnth
e nvitalnsignsnofnanpatientnwho nisncomplainin
gnofnlegnpain.
, d. Anpatientnnewly ndiagnosednwith ndiabetesn
mellitusncomesnto ntestnhisnfastingnbloodnglu
cose nlevel.
ANSWER:nB
Anhealth nfairnatnanlocalnmallnthatnprovidesncholesterolnandnbloodnpressure nchecksnisnannexample n
ofnanscreeningnassessmentnfocusednon ndisease ndetection.nAndetailednhistory nandnphysicalnexami
nation nconductednduringnanfirst-
time nvisitnto nan nobstetricnclinicnisnannexample no fnancomprehensive nassessment.nAssessingnanpatientn
complainingnofnlegnpain ninnthe ntriage nareanofnannurgentncare ncenternisnan nexample nofnanproblem
-
based/focusednassessment.nAnpatient’snreturn nappointmentn1nmonth nafterntoday’snoffice nvisitnto n
reportnfastingnbloodnglucose nlevelsnisnannexample nofnan nepisodicnornfollow-upn assessment.
DIF:nnnCognitive nLevel:nUnderstand REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nHealth nPromotion nandnMaintenance:nHealth nScreening
3. Fornwhich nperson nisnanscreeningnassessmentnindicated?
a. The nperson nwho nhadnabdominalnsurgery ny
esterday
b. The nperson nwho nisnunaware nofnhisnhigh nse
rumnglucose nlevels
c. The nperson nwho nisnbeingnadmittednto nanl
ong-termncare nfacility
d. The nperson nwho nisnbeginningnrehabilitation naft
ernanknee nreplacement
ANSWER:nB
Anscreeningnassessmentnisnperformednfornthe npurpose nofndisease ndetection.nIn nthisncase nthisnpers
onnmay nhave ndiabetesnmellitus.nAnshiftnassessmentnisnmostnappropriate nfornthe nperson nwho nisnre
coveringninnthe nhospitalnfromnsurgery.nAncomprehensive nassessmentnisnperformednduringnadmiss
ionnto nanfacility nto nobtain nandetailednhistory nandncomplete nphysicalnexamination.nAn nepisodicn
ornfollow-
upnassessmentnisnperformednafternknee nreplacementnto ne valuate nthe noutcome nofnthe nprocedure
.
DIF:nnnCognitive nLevel:nUnderstand REF:nBox n1-
3n|np.n3nTOP:nNursingnProcess:nAssessment
MSC:nNCLEXnPatientnNeeds:nSafenandnEffective nCarenEnvironment:nManagementnofnCare:nEstablishingnPri
orities
4. Fornwhich nperson nisnanshiftnassessmentnindicated?
a. The nperson nwho nhadnabdominalnsurgery ny
esterday
b. The nperson nwho nisnunaware nofnhisnhigh nse
rumnglucose nlevels
c. The nperson nwho nisnbeingnadmittednto na
long-termncare nfacility
d. The nperson nwho nisnbeginningnrehabilitation naf
ternanknee nreplacement
ANSWER:n A
Anshiftnassessmentnisnmostnappropriate nfornthe nperson nwho nisnrecoveringninnthe nhospitalnfromnsurg
ery.nAnscreeningnassessmentnisnperformednfornthe npurpose nofndisease ndetection,nin nthisncase ndiab
etesnmellitus.nAncomprehensive nassessmentnisnperformednduringnadmission nto na
