TablewofwContents
UnitwI.wFoundationswforwHealthwAssessment
1. IntroductionwtowHealthwAssessment
2. InterviewingwPatientswtowObtainwawHealthwHistory
3. TechniqueswandwEquipmentwforwPhysicalwAssessment
4. GeneralwInspectionwandwMeasurementwofwVitalwSigns
5. Ethnic,wCultural,wandwSpiritualwConsiderations
6. PainwAssessment
7. MentalwHealthwandwAbusivewBehaviorwAssessment
8. NutritionalwAssessment
UnitwII.wHealthwAssessmentwofwthewAdult
9. Skin,wHair,wandwNails
10. Head,wEyes,wEars,wNose,wandwThroat
11. LungswandwRespiratorywSystem
12. HeartwandwPeripheralwVascularwSystem
13. AbdomenwandwGastrointestinalwSystem
,14. MusculoskeletalwSystem
15. NeurologicwSystem
16. BreastswandwAxillae
17. ReproductivewSystemwandwthewPerineum
UnitwIII.wHealthwAssessmentwAcrosswthewLifewSpan
18. DevelopmentalwAssessmentwThroughoutwthewLifewSpan
19. AssessmentwofwthewInfant,wChild,wandwAdolescent
20. AssessmentwofwthewPregnantwPatient
21. AssessmentwofwthewOlderwAdult
UnitwIV.wSynthesiswandwApplicationwofwHealthwAssessment
22. ConductingwawHead-to-ToewExamination
23. DocumentingwthewHead-to-ToewHealthwAssessment
24. AdaptingwHealthwAssessmentwtowanwIllwPatient
, Chapter 01: Introduction to Health Assessment
w w w w w
Wilson: Health Assessment for Nursing Practice, 6th Edition
w w w w w w w
MULTIPLEwCHOICE
1. Awpatientwcomeswtowthewemergencywdepartmentwandwtellswthewtriagewnursewthatwhewisw“having
a heartwattack.”wWhatwiswthewnurse’swtopwprioritywatwthiswtime?
w w
a. Determinewthewpatient’swpersonalwdatawandwinsurancewcoverage.
b. Askwthewpatientwtowtakewawseatwinwthewwaitingwroomwuntilwhiswnamewiswcalled.
c. Requestwthatwawnursewcollectwdatawforwawcomprehensivewhistory.
d. Askwawnursewtowstartwawfocusedwassessmentwofwthiswpatientwnow.
ANS:w D
Thewnursewneedswtowbeginwanwassessmentwaswsoonwaswpossiblewthatwiswfocusedwonwthiswpatient’sw
cardiovascularwsystem.wThewtypewofwhealthwassessmentwperformedwbywthewnursewiswalsowdrivenwb
ywpatientwneed.wPersonalwdatawandwinsurancewinformationwwillwbewobtained,wbutwinwthiswsituatio
n,wthesewdatawcanwwaitwuntilwafterwthewpatientwiswassessed.wBasedwalsowonwMaslow’swhierarchywo
fwneeds,wphysiologicwneedswtakewprecedence.wRatherwthanwaskingwthewpatientwtowwait,wthewnurse
wneedswtowbegin wdatawcollection,wsuchwaswvital wsigns,wimmediatelywtowdeterminewthewpatient’swh
ealthwstatus.wComplicationswcanwbewpreventedwifwanwimmediatewassessmentwiswmadewtowanalyzew
thewpatient’swsymptoms.wAwcomprehensivewhistorywiswnotwindicatedwinwthiswsituationwatwthiswtim
e.wSomewsubjectivewdatawwillwbewcollected,wsuchwaswallergieswandwmedicalwhistorywrelatedwtowcar
diovascularwdisease.wEyes,wears,worwawcompletewmusculoskeletalworwmentalwhealthwassessmentwi
swnotwawprioritywatwthiswtime.
DIF: CognitivewLevel:wApply REF:wBoxw1-
3w|wp.w3wTOP:w NursingwProcess:wAssessment
MSC:w NCLEXwPatientwNeeds:wSafewandwEffectivewCarewEnvironment:wManagementwofwCare:wEstablis
hingwPriorities
2. Whichwsituationwillustrateswawscreeningwassessment?
a. Awpatientwvisitswanwobstetricwclinicwforwthewfirstwtimewandwthewnursewconducts
a detailedwhistorywandwphysicalwexamination.
w w
b. Awhospitalwsponsorswawhealthwfairwatwawlocalwmallwandwprovideswcholesterolwandwblo
odwpressurewcheckswtowmallwpatrons.
c. Thewnursewinwanwurgentwcarewcenterwcheckswthewvitalwsignswofwawpatientwwhowis
complainingwofwlegwpain.
d. Awpatientwnewlywdiagnosedwwithwdiabeteswmellituswcomeswtowtestwhiswfastingwbloo
dwglucosewlevel.
ANS:w B