Test Bank for Health Assessment for Nursing Practice 7th
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Edition by Wilson Chapter 1 - 24
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,Chapter 01: Introduction to Health Assessment M
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ULTIPLE CHOICE t
1. A patient comes to the emergency department and tells t
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he triage nurse that heis “having a heart attack.” What is the nurs
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e’s top priority at this time?
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a. Determine the patient’s t t
personal data andinsurance cov t t t
erage.
b. Ask the patient to take a seat in
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the waitingroom until his name i
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s called.
t
c. Request that a nurse collec t t t t
t data for a
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comprehensive history. t
d. Ask a nurse to start a focused ass
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essmentof this patient t t
now.
ANSWER: D t
The nurse needs to begin an assessment as soon as possible that is
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focused on this patient’scardiovascular system. The type of health
t t t t t t t t
assessment performed by the nurse is also drivenby patient need.
t t t t t t t t t t
Personal data and insurance information will be obtained, but in t
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his situation, these data can wait until after the patient is assessed.
t t t t t t t t t t t
Based also on Maslow’s hierarchy of needs, physiologic needs tak
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e precedence. Rather than asking the patient to wait, the nurse ne
t t t t t t t t t t t
eds to begin data collection, such as vital signs, immediately to det
t t t t t t t t t t t
erminethe patient’s health status. Complications can be prevente
t t t t t t t
d if an immediate assessment is made to analyze the patient’s sym
t t t t t t t t t t t
ptoms. A comprehensive t t
,history is not indicated in this situation at this time. Some subjecti
t t t t t t t t t t t
ve data will be collected, such as allergies and medical history rel
t t t t t t t t t t t
ated to cardiovascular disease. Eyes, ears, or a complete musculo
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skeletal or mental health assessment is not a priority at this time.
t t t t t t t t t t t
DIF: Cognitive Level: Apply
tt t t REF: Box 1-3
t t
| p. 3TOP: Nursing Process: Assessment
t t t t t
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Managemen
t t t t t t t t t
t of Care:Establishing Priorities
t t t
2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clini
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c for the first time and the nurse c
t t t t t t t t
onducts a detailed history and p t t t t t
hysical
examination.
b. A hospital sponsors a health fai
t t t t t
r at a localmall and provides ch
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olesterol and blood pressure c t t t t
hecks to mall t t
patrons.
c. The nurse in an urgent care c t t t t t t
enter checksthe vital signs o t t t t
f a patient who is
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complaining of leg pain. t t t
, d. A patient newly diagnosed w
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ith diabetesmellitus comes t
t t t
o test his fasting blood
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glucose level. t
ANSWER: B t
A health fair at a local mall that provides cholesterol and blood pres
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sure checks is an example of a screening assessment focused on dis
t t t t t t t t t t t
ease detection. A detailed history and physical examination conduc
t t t t t t t t
ted during a first-
t t t
time visit to an obstetric clinic is an exampleof a comprehensive ass
t t t t t t t t t t t
essment. Assessing a patient complaining of leg pain in the triage ar
t t t t t t t t t t t
ea of an urgent care center is an example of a problem-
t t t t t t t t t t t
based/focused assessment. A patient’s return appointment 1 mont t t t t t t t
h after today’s office visit to report fasting blood glucose levels is an
t t t t t t t t t t t t t
example of an episodic or follow-up assessment.
t t t t t t
DIF: Cognitive Level: Understand
tt t t REF:
Box 1-3 | p. 3TOP: Nursing Process:
t t t t t t
Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Scree
t t t t t t t t t
ning
3. For which person is a screening assessment indicated?
t t t t t t t
a. The person who had t t t
abdominal surgery yester t t
day
b. The person who is unaware
t t t t
of his highserum glucose le
t t t t
vels
c. The person who is being admitte
t t t t t
d to along-term
t t
care facility t
t t t t t t t tt t
Edition by Wilson Chapter 1 - 24
t t t t t t
,Chapter 01: Introduction to Health Assessment M
t t t t t t
ULTIPLE CHOICE t
1. A patient comes to the emergency department and tells t
t t t t t t t t t
he triage nurse that heis “having a heart attack.” What is the nurs
t t t t t t t t t t t t
e’s top priority at this time?
t t t t t
a. Determine the patient’s t t
personal data andinsurance cov t t t
erage.
b. Ask the patient to take a seat in
t t t t t t t
the waitingroom until his name i
t t t t t
s called.
t
c. Request that a nurse collec t t t t
t data for a
t t t
comprehensive history. t
d. Ask a nurse to start a focused ass
t t t t t t t
essmentof this patient t t
now.
ANSWER: D t
The nurse needs to begin an assessment as soon as possible that is
t t t t t t t t t t t t t
focused on this patient’scardiovascular system. The type of health
t t t t t t t t
assessment performed by the nurse is also drivenby patient need.
t t t t t t t t t t
Personal data and insurance information will be obtained, but in t
t t t t t t t t t t t
his situation, these data can wait until after the patient is assessed.
t t t t t t t t t t t
Based also on Maslow’s hierarchy of needs, physiologic needs tak
t t t t t t t t t t
e precedence. Rather than asking the patient to wait, the nurse ne
t t t t t t t t t t t
eds to begin data collection, such as vital signs, immediately to det
t t t t t t t t t t t
erminethe patient’s health status. Complications can be prevente
t t t t t t t
d if an immediate assessment is made to analyze the patient’s sym
t t t t t t t t t t t
ptoms. A comprehensive t t
,history is not indicated in this situation at this time. Some subjecti
t t t t t t t t t t t
ve data will be collected, such as allergies and medical history rel
t t t t t t t t t t t
ated to cardiovascular disease. Eyes, ears, or a complete musculo
t t t t t t t t t
skeletal or mental health assessment is not a priority at this time.
t t t t t t t t t t t
DIF: Cognitive Level: Apply
tt t t REF: Box 1-3
t t
| p. 3TOP: Nursing Process: Assessment
t t t t t
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Managemen
t t t t t t t t t
t of Care:Establishing Priorities
t t t
2. Which situation illustrates a screening assessment?
t t t t t
a. A patient visits an obstetric clini
t t t t t
c for the first time and the nurse c
t t t t t t t t
onducts a detailed history and p t t t t t
hysical
examination.
b. A hospital sponsors a health fai
t t t t t
r at a localmall and provides ch
t t t t t t
olesterol and blood pressure c t t t t
hecks to mall t t
patrons.
c. The nurse in an urgent care c t t t t t t
enter checksthe vital signs o t t t t
f a patient who is
t t t t
complaining of leg pain. t t t
, d. A patient newly diagnosed w
t t t t
ith diabetesmellitus comes t
t t t
o test his fasting blood
t t t t
glucose level. t
ANSWER: B t
A health fair at a local mall that provides cholesterol and blood pres
t t t t t t t t t t t t
sure checks is an example of a screening assessment focused on dis
t t t t t t t t t t t
ease detection. A detailed history and physical examination conduc
t t t t t t t t
ted during a first-
t t t
time visit to an obstetric clinic is an exampleof a comprehensive ass
t t t t t t t t t t t
essment. Assessing a patient complaining of leg pain in the triage ar
t t t t t t t t t t t
ea of an urgent care center is an example of a problem-
t t t t t t t t t t t
based/focused assessment. A patient’s return appointment 1 mont t t t t t t t
h after today’s office visit to report fasting blood glucose levels is an
t t t t t t t t t t t t t
example of an episodic or follow-up assessment.
t t t t t t
DIF: Cognitive Level: Understand
tt t t REF:
Box 1-3 | p. 3TOP: Nursing Process:
t t t t t t
Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Scree
t t t t t t t t t
ning
3. For which person is a screening assessment indicated?
t t t t t t t
a. The person who had t t t
abdominal surgery yester t t
day
b. The person who is unaware
t t t t
of his highserum glucose le
t t t t
vels
c. The person who is being admitte
t t t t t
d to along-term
t t
care facility t
