Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,TABLE OF CONTENTS q q q
Unit I: Foundations for Health Assessment
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1. Introduction to Health Assessment q q q
2. Interviewing Patients to Obtain a Health History q q q q q q
3. Techniques and Equipment for Physical Assessment q q q q q
4. General Inspection and Measurement of Vital Signs
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5. Ethnic, Cultural, and Spiritual Considerations
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6. Pain Assessment
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7. Mental Health and Abusive Behavior Assessment
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8. Nutritional Assessment q
Unit II: Health Assessment of the Adult
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9. Skin, Hair, and Nails
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10. Head, Eyes, Ears, Nose, and Throat
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11. Lungs and Respiratory System q q q
12. Heart and Peripheral Vascular System
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13. Abdomen and Gastrointestinal System q q q
14. Musculoskeletal System q
15. Neurologic System q
16. Breasts and Axillae q q
17. Reproductive System and the Perineum q q q q
Unit III: Health Assessment Across the Life Span
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18. Developmental Assessment Throughout the Life Span q q q q q
19. Assessment of the Infant, Child, and Adolescent q q q q q q
20. Assessment of the Pregnant Patient q q q q
21. Assessment of the Older Adult q q q q
Unit IV: Synthesis and Application of Health Assessment
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22. Conducting a Head-to-Toe Examination q q q
23. Documenting the Head-to-Toe Health Assessment q q q q
24. Adapting Health Assessment q q
Chapter 01: Introduction to Health Assessment
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,MULTIPLE CHOICE q
1. A patient comes to the emergency department and tells the triage nurse that
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q heis “having a heart attack.” What is the nurse’s top priority at this time?
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a. Determine the patient’s personal data and q q q q q
insurance coverage. q q
b. Ask the patient to take a seat in the waiting
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room until his name is called.
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c. Request that a nurse collect data for q q q q q q
acomprehensive history. q
d. Ask a nurse to start a focused assessment
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of this patient now.
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ANSWER: D q
The nurse needs to begin an assessment as soon as possible that is focused on this patient’s
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cardiovascular system. The type of health assessment performed by the nurse is also driven by
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patient need. Personal data and insurance information will be obtained, but in this situation,
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these data can wait until after the patient is assessed. Based also on Maslow’s hierarchy of
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needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
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needs to begin data collection, such as vital signs, immediately to determine the patient’s
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health status. Complications can be prevented if an immediate assessment is made to
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analyze the patient’s symptoms. A comprehensive history is not indicated in this situation at
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this time. Some subjective data will be collected, such as allergies and medical history
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related to cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental
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health assessment is not a priority at this time.
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DIF: Cognitive Level: Apply
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TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
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Priorities
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2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first q q q q q q q q
time and the nurse conducts a detailedhistory q q q q q q
and physical examination. q q q
b. A hospital sponsors a health fair at a
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localmall and provides cholesterol and q q q q
qblood pressure checks to mall patrons. q q q q q
c. The nurse in an urgent care center checks
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the vital signs of a patient who is
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complaining of leg pain.
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, d. A patient newly diagnosed with
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diabetesmellitus comes to test his fasting q q q q q
blood glucose level.
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ANSWER: B q
A health fair at a local mall that provides cholesterol and blood pressure checks is an
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example of a screening assessment focused on disease detection. A detailed history and
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physical examination conducted during a first-time visit to an obstetric clinic is an exampleof a
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comprehensive assessment. Assessing a patient complaining of leg pain in the triage area of
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an urgent care center is an example of a problem-based/focused assessment. A patient’s
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return appointment 1 month after today’s office visit to report fasting blood glucose levels is
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an example of an episodic or follow-up assessment.
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DIF: Cognitive Level: Understand
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TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery q q q q q
yesterday
b. The person who is unaware of his high
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serum glucose levels
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c. The person who is being admitted to a
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long-term care facility q q
d. The person who is beginning rehabilitation
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after a knee replacement q q q
ANSWER: B q
A screening assessment is performed for the purpose of disease detection. In this case this
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person may have diabetes mellitus. A shift assessment is most appropriate for the person
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who is recovering in the hospital from surgery. A comprehensive assessment is performed
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during admission to a facility to obtain a detailed history and complete physical
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examination. An episodic or follow-up assessment is performed after knee replacement to
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evaluate the outcome of the procedure.
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DIF: Cognitive Level: Understand
q REF: Box 1-3 | p. 3 q q q q q q q
TOP: Nursing Process: Assessment
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MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care:Establishing
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qPriorities
4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery q q q q q
yesterday
b. The person who is unaware of his high
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serum glucose levels q q
c. The person who is being admitted to a
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long-term care facility q q
d. The person who is beginning rehabilitation
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after a knee replacement q q q
ANSWER: A q
A shift assessment is most appropriate for the person who is recovering in the hospital from
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surgery. A screening assessment is performed for the purpose of disease detection, in this
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case diabetes mellitus. A comprehensive assessment is performed during admission to a
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