Test Bank for Health Assessment for
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Nursing Practice 7th Edition by Wilson
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Chapter 1 - 24
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,Chapter 01: Introduction to Health Assessment
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MULTIPLE CHOICE mk
1. A patient comes to the emergency department and tells the triage nurse
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mk that heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
mk m
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a. Determine the patient‘s personal data and mk mk mk mk mk
insurance coverage. m
k mk
b. Ask the patient to take a seat in the
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waitingroom until his name is called.
mk m
k mk mk mk mk mk
c. Request that a nurse collect data
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for acomprehensive history.
mk mk m
k mk
d. Ask a nurse to start a focused
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assessmentof this patient now.
mk m
k mk mk mk
ANSWER: D mk
The nurse needs to begin an assessment as soon as possible that is focused on
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
this patient‘scardiovascular system. The type of health assessment performed by
mk mk m
k mk mk mk mk mk mk mk mk
the nurse is also drivenby patient need. Personal data and insurance information
mk mk mk mk mk m
k mk mk mk mk mk mk mk
will be obtained, but in this situation, these data can wait until after the patient
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
is assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take
mk mk mk mk mk mk mk mk mk mk mk mk
precedence. Rather than asking the patient to wait, the nurse needs to begin data
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
collection, such as vital signs, immediately to determinethe patient‘s health status.
mk mk mk mk mk mk mk mk m
k mk mk mk
Complications can be prevented if an immediate assessment is made to analyze
mk mk mk mk mk mk mk mk mk mk mk mk
the patient‘s symptoms. A comprehensive history is not indicated in this situation
mk mk mk mk mk mk mk mk mk mk mk mk
at this time. Some subjective data will be collected, such as allergies and medical
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
mk mk mk mk mk mk mk mk mk mk mk
or mental health assessment is not a priority at this time.
mk mk mk mk mk mk mk mk mk mk mk
DIF: Cognitive Level: Apply
mknj m k REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for mk mk mk mk mk mk
the first time and the nurse conducts a mk mk mk mk mk mk mk mk
detailedhistory and physical examination. mk m
k mk mk mk
b. A hospital sponsors a health fair at a mk mk mk mk mk mk mk
localmall and provides cholesterol mk m
k mk mk mk
and blood pressure checks to mall mk mk mk mk mk mk
patrons. mk
c. The nurse in an urgent care center mk mk mk mk mk mk
checksthe vital signs of a patient mk m
k mk mk mk mk mk
who is complaining of leg pain. mk mk mk mk mk mk
, d. A patient newly diagnosed with
mk mk mk mk
diabetesmellitus comes to test his
mk m
k mk mk mk mk
fasting blood glucose level.
mk mk mk mk
ANSWER: B mk
A health fair at a local mall that provides cholesterol and blood pressure checks
mk mk mk mk mk mk mk mk mk mk mk mk mk
is an example of a screening assessment focused on disease detection. A detailed
mk mk mk mk mk mk mk mk mk mk mk mk mk
history and physical examination conducted during a first-time visit to an obstetric
mk mk mk mk mk mk mk mk mk mk mk mk
clinic is an example of a comprehensive assessment. Assessing a patient
mk mk mk mk m
k mk mk mk mk mk mk
complaining of leg pain in the triage area of an urgent care center is an example
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
of a problem-based/focused assessment. A patient‘s return appointment 1 month
mk mk mk mk mk mk mk mk mk mk
after today‘s office visit to report fasting blood glucose levels is an example of an
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
episodic or follow-up assessment.
mk mk mk mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
mk mk mk mk mk mk mk mk mk
3. For which person is a screening assessment indicated?
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a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted mk mk mk mk mk
to a long-term care facility mk mk m
k mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: B mk
A screening assessment is performed for the purpose of disease detection. In this
mk mk mk mk mk mk mk mk mk mk mk mk
case thisperson may have diabetes mellitus. A shift assessment is most
mk mk m
k mk mk mk mk mk mk mk mk mk
appropriate for the person who is recovering in the hospital from surgery. A
mk mk mk mk mk mk mk mk mk mk mk mk mk
comprehensive assessment is performedduring admission to a facility to obtain a
mk mk mk mk m
k mk mk mk mk mk mk mk
detailed history and complete physical examination. An episodic or follow-up
mk mk mk mk mk mk mk mk mk mk
assessment is performed after knee replacement toevaluate the outcome of the
mk mk mk mk mk mk mk m
k mk mk mk mk
procedure.
mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
4. For which person is a shift assessment indicated?
mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted to a mk mk mk mk mk mk mk
long-term care facility mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: A mk
A shift assessment is most appropriate for the person who is recovering in the
mk mk mk mk mk mk mk mk mk mk mk mk mk
hospital from surgery. A screening assessment is performed for the purpose of
mk mk m
k mk mk mk mk mk mk mk mk mk
disease detection, in this case diabetes mellitus. A comprehensive assessment is
mk mk mk mk mk mk mk mk mk mk mk
performed during admission to a
mk mk mk mk mk
, facility to obtain a detailed history and complete physical examination. An
mk mk mk mk mk mk mk mk mk mk
episodic or follow-up assessment is performed after knee replacement to evaluate
mk mk mk mk mk mk mk mk mk mk mk
the outcome of the procedure.
mk mk mk mk m
k
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 4 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
5. For which person is a comprehensive assessment indicated?
mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted mk mk mk mk mk
to a long-term care facility mk mk m
k mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: C mk
A comprehensive assessment is performed during admission to a facility to obtain a
mk mk mk mk mk mk mk mk mk mk mk mk
detailed history and complete physical examination. A shift assessment is most
mk mk mk mk mk mk mk mk mk mk
appropriatefor the person who is recovering in the hospital from surgery. A
mk m
k mk mk mk mk mk mk mk mk mk mk mk
screening assessment is performed for the purpose of disease detection, in this
mk mk mk mk mk mk mk mk mk mk mk mk
case diabetes mellitus. An episodic or follow-up assessment is performed after
mk mk mk mk mk mk mk mk mk mk mk
knee replacement to evaluate the outcome of the procedure.
mk mk mk mk mk mk mk mk mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
6. For which person is an episodic or follow-up assessment indicated?
mk mk mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted to a mk mk mk mk mk mk mk
long-term care facility mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: D mk
An episodic or follow-up assessment is performed after the knee replacement to
mk mk mk mk mk mk mk mk mk mk mk
evaluate the outcome of the procedure. A shift assessment is most appropriate
mk mk mk mk mk mk mk mk mk mk mk mk
for the person who isrecovering in the hospital from surgery. A screening
mk mk mk mk mk m
k mk mk mk mk mk mk mk
assessment is performed for the purpose of disease detection, in this case diabetes
mk mk mk mk mk mk mk mk mk mk mk mk mk
mellitus. A comprehensive assessment is performed during admission to a facility
mk mk mk mk mk mk mk mk mk mk mk
to obtain a detailed history and complete physicalexamination.
mk mk mk mk mk mk mk mk m
k
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
mk mk mk mk mk
Nursing Practice 7th Edition by Wilson
mk mk mk mk mk mk
Chapter 1 - 24
mk mk mk mk
,Chapter 01: Introduction to Health Assessment
mk mk mk mk mk
MULTIPLE CHOICE mk
1. A patient comes to the emergency department and tells the triage nurse
mk mk mk mk mk mk mk mk mk mk mk
mk that heis ―having a heart attack.‖ What is the nurse‘s top priority at this time?
mk m
k mk mk mk mk mk mk mk mk mk mk mk mk mk
a. Determine the patient‘s personal data and mk mk mk mk mk
insurance coverage. m
k mk
b. Ask the patient to take a seat in the
mk mk mk mk mk mk mk mk
waitingroom until his name is called.
mk m
k mk mk mk mk mk
c. Request that a nurse collect data
mk mk mk mk mk
for acomprehensive history.
mk mk m
k mk
d. Ask a nurse to start a focused
mk mk mk mk mk mk
assessmentof this patient now.
mk m
k mk mk mk
ANSWER: D mk
The nurse needs to begin an assessment as soon as possible that is focused on
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
this patient‘scardiovascular system. The type of health assessment performed by
mk mk m
k mk mk mk mk mk mk mk mk
the nurse is also drivenby patient need. Personal data and insurance information
mk mk mk mk mk m
k mk mk mk mk mk mk mk
will be obtained, but in this situation, these data can wait until after the patient
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
is assessed. Based also on Maslow‘s hierarchy of needs, physiologic needs take
mk mk mk mk mk mk mk mk mk mk mk mk
precedence. Rather than asking the patient to wait, the nurse needs to begin data
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
collection, such as vital signs, immediately to determinethe patient‘s health status.
mk mk mk mk mk mk mk mk m
k mk mk mk
Complications can be prevented if an immediate assessment is made to analyze
mk mk mk mk mk mk mk mk mk mk mk mk
the patient‘s symptoms. A comprehensive history is not indicated in this situation
mk mk mk mk mk mk mk mk mk mk mk mk
at this time. Some subjective data will be collected, such as allergies and medical
mk mk mk mk mk mk mk mk mk mk mk mk mk mk
history related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal
mk mk mk mk mk mk mk mk mk mk mk
or mental health assessment is not a priority at this time.
mk mk mk mk mk mk mk mk mk mk mk
DIF: Cognitive Level: Apply
mknj m k REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
2. Which situation illustrates a screening assessment?
mk mk mk mk mk
a. A patient visits an obstetric clinic for mk mk mk mk mk mk
the first time and the nurse conducts a mk mk mk mk mk mk mk mk
detailedhistory and physical examination. mk m
k mk mk mk
b. A hospital sponsors a health fair at a mk mk mk mk mk mk mk
localmall and provides cholesterol mk m
k mk mk mk
and blood pressure checks to mall mk mk mk mk mk mk
patrons. mk
c. The nurse in an urgent care center mk mk mk mk mk mk
checksthe vital signs of a patient mk m
k mk mk mk mk mk
who is complaining of leg pain. mk mk mk mk mk mk
, d. A patient newly diagnosed with
mk mk mk mk
diabetesmellitus comes to test his
mk m
k mk mk mk mk
fasting blood glucose level.
mk mk mk mk
ANSWER: B mk
A health fair at a local mall that provides cholesterol and blood pressure checks
mk mk mk mk mk mk mk mk mk mk mk mk mk
is an example of a screening assessment focused on disease detection. A detailed
mk mk mk mk mk mk mk mk mk mk mk mk mk
history and physical examination conducted during a first-time visit to an obstetric
mk mk mk mk mk mk mk mk mk mk mk mk
clinic is an example of a comprehensive assessment. Assessing a patient
mk mk mk mk m
k mk mk mk mk mk mk
complaining of leg pain in the triage area of an urgent care center is an example
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
of a problem-based/focused assessment. A patient‘s return appointment 1 month
mk mk mk mk mk mk mk mk mk mk
after today‘s office visit to report fasting blood glucose levels is an example of an
mk mk mk mk mk mk mk mk mk mk mk mk mk mk mk
episodic or follow-up assessment.
mk mk mk mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
mk mk mk mk mk mk mk mk mk
3. For which person is a screening assessment indicated?
mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted mk mk mk mk mk
to a long-term care facility mk mk m
k mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: B mk
A screening assessment is performed for the purpose of disease detection. In this
mk mk mk mk mk mk mk mk mk mk mk mk
case thisperson may have diabetes mellitus. A shift assessment is most
mk mk m
k mk mk mk mk mk mk mk mk mk
appropriate for the person who is recovering in the hospital from surgery. A
mk mk mk mk mk mk mk mk mk mk mk mk mk
comprehensive assessment is performedduring admission to a facility to obtain a
mk mk mk mk m
k mk mk mk mk mk mk mk
detailed history and complete physical examination. An episodic or follow-up
mk mk mk mk mk mk mk mk mk mk
assessment is performed after knee replacement toevaluate the outcome of the
mk mk mk mk mk mk mk m
k mk mk mk mk
procedure.
mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
4. For which person is a shift assessment indicated?
mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted to a mk mk mk mk mk mk mk
long-term care facility mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: A mk
A shift assessment is most appropriate for the person who is recovering in the
mk mk mk mk mk mk mk mk mk mk mk mk mk
hospital from surgery. A screening assessment is performed for the purpose of
mk mk m
k mk mk mk mk mk mk mk mk mk
disease detection, in this case diabetes mellitus. A comprehensive assessment is
mk mk mk mk mk mk mk mk mk mk mk
performed during admission to a
mk mk mk mk mk
, facility to obtain a detailed history and complete physical examination. An
mk mk mk mk mk mk mk mk mk mk
episodic or follow-up assessment is performed after knee replacement to evaluate
mk mk mk mk mk mk mk mk mk mk mk
the outcome of the procedure.
mk mk mk mk m
k
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 4 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
5. For which person is a comprehensive assessment indicated?
mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted mk mk mk mk mk
to a long-term care facility mk mk m
k mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: C mk
A comprehensive assessment is performed during admission to a facility to obtain a
mk mk mk mk mk mk mk mk mk mk mk mk
detailed history and complete physical examination. A shift assessment is most
mk mk mk mk mk mk mk mk mk mk
appropriatefor the person who is recovering in the hospital from surgery. A
mk m
k mk mk mk mk mk mk mk mk mk mk mk
screening assessment is performed for the purpose of disease detection, in this
mk mk mk mk mk mk mk mk mk mk mk mk
case diabetes mellitus. An episodic or follow-up assessment is performed after
mk mk mk mk mk mk mk mk mk mk mk
knee replacement to evaluate the outcome of the procedure.
mk mk mk mk mk mk mk mk mk
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:
mk mk mk mk mk mk mk mk mk mk mk
Establishing Priorities
m
k mk
6. For which person is an episodic or follow-up assessment indicated?
mk mk mk mk mk mk mk mk mk
a. The person who had abdominal mk mk mk mk
surgery yesterday mk m
k
b. The person who is unaware of his mk mk mk mk mk mk
high serum glucose levels mk m
k mk mk
c. The person who is being admitted to a mk mk mk mk mk mk mk
long-term care facility mk mk
d. The person who is beginning mk mk mk mk
rehabilitationafter a knee replacement mk m
k mk mk mk
ANSWER: D mk
An episodic or follow-up assessment is performed after the knee replacement to
mk mk mk mk mk mk mk mk mk mk mk
evaluate the outcome of the procedure. A shift assessment is most appropriate
mk mk mk mk mk mk mk mk mk mk mk mk
for the person who isrecovering in the hospital from surgery. A screening
mk mk mk mk mk m
k mk mk mk mk mk mk mk
assessment is performed for the purpose of disease detection, in this case diabetes
mk mk mk mk mk mk mk mk mk mk mk mk mk
mellitus. A comprehensive assessment is performed during admission to a facility
mk mk mk mk mk mk mk mk mk mk mk
to obtain a detailed history and complete physicalexamination.
mk mk mk mk mk mk mk mk m
k
DIF: Cognitive Level: Understand
mknj mk REF: Box 1-3 | mk mk mk mk mk
p. 3 TOP: Nursing Process: Assessment
mk mk m
k mk mk mk
