lOMoARcPSD|6536636
Test Bank and Solutions For Health Assessment for
Nursing Practice 7th Edition By Susan Fickertt Wilson
Contemporary Nursing Practice (University of East London)
, lOMoARcPSD|6536636
Chapter 01_7e
MULTIPLE CHOICE
1.A patient comes to the emergency department and tells the triage
nurse that he is "having a heart attack." What is the nurse's top
priority at this time?
a. Determine the patient's personal data and insurance coverage.
b. Ask the patient to take a seat in the waiting room until his name is
called.
c. Request that a nurse collect data for a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
ANS: d
The nurse needs to begin an assessment as soon as possible that is
focused on this patient's cardiovascular system. The type of health
assessment performed by the nurse is also driven by patient need.
Personal data and insurance information will be obtained, but in this
situation, these data can wait until after the patient is assessed. Based
also on Maslow's hierarchy of needs, physiologic needs take
precedence. Rather than asking the patient to wait, the nurse needs to
begin data collection, such as vital signs, immediately to determine the
patient's health status. Complications can be prevented if an immediate
assessment is made to analyze the patient's symptoms. A comprehensive
history is not indicated in this situation at this time. Some subjective
data will be collected, such as allergies and medical history related to
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
mental health assessment is not a priority at this time.
PTS: 1
DIF: Cognitive Level: Apply
REF: Box 1-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment:
Management of Care: Establishing Priorities
2. Which situation illustrates a screening assessment?
Test Bank and Solutions For Health Assessment for
Nursing Practice 7th Edition By Susan Fickertt Wilson
Contemporary Nursing Practice (University of East London)
, lOMoARcPSD|6536636
Chapter 01_7e
MULTIPLE CHOICE
1.A patient comes to the emergency department and tells the triage
nurse that he is "having a heart attack." What is the nurse's top
priority at this time?
a. Determine the patient's personal data and insurance coverage.
b. Ask the patient to take a seat in the waiting room until his name is
called.
c. Request that a nurse collect data for a comprehensive history.
d. Ask a nurse to start a focused assessment of this patient now.
ANS: d
The nurse needs to begin an assessment as soon as possible that is
focused on this patient's cardiovascular system. The type of health
assessment performed by the nurse is also driven by patient need.
Personal data and insurance information will be obtained, but in this
situation, these data can wait until after the patient is assessed. Based
also on Maslow's hierarchy of needs, physiologic needs take
precedence. Rather than asking the patient to wait, the nurse needs to
begin data collection, such as vital signs, immediately to determine the
patient's health status. Complications can be prevented if an immediate
assessment is made to analyze the patient's symptoms. A comprehensive
history is not indicated in this situation at this time. Some subjective
data will be collected, such as allergies and medical history related to
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or
mental health assessment is not a priority at this time.
PTS: 1
DIF: Cognitive Level: Apply
REF: Box 1-3
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment:
Management of Care: Establishing Priorities
2. Which situation illustrates a screening assessment?
