,
,Chapter 01: Introduction to Health Assessment
nz nz nz nz nz
Wilson: Health Assessment for Nursing Practice, 7th Edition
nz nz nz nz nz nz nz
MULTIPLE CHOICE nz
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
a heart attack.‖ What is the nurse‘s top priority at this time?
nz nz nz nz nz nz nz nz nz nz nz
a. Determine the patient‘s personal data and insurance coverage. nz nz nz nz nz nz nz
b. Ask the patient to take a seat in the waiting room until his name is called.
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
c. Request that a nurse collect data for a comprehensive history. nz nz nz nz nz nz nz nz nz
d. Ask a nurse to start a focused assessment of this patient now.
nz nz nz nz nz nz nz nz nz nz nz
ANS: D n z
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
cardiovascular system. The type of health assessment performed by the nurse is also driven b
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
y patient need. Personal data and insurance information will be obtained, but in this situatio
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
n, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy o
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
f needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
needs to begin data collection, such as vital signs, immediately to determine the patient‘s h
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
ealth status. Complications can be prevented if an immediate assessment is made to analyze
nz nz nz nz nz nz nz nz nz nz nz nz nz n
the patient‘s symptoms. A comprehensive history is not indicated in this situation at this ti
z nz nz nz nz nz nz nz nz nz nz nz nz nz nz
me. Some subjective data will be collected, such as allergies and medical history related to
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessme
nz nz nz nz nz nz nz nz nz nz nz
nt is not a priority at this time.
nz nz nz nz nz nz nz
DIF:Cognitive Level: Apply REF: Box 1- nz nz n z nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
2. Which situation illustrates a screening assessment?
nz nz nz nz nz
a. A patient visits an obstetric clinic for the first time and the nurse conducts
nz nz nz nz nz nz nz nz nz nz nz nz nz n
a detailed history and physical examination.
z nz nz nz nz nz
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
od pressure checks to mall patrons.
nz nz nz nz nz
c. The nurse in an urgent care center checks the vital signs of a patient who
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
is complaining of leg pain.nz nz nz nz
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
nz nz nz nz nz nz nz nz nz nz nz nz
d glucose level. nz nz
ANS: B n z
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
ple of a screening assessment focused on disease detection. A detailed history and physical
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
examination conducted during a first- nz nz nz nz
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
atient complaining of leg pain in the triage area of an urgent care center is an example of a
nz nz nz nz nz nz nz nz nz n z nz nz nz nz nz nz nz nz n
problem-
z
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
nz nz nz nz nz nz nz nz nz nz nz nz
to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
DIF:Cognitive Level: Understand nz nz REF: Box 1-3 nz nz
, TOP:Nursing Process: Assessment nz nz
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
nz nz nz nz nz nz nz nz
3. For which person is a screening assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: B nz
A screening assessment is performed for the purpose of disease detection. In this case this p
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
erson may have diabetes mellitus. A shift assessment is most appropriate for the person who
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
nzis recovering in the hospital from surgery. A comprehensive assessment is performed durin
nz nz nz nz nz nz nz nz nz nz nz nz
g admission to a facility to obtain a detailed history and complete physical examination. An
nz nz nz nz nz nz nz nz nz nz nz nz nz nz n
zepisodic or follow- nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedure
nz nz nz nz nz nz nz nz nz nz nz nz nz
.
DIF:Cognitive Level: Understand REF: Box 1- nz nz nz nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
4. For which person is a shift assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: A nz
A shift assessment is most appropriate for the person who is recovering in the hospital from
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
surgery. A screening assessment is performed for the purpose of disease detection, in this cas
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
nz nz nz nz nz nz nz nz nz nz nz nz nz
to obtain a detailed history and complete physical examination. An episodic or follow-
nz nz nz nz nz nz nz nz nz nz nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
nz nz nz nz nz nz nz nz nz nz nz nz nz
DIF:Cognitive Level: Understand REF: Box 1- nz nz nz nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
5. For which person is a comprehensive assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: C nz
A comprehensive assessment is performed during admission to a facility to obtain a detailed
nz nz nz nz nz nz nz nz nz nz nz nz nz
history and complete physical examination. A shift assessment is most appropriate for the
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
person who is recovering in the hospital from surgery. A screening assessment is performe
nz nz nz nz nz nz nz nz nz nz nz nz nz
d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedur
nz nz nz nz nz nz nz nz nz nz nz nz nz
e.
,Chapter 01: Introduction to Health Assessment
nz nz nz nz nz
Wilson: Health Assessment for Nursing Practice, 7th Edition
nz nz nz nz nz nz nz
MULTIPLE CHOICE nz
1. A patient comes to the emergency department and tells the triage nurse that he is ―having
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
a heart attack.‖ What is the nurse‘s top priority at this time?
nz nz nz nz nz nz nz nz nz nz nz
a. Determine the patient‘s personal data and insurance coverage. nz nz nz nz nz nz nz
b. Ask the patient to take a seat in the waiting room until his name is called.
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
c. Request that a nurse collect data for a comprehensive history. nz nz nz nz nz nz nz nz nz
d. Ask a nurse to start a focused assessment of this patient now.
nz nz nz nz nz nz nz nz nz nz nz
ANS: D n z
The nurse needs to begin an assessment as soon as possible that is focused on this patient‘s
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
cardiovascular system. The type of health assessment performed by the nurse is also driven b
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
y patient need. Personal data and insurance information will be obtained, but in this situatio
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
n, these data can wait until after the patient is assessed. Based also on Maslow‘s hierarchy o
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
f needs, physiologic needs take precedence. Rather than asking the patient to wait, the nurse
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
needs to begin data collection, such as vital signs, immediately to determine the patient‘s h
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
ealth status. Complications can be prevented if an immediate assessment is made to analyze
nz nz nz nz nz nz nz nz nz nz nz nz nz n
the patient‘s symptoms. A comprehensive history is not indicated in this situation at this ti
z nz nz nz nz nz nz nz nz nz nz nz nz nz nz
me. Some subjective data will be collected, such as allergies and medical history related to
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
cardiovascular disease. Eyes, ears, or a complete musculoskeletal or mental health assessme
nz nz nz nz nz nz nz nz nz nz nz
nt is not a priority at this time.
nz nz nz nz nz nz nz
DIF:Cognitive Level: Apply REF: Box 1- nz nz n z nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
2. Which situation illustrates a screening assessment?
nz nz nz nz nz
a. A patient visits an obstetric clinic for the first time and the nurse conducts
nz nz nz nz nz nz nz nz nz nz nz nz nz n
a detailed history and physical examination.
z nz nz nz nz nz
b. A hospital sponsors a health fair at a local mall and provides cholesterol and blo
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
od pressure checks to mall patrons.
nz nz nz nz nz
c. The nurse in an urgent care center checks the vital signs of a patient who
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
is complaining of leg pain.nz nz nz nz
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting bloo
nz nz nz nz nz nz nz nz nz nz nz nz
d glucose level. nz nz
ANS: B n z
A health fair at a local mall that provides cholesterol and blood pressure checks is an exam
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
ple of a screening assessment focused on disease detection. A detailed history and physical
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
examination conducted during a first- nz nz nz nz
time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing a p
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
atient complaining of leg pain in the triage area of an urgent care center is an example of a
nz nz nz nz nz nz nz nz nz n z nz nz nz nz nz nz nz nz n
problem-
z
based/focused assessment. A patient‘s return appointment 1 month after today‘s office visit
nz nz nz nz nz nz nz nz nz nz nz nz
to report fasting blood glucose levels is an example of an episodic or follow-up assessment.
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
DIF:Cognitive Level: Understand nz nz REF: Box 1-3 nz nz
, TOP:Nursing Process: Assessment nz nz
MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
nz nz nz nz nz nz nz nz
3. For which person is a screening assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: B nz
A screening assessment is performed for the purpose of disease detection. In this case this p
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
erson may have diabetes mellitus. A shift assessment is most appropriate for the person who
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
nzis recovering in the hospital from surgery. A comprehensive assessment is performed durin
nz nz nz nz nz nz nz nz nz nz nz nz
g admission to a facility to obtain a detailed history and complete physical examination. An
nz nz nz nz nz nz nz nz nz nz nz nz nz nz n
zepisodic or follow- nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedure
nz nz nz nz nz nz nz nz nz nz nz nz nz
.
DIF:Cognitive Level: Understand REF: Box 1- nz nz nz nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
4. For which person is a shift assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: A nz
A shift assessment is most appropriate for the person who is recovering in the hospital from
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
surgery. A screening assessment is performed for the purpose of disease detection, in this cas
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
e diabetes mellitus. A comprehensive assessment is performed during admission to a facility
nz nz nz nz nz nz nz nz nz nz nz nz nz
to obtain a detailed history and complete physical examination. An episodic or follow-
nz nz nz nz nz nz nz nz nz nz nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedure.
nz nz nz nz nz nz nz nz nz nz nz nz nz
DIF:Cognitive Level: Understand REF: Box 1- nz nz nz nz
3 TOP:Nursing Process: Assessment
nz nz nz
MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establish
nz nz nz nz nz nz nz nz nz nz nz
ing Priorities nz
5. For which person is a comprehensive assessment indicated?
nz nz nz nz nz nz nz
a. The person who had abdominal surgery yesterday
nz nz nz nz nz nz
b. The person who is unaware of his high serum glucose levels
nz nz nz nz nz nz nz nz nz nz
c. The person who is being admitted to a long-term care facility
nz nz nz nz nz nz nz nz nz nz
d. The person who is beginning rehabilitation after a knee replacement
nz nz nz nz nz nz nz nz nz
ANS: C nz
A comprehensive assessment is performed during admission to a facility to obtain a detailed
nz nz nz nz nz nz nz nz nz nz nz nz nz
history and complete physical examination. A shift assessment is most appropriate for the
nz nz nz nz nz nz nz nz nz nz nz nz nz nz
person who is recovering in the hospital from surgery. A screening assessment is performe
nz nz nz nz nz nz nz nz nz nz nz nz nz
d for the purpose of disease detection, in this case diabetes mellitus. An episodic or follow-
nz nz nz nz nz nz nz nz nz nz nz nz nz nz nz
up assessment is performed after knee replacement to evaluate the outcome of the procedur
nz nz nz nz nz nz nz nz nz nz nz nz nz
e.
