Chapter 03: Techniques and Equipment for Physical Assessment
Chapter 04: General Inspection and Measurement of Vital Signs
Chapter 05: Cultural Assessment
Chapter 06: Pain Assessment
Chapter 07: Mental Health Assessment
Chapter 08: Nutritional Assessment
Chapter 09: Skin, Hair, and Nails
Chapter 10: Head, Eyes, Ears, Nose, and Throat
Chapter 11: Lungs and Respiratory System
Chapter 12: Heart and Peripheral Vascular System
Chapter 13: Abdomen and Gastrointestinal System
Chapter 14: Musculoskeletal System
Chapter 15: Neurologic System
Chapter 16: Breasts and Axillae
Chapter 17: Reproductive System and the Perineum
Chapter 18: DevelopmentalASSESSMENTThroughout the Life Span
Chapter 19:ASSESSMENTof the Infant, Child, and Adolescent
Chapter 20:ASSESSMENTof the Pregnant Patient
Chapter 21:ASSESSMENTof the Older Adult
Chapter 22: Conducting a Head-to-Toe Examination
Chapter 23: Documenting the Comprehensive Health Assessment
Chapter 24: Adapting HealthASSESSMENTto the Hospitalized Patient
,Chapter 01: Introduction to Health Assessment
Wilson: HealthASSESSMENTfor NURSING Practice, 7th
EditionMULTIPLE CHOICE
1. A patient comes to the emergency department and tells the triageNursethat he is “having a
heart attack.” What is the NURSE’s top priority at this time?
a. Determine the patient’s personal data and insurance coverage.
b. Ask the patient to take a seat in the waiting room until his name is called.
c. Request that aNursecollect data for a comprehensive history.
d. Ask aNurseto start a focusedASSESSMENTof this patient now.
SOLUTIOND
TheNurseneeds to begin anASSESSMENTas soon as possible that is focused on this patient’s
cardiovascular system. The type of HealthASSESSMENTperformed by theNurseis also driven by 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, theNurseneeds to begin data collection,
suchas vital signs, immediately to determine the patient’s Health status. Complicationscan be
prevented if an immediateASSESSMENTis 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 HealthASSESSMENTis not a priority at this time.
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 theNurseconducts a detailed history
andphysical examination.
b. A hospital sponsors a Health fair at a local mall and provides cholesterol and
bloodpressure checks to mall patrons.
c. TheNursein an urgent care center checks the vital signs of a patient who is complaining of
legpain.
d. A patient newly diagnosed with diabetes mellitus comes to test his fasting
bloodglucose level.
SOLUTIONB
A Health fair at a local mall that provides cholesterol and blood pressure checks is an example of a
screeningASSESSMENTfocused on disease detection. A detailed history and physical examination
conducted during a first-time visit to an obstetric clinic is an example of 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
toreport fasting blood glucose levels is an example of an episodic or follow-up assessment.
NURSING Process:ASSESSMENTMSC: NCLEX Patient Needs: Health Promotion and
Maintenance: HealthScreening
3. For which person is a screeningASSESSMENTindicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose levels
c. The person who is being admitted to a long-term care facility
d. The person who is beginning rehabilitation after a knee replacement
SOLUTIONB
A screeningASSESSMENTis performed for the purpose of disease detection. In this case this person may
have diabetes mellitus. A shiftASSESSMENTis most appropriate for the person who is recovering in the
hospital from surgery. A comprehensiveASSESSMENTis performed during admission to a facility to
obtaina detailed history and complete physical examination. An episodic or follow-upASSESSMENTis
performedafter knee replacement to evaluate the outcome of the procedure.
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