Test Bank for Health Assessment for Nursing Practice
7th Edition by Wilson Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and
tells the triage nurse that heis “having a heart attack.” What is
the nurse’s top priority at this time?
a. Determine the patient’s
personal data andinsurance
coverage.
b. Ask the patient to take a seat in
the waitingroom until his name
is called.
c. Request that a nurse
collect data for a
comprehensive history.
d. Ask a nurse to start a focused
assessmentof this patient
now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that
is focused on this patient’scardiovascular system. The type of
health assessment performed by the nurse is also drivenby
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 determinethe 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.
DIF: Cognitive Level: Apply REF: Box 1-3
| p. 3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment:
Management of Care:Establishing Priorities
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 localmall and
provides cholesterol and
blood pressure checks to mall
patrons.
c. The nurse in an urgent care
center checksthe vital signs
of a patient who is
complaining of leg pain.
, d. A patient newly diagnosed
with diabetesmellitus
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
examination conducted during a first-time visit to an obstetric
clinic is an exampleof 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.
DIF: Cognitive Level: Understand REF:
Box 1-3 | p. 3TOP: Nursing Process:
Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health
Screening
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 highserum glucose
levels
c. The person who is being
admitted to along-term
care facility
7th Edition by Wilson Chapter 1 - 24
,Chapter 01: Introduction to Health Assessment
MULTIPLE CHOICE
1. A patient comes to the emergency department and
tells the triage nurse that heis “having a heart attack.” What is
the nurse’s top priority at this time?
a. Determine the patient’s
personal data andinsurance
coverage.
b. Ask the patient to take a seat in
the waitingroom until his name
is called.
c. Request that a nurse
collect data for a
comprehensive history.
d. Ask a nurse to start a focused
assessmentof this patient
now.
ANSWER: D
The nurse needs to begin an assessment as soon as possible that
is focused on this patient’scardiovascular system. The type of
health assessment performed by the nurse is also drivenby
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 determinethe 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.
DIF: Cognitive Level: Apply REF: Box 1-3
| p. 3TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment:
Management of Care:Establishing Priorities
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 localmall and
provides cholesterol and
blood pressure checks to mall
patrons.
c. The nurse in an urgent care
center checksthe vital signs
of a patient who is
complaining of leg pain.
, d. A patient newly diagnosed
with diabetesmellitus
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
examination conducted during a first-time visit to an obstetric
clinic is an exampleof 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.
DIF: Cognitive Level: Understand REF:
Box 1-3 | p. 3TOP: Nursing Process:
Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health
Screening
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 highserum glucose
levels
c. The person who is being
admitted to along-term
care facility
