HEALTH ASSESSMENT FOR NURSING PRACTICE, 7TH EDITION BY
SUSAN F WILSON, JEAN FORET GIDDENS ALL CHAPTERS 1-24
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,TABLE OF CONTENTS
CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT .................................................................................... 3
CHAPTER 02: OBTAINING A HEALTH HISTORY ......................................................................................................... 9
CHAPTER 03: TECHNIQUES AND EQUIPMENT FOR PHYSICAL ASSESSMENT.................................................. 24
CHAPTER 04: GENERAL INSPECTION AND MEASUREMENT OF VITAL SIGNS ............................................... 37
CHAPTER 05: CULTURAL ASSESSMENT................................................................................................................... 45
CHAPTER 06: PAIN ASSESSMENT ............................................................................................................................... 53
CHAPTER 07: MENTAL HEALTH ASSESSMENT ...................................................................................................... 61
CHAPTER 08: NUTRITIONAL ASSESSMENT ............................................................................................................. 70
CHAPTER 09: SKIN, HAIR, AND NAILS....................................................................................................................... 84
CHAPTER 10: HEAD, EYES, EARS, NOSE, AND THROAT ....................................................................................... 99
CHAPTER 11: LUNGS AND RESPIRATORY SYSTEM............................................................................................ 133
CHAPTER 12: HEART AND PERIPHERAL VASCULAR SYSTEM ........................................................................ 149
CHAPTER 13: ABDOMEN AND GASTROINTESTINAL SYSTEM ........................................................................ 164
CHAPTER 14: MUSCULOSKELETAL SYSTEM ....................................................................................................... 183
CHAPTER 15: NEUROLOGIC SYSTEM...................................................................................................................... 196
CHAPTER 16: BREASTS AND AXILLAE................................................................................................................... 213
CHAPTER 17: REPRODUCTIVE SYSTEM AND THE PERINEUM .......................................................................... 215
CHAPTER 18: DEVELOPMENTAL ASSESSMENT THROUGHOUT THE LIFE SPAN......................................... 233
CHAPTER 19: ASSESSMENT OF THE INFANT, CHILD, AND ADOLESCENT TEST BANK ............................ 242
CHAPTER 20: ASSESSMENT OF THE PREGNANT PATIENT ............................................................................... 268
CHAPTER 21: ASSESSMENT OF THE OLDER ADULT ........................................................................................... 281
CHAPTER 22: CONDUCTING A HEAD-TO-TOE EXAMINATION ......................................................................... 291
CHAPTER 23: DOCUMENTING THE COMPREHENSIVE HEALTH ASSESSMENT .............................................. 295
CHAPTER 24: ADAPTING HEALTH ASSESSMENT TO THE HOSPITALIZED PATIENT .................................... 298
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CHAPTER 01: INTRODUCTION TO HEALTH ASSESSMENT
WILSON: HEALTH ASSESSMENT FOR NURSING PRACTICE, 7TH EDITION
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. ANSWER: 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.
2. WHICH SITUATION ILLUSTRATES A SCREENING ASSESSMENT?
a. A PATIENT VISITS AN OBSTETRIC CLINIC FOR THE FIRST TIME AND
THE NURSE CONDUCTS A DETAILED HISTORY AND PHYSICAL EXAMINATION.
b. A HOSPITAL SPONSORS A HEALTH FAIR AT A LOCAL MALL AND
PROVIDES CHOLESTEROL AND BLOOD PRESSURE CHECKS TO MALL
PATRONS.
c. THE NURSE IN AN URGENT CARE CENTER CHECKS THE VITAL SIGNS
OF A PATIENT WHO IS COMPLAINING OF LEG PAIN.
d. A PATIENT NEWLY DIAGNOSED WITH DIABETES MELLITUS COMES
TO TEST HIS FASTING BLOOD GLUCOSE LEVEL.
ANSWER: B
A HEALTH FAIR AT A LOCAL MALL THAT PROVIDES CHOLESTEROL AND BLOOD
PRESSURE CHECKS IS AN EXAMPLE OF A SCREENING ASSESSMENT FOCUSED ON
DISEASE DETECTION. A DETAILED HISTORY AND PHYSICAL
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EXAMINATION CONDUCTED DURING A FIRST-TIME VISIT TO AN OBSTETRIC
CLINIC IS AN EXAMPLE OF A COMPREHENSIVE ASSESSMENT. ASSESSING A
PATIENT COMPLAINING OF LEG PAIN IN THE TRIAGE AREA OF AN URGENT CARE
CENTER IS AN EXAMPLE OF A PROBLEM-BASED/FOCUSED ASSESSMENT. A
PATIENT’S RETURN APPOINTMENT 1 MONTH AFTER TODAY’S OFFICE VISIT TO
REPORT FASTING BLOOD GLUCOSE LEVELS IS AN EXAMPLE OF AN EPISODIC OR
FOLLOW-UP ASSESSMENT.
3. FOR WHICH PERSON IS A SCREENING ASSESSMENT INDICATED?
a. THE PERSON WHO HAD ABDOMINAL SURGERY YESTERDAY
b. THE PERSON WHO IS UNAWARE OF HIS HIGH SERUM GLUCOSE LEVELS
c. THE PERSON WHO IS BEING ADMITTED TO A LONG-TERM CARE FACILITY
d. THE PERSON WHO IS BEGINNING
REHABILITATION AFTER A KNEE REPLACEMENT
ANSWER: B
A SCREENING ASSESSMENT IS PERFORMED FOR THE PURPOSE OF DISEASE
DETECTION. IN THIS CASE THIS PERSON MAY HAVE DIABETES MELLITUS. A SHIFT
ASSESSMENT IS MOST APPROPRIATE FOR THE PERSON WHO IS RECOVERING IN
THE HOSPITAL FROM SURGERY. A COMPREHENSIVE ASSESSMENT IS PERFORMED
DURING ADMISSION TO A FACILITY TO OBTAIN A DETAILED HISTORY AND
COMPLETE PHYSICAL EXAMINATION. AN EPISODIC OR FOLLOW-UP ASSESSMENT
IS PERFORMED AFTER KNEE REPLACEMENT TO EVALUATE THE OUTCOME OF THE
PROCEDURE.
4. FOR WHICH PERSON IS A SHIFT ASSESSMENT INDICATED?
a. THE PERSON WHO HAD ABDOMINAL SURGERY YESTERDAY
b. THE PERSON WHO IS UNAWARE OF HIS HIGH SERUM GLUCOSE LEVELS
c. THE PERSON WHO IS BEING ADMITTED TO A LONG-TERM CARE FACILITY
d. THE PERSON WHO IS BEGINNING
REHABILITATION AFTER A KNEE REPLACEMENT
ANSWER: A
A SHIFT ASSESSMENT IS MOST APPROPRIATE FOR THE PERSON WHO IS
RECOVERING IN THE HOSPITAL FROM SURGERY. A SCREENING ASSESSMENT IS
PERFORMED FOR THE PURPOSE OF DISEASE DETECTION, IN THIS CASE DIABETES
MELLITUS. A COMPREHENSIVE ASSESSMENT IS PERFORMED DURING ADMISSION
TO A FACILITY TO OBTAIN A DETAILED HISTORY AND COMPLETE PHYSICAL
EXAMINATION. AN EPISODIC OR FOLLOW-UP ASSESSMENT IS PERFORMED AFTER
KNEE REPLACEMENT TO EVALUATE THE OUTCOME OF THE PROCEDURE.
5. FOR WHICH PERSON IS A COMPREHENSIVE ASSESSMENT INDICATED?
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