,Chapter 01: Introduction to Health Assessment
x x x x x
Wilson: Health Assessment for Nursing Practice, 7th Edition
x x x x x x x
MULTIPLE CHOICE x
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a he
x x x x x x x x x x x x x x x x x
art attack.‖ What is the nurse‘s top priority at this time?
x x x x x x x x x x
a. Determine the patient‘s personal data and insurance coverage. x x x x x x x
b. Ask the patient to take a seat in the waiting room until his name is called.
x x x x x x x x x x x x x x x
c. Request that a nurse collect data for a comprehensive history. x x x x x x x x x
d. Ask a nurse to start a focused assessment of this patient now.
x x x x x x x x x x x
ANS: D x
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s cardio
x x x x x x x x x x x x x x x x x
vascular system. The type of health assessment performed by the nurse is also driven by patient n
x x x x x x x x x x x x x x x x
eed. Personal data and insurance information will be obtained, but in this situation, these data can
x x x x x x x x x x x x x x x
wait until after the patient is assessed. Based also on Maslow‘s hierarchy of needs, physiologic n
x x x x x x x x x x x x x x x x
eeds take precedence. Rather than asking the patient to wait, the nurse needs to begin data collecti
x x x x x x x x x x x x x x x x
on, such as vital signs, immediately to determine the patient‘s health status. Complications can b
x x x x x x x x x x x x x x
e prevented if an immediate assessment is made to analyze the patient‘s symptoms. A comprehen
x x x x x x x x x x x x x x
sive history is not indicated in this situation at this time. Some subjective data will be collected, s
x x x x x x x x x x x x x x x x x
uch as allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete m
x x x x x x x x x x x x x x x
usculoskeletal or mental health assessment is not a priority at this time. x x x x x x x x x x x
DIF:Cognitive Level: Apply REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
2. Which situation illustrates a screening assessment?
x x x x x
a. A patient visits an obstetric clinic for the first time and the nurse conducts a de
x x x x x x x x x x x x x x x
tailed history and physical examination.
x x x x
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pr
x x x x x x x x x x x x x x x
essure checks to mall patrons. x x x x
c. The nurse in an urgent care center checks the vital signs of a patient who is co
x x x x x x x x x x x x x x x x
mplaining of leg pain. x x x
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood gl
x x x x x x x x x x x x x
ucose level. x
ANS: B x
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of
x x x x x x x x x x x x x x x x x x
a screening assessment focused on disease detection. A detailed history and physical examinatio
x x x x x x x x x x x x
n conducted during a first-
x x x x
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a patient
x x x x x x x x x x x x x x x
xcomplaining of leg pain in the triage area of an urgent care center is an example of a problem-
x x x x x x x x x x x x x x x x x x
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit to re
x x x x x x x x x x x x x
port fasting blood glucose levels is an example of an episodic or follow-up assessment.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand x x REF: Box 1-3 x x
, TOP:Nursing Process: Assessment x x
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x x x x x x x x
3. For which person is a screening assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: B x
A screening assessment is performed for the purpose of disease detection. In this case this person
x x x x x x x x x x x x x x x x
may have diabetes mellitus. A shift assessment is most appropriate for the person who is recoveri
x x x x x x x x x x x x x x x
ng in the hospital from surgery. A comprehensive assessment is performed during admission to a
x x x x x x x x x x x x x x x
facility to obtain a detailed history and complete physical examination. An episodic or follow-
x x x x x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
4. For which person is a shift assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: A x
A shift assessment is most appropriate for the person who is recovering in the hospital from surge
x x x x x x x x x x x x x x x x
ry. A screening assessment is performed for the purpose of disease detection, in this case diabetes
x x x x x x x x x x x x x x x x
mellitus. A comprehensive assessment is performed during admission to a facility to obtain a deta
x x x x x x x x x x x x x x
iled history and complete physical examination. An episodic or follow-
x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
5. For which person is a comprehensive assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: C x
A comprehensive assessment is performed during admission to a facility to obtain a detailed hist
x x x x x x x x x x x x x x
ory and complete physical examination. A shift assessment is most appropriate for the person w
x x x x x x x x x x x x x x
ho is recovering in the hospital from surgery. A screening assessment is performed for the purpo
x x x x x x x x x x x x x x x
se of disease detection, in this case diabetes mellitus. An episodic or follow-
x x x x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
, DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
6. For which person is an episodic or follow-up assessment indicated?
x x x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: D x
An episodic or follow-
x x x
up assessment is performed after the knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x x
A shift assessment is most appropriate for the person who is recovering in the hospital from surg
x x x x x x x x x x x x x x x x x
ery. A screening assessment is performed for the purpose of disease detection, in this case diabet
x x x x x x x x x x x x x x x
es mellitus. A comprehensive assessment is performed during admission to a facility to obtain a
x x x x x x x x x x x x x x x
detailed history and complete physical examination.
x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
7. Which is an example of data a nurse collects during a physical examination?
x x x x x x x x x x x x
a. The patient‘s lack of hair and shiny skin over both shins
x x x x x x x x x x
b. The patient‘s stated concern about lack of money for prescriptions
x x x x x x x x x
c. The patient‘s complaints of tingling sensations in the feet
x x x x x x x x
d. The patient‘s mother‘s statements that the patient is very nervous lately
x x x x x x x x x x
ANS: A x
The lack of hair and shiny skin over both shins are objective data or signs that are part of the phys
x x x x x x x x x x x x x x x x x x x x
ical examination. A patient‘s concerns about lack of money are subjective data and are part of th
x x x x x x x x x x x x x x x x
e health history. A patient‘s complaints of tingling sensations in the feet are subjective data and a
x x x x x x x x x x x x x x x x
re part of the health history. A patient‘s family statements are considered secondary data, are sub
x x x x x x x x x x x x x x x
jective data, and are part of the health history.
x x x x x x x x
DIF:Cognitive Level: Apply REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific Ass
x x x x x x x x x x x
essments
8. The nurse documents which information in the patient‘s history?
x x x x x x x x
a. The patient‘s skin feels warm to the touch.
x x x x x x x
b. The patient is scratching his arm. x x x x x
c. The patient‘s temperature is 100 F. x x x x x
d. The patient complains of itching. x x x x
ANS: D x
x x x x x
Wilson: Health Assessment for Nursing Practice, 7th Edition
x x x x x x x
MULTIPLE CHOICE x
1. A patient comes to the emergency department and tells the triage nurse that he is ―having a he
x x x x x x x x x x x x x x x x x
art attack.‖ What is the nurse‘s top priority at this time?
x x x x x x x x x x
a. Determine the patient‘s personal data and insurance coverage. x x x x x x x
b. Ask the patient to take a seat in the waiting room until his name is called.
x x x x x x x x x x x x x x x
c. Request that a nurse collect data for a comprehensive history. x x x x x x x x x
d. Ask a nurse to start a focused assessment of this patient now.
x x x x x x x x x x x
ANS: D x
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s cardio
x x x x x x x x x x x x x x x x x
vascular system. The type of health assessment performed by the nurse is also driven by patient n
x x x x x x x x x x x x x x x x
eed. Personal data and insurance information will be obtained, but in this situation, these data can
x x x x x x x x x x x x x x x
wait until after the patient is assessed. Based also on Maslow‘s hierarchy of needs, physiologic n
x x x x x x x x x x x x x x x x
eeds take precedence. Rather than asking the patient to wait, the nurse needs to begin data collecti
x x x x x x x x x x x x x x x x
on, such as vital signs, immediately to determine the patient‘s health status. Complications can b
x x x x x x x x x x x x x x
e prevented if an immediate assessment is made to analyze the patient‘s symptoms. A comprehen
x x x x x x x x x x x x x x
sive history is not indicated in this situation at this time. Some subjective data will be collected, s
x x x x x x x x x x x x x x x x x
uch as allergies and medical history related to cardiovascular disease. Eyes, ears, or a complete m
x x x x x x x x x x x x x x x
usculoskeletal or mental health assessment is not a priority at this time. x x x x x x x x x x x
DIF:Cognitive Level: Apply REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
2. Which situation illustrates a screening assessment?
x x x x x
a. A patient visits an obstetric clinic for the first time and the nurse conducts a de
x x x x x x x x x x x x x x x
tailed history and physical examination.
x x x x
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blood pr
x x x x x x x x x x x x x x x
essure checks to mall patrons. x x x x
c. The nurse in an urgent care center checks the vital signs of a patient who is co
x x x x x x x x x x x x x x x x
mplaining of leg pain. x x x
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting blood gl
x x x x x x x x x x x x x
ucose level. x
ANS: B x
A health fair at a local mall that provides cholesterol and blood pressure checks is an example of
x x x x x x x x x x x x x x x x x x
a screening assessment focused on disease detection. A detailed history and physical examinatio
x x x x x x x x x x x x
n conducted during a first-
x x x x
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a patient
x x x x x x x x x x x x x x x
xcomplaining of leg pain in the triage area of an urgent care center is an example of a problem-
x x x x x x x x x x x x x x x x x x
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit to re
x x x x x x x x x x x x x
port fasting blood glucose levels is an example of an episodic or follow-up assessment.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand x x REF: Box 1-3 x x
, TOP:Nursing Process: Assessment x x
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
x x x x x x x x
3. For which person is a screening assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: B x
A screening assessment is performed for the purpose of disease detection. In this case this person
x x x x x x x x x x x x x x x x
may have diabetes mellitus. A shift assessment is most appropriate for the person who is recoveri
x x x x x x x x x x x x x x x
ng in the hospital from surgery. A comprehensive assessment is performed during admission to a
x x x x x x x x x x x x x x x
facility to obtain a detailed history and complete physical examination. An episodic or follow-
x x x x x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
4. For which person is a shift assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: A x
A shift assessment is most appropriate for the person who is recovering in the hospital from surge
x x x x x x x x x x x x x x x x
ry. A screening assessment is performed for the purpose of disease detection, in this case diabetes
x x x x x x x x x x x x x x x x
mellitus. A comprehensive assessment is performed during admission to a facility to obtain a deta
x x x x x x x x x x x x x x
iled history and complete physical examination. An episodic or follow-
x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
5. For which person is a comprehensive assessment indicated?
x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: C x
A comprehensive assessment is performed during admission to a facility to obtain a detailed hist
x x x x x x x x x x x x x x
ory and complete physical examination. A shift assessment is most appropriate for the person w
x x x x x x x x x x x x x x
ho is recovering in the hospital from surgery. A screening assessment is performed for the purpo
x x x x x x x x x x x x x x x
se of disease detection, in this case diabetes mellitus. An episodic or follow-
x x x x x x x x x x x x
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x
, DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
6. For which person is an episodic or follow-up assessment indicated?
x x x x x x x x x
a. The person who had abdominal surgery yesterday
x x x x x x
b. The person who is unaware of his high serum glucose levels
x x x x x x x x x x
c. The person who is being admitted to a long-term care facility
x x x x x x x x x x
d. The person who is beginning rehabilitation after a knee replacement
x x x x x x x x x
ANS: D x
An episodic or follow-
x x x
up assessment is performed after the knee replacement to evaluate the outcome of the procedure.
x x x x x x x x x x x x x x
A shift assessment is most appropriate for the person who is recovering in the hospital from surg
x x x x x x x x x x x x x x x x x
ery. A screening assessment is performed for the purpose of disease detection, in this case diabet
x x x x x x x x x x x x x x x
es mellitus. A comprehensive assessment is performed during admission to a facility to obtain a
x x x x x x x x x x x x x x x
detailed history and complete physical examination.
x x x x x
DIF:Cognitive Level: Understand REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establishing
x x x x x x x x x x x x
Priorities
7. Which is an example of data a nurse collects during a physical examination?
x x x x x x x x x x x x
a. The patient‘s lack of hair and shiny skin over both shins
x x x x x x x x x x
b. The patient‘s stated concern about lack of money for prescriptions
x x x x x x x x x
c. The patient‘s complaints of tingling sensations in the feet
x x x x x x x x
d. The patient‘s mother‘s statements that the patient is very nervous lately
x x x x x x x x x x
ANS: A x
The lack of hair and shiny skin over both shins are objective data or signs that are part of the phys
x x x x x x x x x x x x x x x x x x x x
ical examination. A patient‘s concerns about lack of money are subjective data and are part of th
x x x x x x x x x x x x x x x x
e health history. A patient‘s complaints of tingling sensations in the feet are subjective data and a
x x x x x x x x x x x x x x x x
re part of the health history. A patient‘s family statements are considered secondary data, are sub
x x x x x x x x x x x x x x x
jective data, and are part of the health history.
x x x x x x x x
DIF:Cognitive Level: Apply REF: Box 1- x x x x
3 TOP:Nursing Process: Assessment
x x x
MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specific Ass
x x x x x x x x x x x
essments
8. The nurse documents which information in the patient‘s history?
x x x x x x x x
a. The patient‘s skin feels warm to the touch.
x x x x x x x
b. The patient is scratching his arm. x x x x x
c. The patient‘s temperature is 100 F. x x x x x
d. The patient complains of itching. x x x x
ANS: D x
