Test Bank for Health Assessment for N
m m m m m m
ursing Practice 7th Edition by Wilson Ch
m m m m m m
apter 1 - 24m m m
,Chapterm01:mIntroductionmtomHealthmAssessment
MULTIPLEmCHOICE
1. Ampatientmcomesmtomthememergencymdepartmentmandmtellsmthemtriagemnursemth
atmhemism“havingmamheartmattack.”mWhatmismthemnurse’smtopmprioritymatmthismtime?
a. Determinemthempatient’smpersonalmdatamandmi
nsurancemcoverage.
b. Askmthempatientmtomtakemamseatminmthemwaiti
ngmroommuntilmhismnamemismcalled.
c. Requestmthatmamnursemcollectmdatamfo
rmamcomprehensivemhistory.
d. Askmamnursemtomstartmamfocusedmassessm
entmofmthismpatientmnow.
ANSWER:mD
Themnursemneedsmtombeginmanmassessmentmasmsoonmasmpossiblemthatmismfocusedmonmthismpa
tient’smcardiovascularmsystem.mThemtypemofmhealthmassessmentmperformedmbymthemnursemis
malsomdrivenmbympatientmneed.mPersonalmdata mandminsuranceminformationmwill mbemobtained,
mbutminmthismsituation,mthese mdatamcanmwaitmuntil maftermthempatientmismassessed. mBasedmalso
monmMaslow’smhierarchymofmneeds,mphysiologic mneedsmtake mprecedence.mRathermthanmaski
ngmthempatientmtomwait,mthemnursemneedsmtombeginmdatamcollection,msuchmasmvitalmsigns,mim
mediatelymtomdeterminemthempatient’smhealthmstatus.mComplicationsmcanmbempreventedmifma
nmimmediatemassessmentmismmademtomanalyzemthempatient’smsymptoms.mAmcomprehensivem
historymismnotmindicatedminmthismsituationmatmthismtime.mSomemsubjectivemdatamwillmbemcoll
ected,msuchmasmallergiesmandmmedicalmhistorymrelatedmtomcardiovascularmdisease.mEyes,mear
s,mormamcompletemmusculoskeletalmormmentalmhealthmassessmentmismnotmamprioritymatmthismti
me.
DIF:mmm CognitivemLevel:mApply REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
2. Whichmsituationmillustratesmamscreeningmassessment?
a. Ampatientmvisitsmanmobstetricmclinicmformthe
mfirstmtimemandmthemnurse mconductsmamdetail
edmhistorymandmphysicalmexamination.
b. Amhospitalmsponsorsmamhealthmfairmatmamlo
calmmallmandmprovidesmcholesterolmandmbl
oodmpressuremchecksmtommallmpatrons.
c. Themnurseminmanmurgentmcaremcentermche
cksmthemvitalmsignsmofmampatientmwhomism
complainingmofmlegmpain.
, d. Ampatientmnewlymdiagnosedmwithmdiabet
esmmellitusmcomesmtomtestmhismfastingmbl
oodmglucosemlevel.
ANSWER:mB
Amhealthmfairmatmamlocalmmallmthatmprovidesmcholesterolmandmbloodmpressuremchecksmisman
mexamplemofmamscreeningmassessmentmfocusedmonmdiseasemdetection.mAmdetailedmhistoryma
ndmphysicalmexaminationmconductedmduringmamfirst-
timemvisitmtomanmobstetricmclinicmismanmexamplemofmamcomprehensivemassessment.mAssessin
gmampatientmcomplainingmofmlegmpainminmthemtriagemareamofmanmurgentmcaremcentermismanme
xamplemofmamproblem-
based/focusedmassessment.mAmpatient’smreturnmappointmentm1mmonthmaftermtoday’smofficem
visitmtomreportmfastingmbloodmglucosemlevelsmismanmexamplemofmanmepisodicmormfollow-
upmassessment.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mHealthmPromotionmandmMaintenance:mHealthmScreening
3. Formwhichmpersonmismamscreeningmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmt
omamlong-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mB
Amscreeningmassessmentmismperformedmformthempurposemofmdiseasemdetection.mInmthismcas
emthismpersonmmaymhavemdiabetesmmellitus.mAmshiftmassessmentmismmostmappropriatemformt
hempersonmwhomismrecoveringminmthemhospitalmfrommsurgery.mAmcomprehensivemassessme
ntmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistorymandmcomple
temphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempro
cedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
4. Formwhichmpersonmismamshiftmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmtoma
long-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitati
onmaftermamkneemreplacement
ANSWER:mA
Amshiftmassessmentmismmostmappropriatemformthempersonmwhomismrecoveringminmthemhospital
mfrommsurgery.mAmscreeningmassessment mismperformedmformthempurposemofmdiseasemdetectio
n,minmthismcasemdiabetesmmellitus.mAmcomprehensivemassessmentmismperformedmduringmadm
issionmtoma
, facilitymtomobtainmamdetailedmhistorymandmcompletemphysicalmexamination.mAnmepisodicm
ormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempr
ocedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m4mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
5. Formwhichmpersonmismamcomprehensivemassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmt
omamlong-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mC
Amcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainma
detailedmhistorymandmcompletemphysicalmexamination.mAmshiftmassessmentmismmostmapprop
riatemformthempersonmwhomismrecoveringminmthemhospitalmfrommsurgery.mAmscreeningmasses
smentmismperformedmformthempurposemofmdiseasemdetection,minmthismcasemdiabetesmmellitus
.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempr
ocedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
6. Formwhichmpersonmismanmepisodicmormfollow-upmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmtoma
long-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mD
Anmepisodicmormfollow-
upmassessmentmismperformedmaftermthemkneemreplacementmtomevaluatemthemoutcomemofmthe
mprocedure.mAmshift massessmentmismmostmappropriatemformthempersonmwhomismrecoveringmin
mthemhospitalmfrom msurgery.mAmscreeningmassessmentmismperformedmformthempurposemofmdi
seasemdetection,minmthismcasemdiabetesmmellitus.mAmcomprehensivemassessmentmismperform
edmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistorymandmcompletemphysicalmex
amination.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
m m m m m m
ursing Practice 7th Edition by Wilson Ch
m m m m m m
apter 1 - 24m m m
,Chapterm01:mIntroductionmtomHealthmAssessment
MULTIPLEmCHOICE
1. Ampatientmcomesmtomthememergencymdepartmentmandmtellsmthemtriagemnursemth
atmhemism“havingmamheartmattack.”mWhatmismthemnurse’smtopmprioritymatmthismtime?
a. Determinemthempatient’smpersonalmdatamandmi
nsurancemcoverage.
b. Askmthempatientmtomtakemamseatminmthemwaiti
ngmroommuntilmhismnamemismcalled.
c. Requestmthatmamnursemcollectmdatamfo
rmamcomprehensivemhistory.
d. Askmamnursemtomstartmamfocusedmassessm
entmofmthismpatientmnow.
ANSWER:mD
Themnursemneedsmtombeginmanmassessmentmasmsoonmasmpossiblemthatmismfocusedmonmthismpa
tient’smcardiovascularmsystem.mThemtypemofmhealthmassessmentmperformedmbymthemnursemis
malsomdrivenmbympatientmneed.mPersonalmdata mandminsuranceminformationmwill mbemobtained,
mbutminmthismsituation,mthese mdatamcanmwaitmuntil maftermthempatientmismassessed. mBasedmalso
monmMaslow’smhierarchymofmneeds,mphysiologic mneedsmtake mprecedence.mRathermthanmaski
ngmthempatientmtomwait,mthemnursemneedsmtombeginmdatamcollection,msuchmasmvitalmsigns,mim
mediatelymtomdeterminemthempatient’smhealthmstatus.mComplicationsmcanmbempreventedmifma
nmimmediatemassessmentmismmademtomanalyzemthempatient’smsymptoms.mAmcomprehensivem
historymismnotmindicatedminmthismsituationmatmthismtime.mSomemsubjectivemdatamwillmbemcoll
ected,msuchmasmallergiesmandmmedicalmhistorymrelatedmtomcardiovascularmdisease.mEyes,mear
s,mormamcompletemmusculoskeletalmormmentalmhealthmassessmentmismnotmamprioritymatmthismti
me.
DIF:mmm CognitivemLevel:mApply REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
2. Whichmsituationmillustratesmamscreeningmassessment?
a. Ampatientmvisitsmanmobstetricmclinicmformthe
mfirstmtimemandmthemnurse mconductsmamdetail
edmhistorymandmphysicalmexamination.
b. Amhospitalmsponsorsmamhealthmfairmatmamlo
calmmallmandmprovidesmcholesterolmandmbl
oodmpressuremchecksmtommallmpatrons.
c. Themnurseminmanmurgentmcaremcentermche
cksmthemvitalmsignsmofmampatientmwhomism
complainingmofmlegmpain.
, d. Ampatientmnewlymdiagnosedmwithmdiabet
esmmellitusmcomesmtomtestmhismfastingmbl
oodmglucosemlevel.
ANSWER:mB
Amhealthmfairmatmamlocalmmallmthatmprovidesmcholesterolmandmbloodmpressuremchecksmisman
mexamplemofmamscreeningmassessmentmfocusedmonmdiseasemdetection.mAmdetailedmhistoryma
ndmphysicalmexaminationmconductedmduringmamfirst-
timemvisitmtomanmobstetricmclinicmismanmexamplemofmamcomprehensivemassessment.mAssessin
gmampatientmcomplainingmofmlegmpainminmthemtriagemareamofmanmurgentmcaremcentermismanme
xamplemofmamproblem-
based/focusedmassessment.mAmpatient’smreturnmappointmentm1mmonthmaftermtoday’smofficem
visitmtomreportmfastingmbloodmglucosemlevelsmismanmexamplemofmanmepisodicmormfollow-
upmassessment.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mHealthmPromotionmandmMaintenance:mHealthmScreening
3. Formwhichmpersonmismamscreeningmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmt
omamlong-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mB
Amscreeningmassessmentmismperformedmformthempurposemofmdiseasemdetection.mInmthismcas
emthismpersonmmaymhavemdiabetesmmellitus.mAmshiftmassessmentmismmostmappropriatemformt
hempersonmwhomismrecoveringminmthemhospitalmfrommsurgery.mAmcomprehensivemassessme
ntmismperformedmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistorymandmcomple
temphysicalmexamination.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempro
cedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
4. Formwhichmpersonmismamshiftmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmtoma
long-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitati
onmaftermamkneemreplacement
ANSWER:mA
Amshiftmassessmentmismmostmappropriatemformthempersonmwhomismrecoveringminmthemhospital
mfrommsurgery.mAmscreeningmassessment mismperformedmformthempurposemofmdiseasemdetectio
n,minmthismcasemdiabetesmmellitus.mAmcomprehensivemassessmentmismperformedmduringmadm
issionmtoma
, facilitymtomobtainmamdetailedmhistorymandmcompletemphysicalmexamination.mAnmepisodicm
ormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempr
ocedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m4mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
5. Formwhichmpersonmismamcomprehensivemassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmt
omamlong-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mC
Amcomprehensivemassessmentmismperformedmduringmadmissionmtomamfacilitymtomobtainma
detailedmhistorymandmcompletemphysicalmexamination.mAmshiftmassessmentmismmostmapprop
riatemformthempersonmwhomismrecoveringminmthemhospitalmfrommsurgery.mAmscreeningmasses
smentmismperformedmformthempurposemofmdiseasemdetection,minmthismcasemdiabetesmmellitus
.mAnmepisodicmormfollow-
upmassessmentmismperformedmaftermkneemreplacementmtomevaluatemthemoutcomemofmthempr
ocedure.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
MSC:mNCLEXmPatientmNeeds:mSafemandmEffectivemCaremEnvironment:mManagementmofmCare:mEsta
blishingmPriorities
6. Formwhichmpersonmismanmepisodicmormfollow-upmassessmentmindicated?
a. Thempersonmwhomhadmabdominalmsurge
rymyesterday
b. Thempersonmwhomismunawaremofmhismh
ighmserummglucosemlevels
c. Thempersonmwhomismbeingmadmittedmtoma
long-termmcaremfacility
d. Thempersonmwhomismbeginningmrehabilitatio
nmaftermamkneemreplacement
ANSWER:mD
Anmepisodicmormfollow-
upmassessmentmismperformedmaftermthemkneemreplacementmtomevaluatemthemoutcomemofmthe
mprocedure.mAmshift massessmentmismmostmappropriatemformthempersonmwhomismrecoveringmin
mthemhospitalmfrom msurgery.mAmscreeningmassessmentmismperformedmformthempurposemofmdi
seasemdetection,minmthismcasemdiabetesmmellitus.mAmcomprehensivemassessmentmismperform
edmduringmadmissionmtomamfacilitymtomobtainmamdetailedmhistorymandmcompletemphysicalmex
amination.
DIF:mmmCognitivemLevel:mUnderstand REF:mBoxm1-
3m|mp.m3mTOP:mNursingmProcess:mAssessment
